Key result
Higher body mass index was associated with lower in-hospital mortality in sepsis (p<0.007), but this benefit disappeared at lactate >5 mmol/L or when adjusting for APACHE III scores.
Why the study?
Multiple studies demonstrate an obesity paradox in ICU patients, but whether the mortality benefit is affected by baseline serum lactate and mean arterial pressure was unknown.
Does higher body mass index reduce in-hospital death in adults hospitalized with sepsis?
Observational (n=7,967)
Yes
Does higher body mass index reduce in-hospital death in adults hospitalized with sepsis?
p-value: p=< 0.007
The obesity paradox in sepsis is attenuated by illness severity, with no mortality benefit observed in obese patients with lactate levels greater than 5 mmol/L.
Should not yet change sepsis management by BMI; hypothesis-generating for severity-adjusted obesity paradox.
OBJECTIVES: Multiple studies have demonstrated an obesity paradox such that obese ICU patients have lower mortality and better outcomes. We conducted this study to determine if the mortality benefit conferred by obesity is affected by baseline serum lactate and mean arterial pressure. DESIGN: Retrospective analysis of prospectively collected clinical data. SETTING: Five community-based and one academic medical center in the Omaha, NE. PATIENTS: 7,967 adults hospitalized with sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were categorized by body mass index as underweight, normal weight, overweight, or obese. Multivariable logistic regression models were used to estimate the odds of in-hospital death by body mass index category; two-way interactions between body mass index and each covariate were also evaluated. Subgroup and sensitivity analyses were conducted using an ICU cohort and Acute Physiology and Chronic Health Evaluation III scores, respectively. The overall unadjusted mortality rate was 12.1% and was consistently lower in higher body mass index categories (all comparisons, p < 0.007). The adjusted mortality benefit observed in patients with higher body mass index was smaller in patients with higher lactate levels with no mortality benefit in higher body mass index categories observed at lactate greater than 5 mmol/L. By contrast, the association between lower MAP and higher mortality was constant across body mass index categories. Similar results were observed in the ICU cohort. Finally, the obesity paradox was not observed after including Acute Physiology and Chronic Health Evaluation III scores as a covariate. CONCLUSIONS: Our retrospective analysis suggests that although patient size (i.e., body mass index) is a predictor of in-hospital death among all-comers with sepsis-providing further evidence to the obesity paradox-it adds that illness severity is critically important whether quantified as higher lactate or by Acute Physiology and Chronic Health Evaluation III score. Our results highlight that the obesity paradox is more than a simple association between body mass index and mortality and reinforces the importance of illness severity.
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Jagan et al. (2020) conducted an observational in Sepsis (n=7,967). Higher body mass index vs. Lower body mass index was evaluated on In-hospital death (p=< 0.007). Higher body mass index was associated with lower in-hospital mortality in sepsis (p<0.007), but this benefit disappeared at lactate >5 mmol/L or when adjusting for APACHE III scores.
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