ELECTRONIC SUPPLEMENT
THE NEW SEPTIC SHOCK 3.0 DEFINITION AND TRIALS:
A VASST EXEPRIENCE
JAMES A. RUSSELL MD, TERRY LEE PhD,
JOEL SINGER PhD, KEITH R. WALLEY, MD
Supplemental Table 1. Names and abbreviations of cytokines.
EGF = epidermal growth factor, Eotaxin = eotaxin, FGF-2 = basic fibroblast growth factor, Flt-3 ligand = Fms-related tyrosine kinase 3 ligand, Fractalkine = fractalkine, G-CSF = Granulocyte colony-stimulating factor, GM-CSF = Granulocyte-macrophage colony-stimulating factor, GRO = CXCL1, IFN-α2 = interferon a2, IFN-γ = interferon g, IL-10 = interleukin-10, IL-12 (p40) = interleukin-12 (p40 subunit), IL-12 (p70) = interleukin-12 (p70 subunit), IL-13 = interleukin-13, IL-1 = interleukin-1, IL-17 = interleukin-17, IL-1ra = interleukin-1 receptor antagonist, IL-1α = interleukin-1a, IL-1β = interleukin-1b, IL-2 = interleukin-2, IL-3 = interleukin-3, IL-4 = interleukin-4, IL-5 = interleukin-5, IL-6 = interleukin-6, IL-7 = interleukin-7, IL-8 = interleukin-8, IL-9 = interleukin-9, IP-10 = CXCL10, MCP-1 = CCL2, MCP-3 = CCL7, MDC = CCL22, MIP-1α, MIP-1 = macrophage inflammatory protein-1-a, TGF-α = transforming growth factor-a, TNF-α = tumor necrosis factor-a, TNF-β = tumor necrosis factor-b, VEGF = vascular endothelial growth factor, sCD40L = soluble CD40-ligand, sIL-2Rα = soluble IL-2 receptora.
Supplemental Table 2. Baseline characteristics of the patients in VASST stratified by baseline lactate.
/ All patients in VASST / Patients with baseline lactate ≤ 2 / Sepsis 3.0 Definition (baseline lactate > 2) /Variable / Lactate ≤ 2 (n=290) / Lactate > 2 (n=375) / P / Vasopressin (n=148) / Norepinephrine (n=142) / P / Vasopressin (n=193) / Norepinephrine (n=182) / P /
Age / 61.9 (15.4) / 59.7 (16.8) / 0.086 / 61.4 (14.8) / 62.4 (15.9) / 0.588 / 57.7 (17.7) / 61.8 (15.7) / 0.020
Male, n (%) / 180 (62.1) / 220 (58.7) / 0.374 / 90 (60.8) / 90 (63.4) / 0.652 / 119 (61.7) / 101 (55.5) / 0.226
Recent surgical history — n (%) / 108 (37.2) / 124 (33.1) / 0.263 / 56 (37.8) / 52 (36.6) / 0.830 / 67 (34.7) / 57 (31.3) / 0.485
APACHE II score / 26.4 (7.1) / 28.6 (7.2) / 0.000 / 26.0 (7.6) / 26.8 (6.5) / 0.322 / 28.8 (7.5) / 28.4 (6.7) / 0.567
White race, n (%) / 253 (87.2) / 302 (80.5) / 0.021 / 126 (85.1) / 127 (89.4) / 0.272 / 156 (80.8) / 146 (80.2) / 0.882
Preexisting conditions, n (%)
Ischemic heart disease / 57 (19.7) / 59 (15.7) / 0.216 / 26 (17.6) / 31 (21.8) / 0.361 / 33 (17.1) / 26 (14.3) / 0.455
Congestive heart failure / 33 (11.6) / 14 (3.8) / <0.001 / 17 (11.8) / 16 (11.3) / 0.904 / 7 (3.7) / 7 (4.0) / 0.876
Chronic obstructive pulmonary disease / 72 (24.8) / 36 (9.6) / <0.001 / 35 (23.6) / 37 (26.1) / 0.635 / 12 (6.2) / 24 (13.2) / 0.022
Chronic renal failure / 40 (13.8) / 36 (9.6) / 0.110 / 19 (12.8) / 21 (14.8) / 0.630 / 14 (7.3) / 22 (12.1) / 0.112
Diabetes / 64 (22.1) / 74 (19.7) / 0.500 / 36 (24.3) / 28 (19.7) / 0.344 / 29 (15.0) / 45 (24.7) / 0.018
Liver disease / 23 (7.9) / 56 (14.9) / 0.005 / 14 (9.5) / 9 (6.3) / 0.325 / 32 (16.6) / 24 (13.2) / 0.357
Alcoholism / 40 (13.8) / 51 (13.6) / 1.000 / 20 (13.5) / 20 (14.1) / 0.888 / 25 (13.0) / 26 (14.3) / 0.707
Injection-drug abuse / 16 (5.5) / 13 (3.5) / 0.251 / 9 (6.1) / 7 (4.9) / 0.668 / 8 (4.1) / 5 (2.7) / 0.460
Cancer / 69 (23.8) / 95 (25.3) / 0.717 / 28 (18.9) / 41 (28.9) / 0.047 / 45 (23.3) / 50 (27.5) / 0.355
Compromised immune system / 46 (15.9) / 83 (22.1) / 0.048 / 19 (12.8) / 27 (19.0) / 0.150 / 43 (22.3) / 40 (22.0) / 0.944
