Clinical Characteristics And TCM Syndromes Of Sepsis Complicated With PICS

BackgroundPersistent inflammation,immunosuppression,catabolism syndrome(PICS)describes the persistent low-level inflammatory response,progressive immunosuppression,metabolic disorders,and organ failures that afflict severe patients in the later stages of sepsis attack.The clinical manifestations are often repetitive nosocomial infections,severe malnutrition,continuous muscle loss and difficulty in wound healing.This group of patients relies heavily on intensive care equipments,which results in serious detention,great hospitalization expenses,and great distress to intensive care unit(ICU)clinicians.At present,our understanding of PICS is still limited.First,the in-depth understanding is.lacking of the early clinical characteristics,risk factors,and prognosis of sepsis patients complicated with PICS.It is still unclear how to identify high-risk patients,and of the necessary of targeted prevention for the high-risk patients.Secondly,is for patients with sepsis who have progressed to PICS,and there is no the effective,targeted,and reliable interventions are still lacking for the sepsis patients who have developed PICS.The syndrome differentiation approach of traditional Chinese medicine(TCM)is advantageous and may help to provide auxiliary treatment for such patients.However,due to the late introduction of the PICS concept,we are still limited in the understanding of its syndrome characteristics;and lack relevant experience in the treatment based on syndrome differentiation.Therefore,the research on the clinical characteristics and TCM syndromes of sepsis complicated with PICS will provide not only the evidence basis for the syndrome differentiation based treatment,but also important guidance to improve the efficacy of TCM syndrome differentiation.ObjectiveWe summarize the clinical characteristics of patients with sepsis complicated with PICS,explore its influencing factors,and provide guidance and basis for early identification of such patients.Meanwhile,we analyzed TCM syndromes characteristics of the sepsis patients complicated with PICS,and provide basis for TCM syndrome differentiation and treatment.MethodsA retrospective case study method was used to collect clinical data of sepsis patients who were hospitalized in the ICU of Guangdong Provincial Hospital of Chinese Medicine for more than 14 days during January 2013 to September 2019,including demographic information,underlying diseases,disease severity,laboratory indicators,disease prognosis and clinical outcomes.They were divided into the sepsis complicating with PICS group(the PICS group)and the sole sepsis group(the non-PICS group).The SPSS 17.0 software was applied for statistical analysis.By adopting logistic regression and other methods to compare the differences in demographic data,underlying diseases,disease severity,laboratory indicators between the PICS group and the non-PICS group,the clinical features and TCM syndrome characteristics of sepsis-complicated PICS were explored;thus the possible influencing factors of sepsis complicated with PICS were found.Results(1)Baseline situation:A total of 216 patients who met the criteria of sepsis were included.They were divided into the sepsis complicating with PICS group(the PICS group)and the sole sepsis group(the non-PICS group),108 cases for each.The PICS group consists of 75 males(69.4%)and 33 females(30.6%),with the age ranging from 18 to 94;in average 76-16 ±13.07.The non-PICS group consists of 65 males(60.2%)and 43 females(39.80%),with the age ranging from 18 to 93;in average 73.94±13.16.There was no significant difference in gender and age between the two groups.(2)Clinical characteristics:Compared with the non-PICS group,the PICS group had higher APACHE Ⅱ score,proportion of combined AKI,levels of procalcitonin,high-sensitivity C-reactive protein,and creatinine;and had lower CD4+T cells/CD8+T cells(%),levels of precursor protein and eGFR.The differences were statistically significant.Compared with the non-PICS group,the PICS group had longer hospital stays[35.69±18.69 vs.29.20 ± 13.27 days]and ICU stays[27.19±15.40 vs.23.14 ±11.45 days],and higher hospitalization costs[29.48±17.34 vs.22.41 ± 9.90 ten thousand yuan].The differences between the two groups were statistically significant(P<0.05).The difference in the 28-day mortality rate was not statistically significant(P>0.05)but the difference in the 90-day mortality rate was statistically significant(P<0.01),suggesting that the complicating PICS may affect the long-term prognosis of sepsis.(3)Characteristics of TCM syndromes:The present research used a method of combining syndromes of deficiency and excess with syndromes.The results demonstrated that the PICS group was dominated by syndromes of deficiency and excess(66.7%):while the non-PICS group has both syndromes of deficiency and excess(50.0%)and excess syndrome(43.5%).The differences in the distribution of deficiency-excess syndromes were statistically significant(P<0.05).In terms of syndrome distribution,both groups were dominated by syndromes of sputum,toxin heat,and qi deficiency,followed by blood stasis syndrome.But the PICS group had higher proportions of toxic heat syndrome and qi deficiency syndrome.The difference between the two groups was statistically significant(P<0.05).(4)Influencing factors:Logistic regression analyses were performed on indicators whose differences between the two groups were statistically significant.We found that APACHE Ⅱ score(βvalue=0.090,OR value=1.094,95%CI:1.003-1.192,P<0.05),hsCRP(β value=0.047,OR value=1.048,95%CI:1.028-1.069,P<0.01),and precursor protein(β value=-0.026,OR value=0.975,95%CI:0.964-0.986,P<0.01)are related to sepsis complicated with PICS and thus may be its influencing factors.The ROC curves were then drawn.For the APACHE Ⅱ score,the area under the curve(AUC)is 0.699(95%CI:0.629-0.769);the optimal cutoff value is 26.5;the sensitivity and specificity are 0.722 and 0.611,respectively.For hsCRP,AUC=0.775(95%CI:0.713-0.837);the best cutoff is 85.45 mg/L;the sensitivity and specificity are 0.769 and 0.718,respectively.For the precursor protein,AUC=0.765(95%CI:0.697-0.834);the optimal cutoff value is 101.5mg/L;and the sensitivity and specificity are 0.906 and 0.554,respectively.Conclusion(1)APACHE II score,hsCRP,and precursor protein levels may be the influencing factors of sepsis complicated with PICS.(2)The sepsis patients complicated with PICS have longer hospital stay,heavier economic burden,and higher 90-day mortality rate,which should be the focus of attention in the prevention and treatment of sepsis.(3)The sepsis patients complicated with PICS are dominated by syndromes of deficiency and excess.The main syndromes are toxin-heat and qi-deficiency.For exorcism,the emphasis should be on heat-clearing and detoxification to eliminate "poison" and "heat." For righteousness,the emphasis should be on Qi-tonifying and right-supporting to correct "qi deficiency."...