Solid-organ transplant / 11 (3.8) / 18 (4.8) / 0.571 / 4 (2.7) / 7 (4.9) / 0.321 / 9 (4.7) / 9 (4.9) / 0.898
Corticosteroid use / 57 (19.7) / 90 (24.0) / 0.188 / 26 (17.6) / 31 (21.8) / 0.361 / 47 (24.4) / 43 (23.6) / 0.869
Recent trauma / 12 (4.1) / 17 (4.5) / 0.804 / 7 (4.7) / 5 (3.5) / 0.605 / 12 (6.2) / 5 (2.7) / 0.106
New organ failure, n (%)
Respiratory / 258 (89.0) / 326 (86.9) / 0.427 / 131 (88.5) / 127 (89.4) / 0.802 / 166 (86.0) / 160 (87.9) / 0.585
Renal / 182 (62.8) / 269 (71.9) / 0.012 / 90 (60.8) / 92 (64.8) / 0.484 / 139 (72.0) / 130 (71.8) / 0.966
Hematologic and coagulation / 49 (16.9) / 134 (35.8) / <0.001 / 27 (18.2) / 22 (15.5) / 0.532 / 78 (40.4) / 56 (30.9) / 0.056
Neurologic / 58 (20.0) / 106 (28.4) / 0.016 / 33 (22.3) / 25 (17.6) / 0.318 / 58 (30.2) / 48 (26.5) / 0.423
Number of organ dysfunctions / 3.2 (1.0) / 3.7 (1.1) / <0.001 / 3.3 (1.0) / 3.2 (1.1) / 0.625 / 3.8 (1.2) / 3.6 (1.1) / 0.088
Source of infection, n (%) / 0.001 / 0.254 / 0.606
Lung / 141 (48.6) / 131 (34.9) / 65 (43.9) / 76 (53.5) / 72 (37.3) / 59 (32.4)
Abdomen / 65 (22.4) / 118 (31.5) / 37 (25.0) / 28 (19.7) / 58 (30.1) / 60 (33.0)
Other / 84 (29.0) / 126 (33.6) / 46 (31.1) / 38 (26.8) / 63 (32.6) / 63 (34.6)
Pathogen type in cultures, n (%) / 0.458 / <0.001 / 0.128
Gram-positive alone / 56 (19.3) / 60 (16.0) / 37 (25.0) / 19 (13.4) / 31 (16.1) / 29 (15.9)
Gram-negative alone / 23 (7.9) / 43 (11.5) / 11 (7.4) / 12 (8.5) / 17 (8.8) / 26 (14.3)
Mixed organisms / 101 (34.8) / 139 (37.1) / 58 (39.2) / 43 (30.3) / 68 (35.2) / 71 (39.0)
Other / 44 (15.2) / 55 (14.7) / 23 (15.5) / 21 (14.8) / 36 (18.7) / 19 (10.4)
No pathogen / 66 (22.8) / 78 (20.8) / 19 (12.8) / 47 (33.1) / 41 (21.2) / 37 (20.3)
Systolic blood pressure — mmHg / 111.7 (15.7) / 107.2 (16.7) / <0.001 / 110.4 (15.5) / 113.1 (15.8) / 0.141 / 106.5 (16.6) / 108.0 (16.9) / 0.409
Mean arterial pressure — mmHg / 73.1 (9.0) / 72.1 (10.1) / 0.183 / 72.4 (9.0) / 73.8 (9.0) / 0.200 / 72.0 (9.3) / 72.2 (11.0) / 0.858
Arterial pH / 7.33 (0.09) / 7.30 (0.11) / <0.001 / 7.33 (0.09) / 7.33 (0.09) / 0.966 / 7.30 (0.10) / 7.30 (0.11) / 0.878
CVP - mmHg / 13.9 (4.2) / 15.6 (5.4) / <0.001 / 14.1 (4.4) / 13.7 (4.1) / 0.553 / 15.8 (5.3) / 15.4 (5.5) / 0.530
PAP - mmHg
Systolic / 43.3 (12.9) / 40.3 (10.0) / 0.114 / 45.6 (14.0) / 40.7 (11.3) / 0.195 / 41.6 (8.9) / 39.0 (11.0) / 0.171
Diastolic / 22.8 (5.2) / 23.3 (6.0) / 0.551 / 23.7 (5.4) / 21.6 (4.9) / 0.177 / 24.1 (5.5) / 22.6 (6.4) / 0.199
Missing, n (%) / 242 (83.4) / 265 (70.7) / 122 (82.4) / 120 (84.5) / 136 (70.5) / 129 (70.9)
PCWP - mmHg / 19.2 (6.7) / 18.7 (5.7) / 0.679 / 20.0 (7.5) / 17.9 (5.2) / 0.352 / 20.4 (4.9) / 16.9 (5.9) / 0.004
Missing, n (%) / 255 (87.9) / 289 (77.1) / 127 (85.8) / 128 (90.1) / 149 (77.2) / 140 (76.9)
Cardiac output / 7.5 (2.5) / 7.2 (2.6) / 0.569 / 7.6 (2.3) / 7.3 (2.8) / 0.685 / 6.9 (2.5) / 7.6 (2.8) / 0.253
Missing, n (%) / 250 (86.2) / 276 (73.6) / 125 (84.5) / 125 (88.0) / 140 (72.5) / 136 (74.7)
Cardiac index / 4.0 (1.1) / 3.8 (1.3) / 0.395 / 4.0 (0.9) / 4.0 (1.4) / 0.813 / 3.7 (1.3) / 3.9 (1.3) / 0.296
Missing, n (%) / 251 (86.6) / 277 (73.9) / 125 (84.5) / 126 (88.7) / 141 (73.1) / 136 (74.7)
Creatinine - umol/L (median & IQR) / 146.5
(88.0, 257.0) / 175.0
(113.0, 277.0) / <0.001 / 141.0
(88.0, 266.0) / 147.0
(88.0, 250.0) / 0.772 / 182.5
(114.5, 266.0) / 169.0
(111.0, 289.0) / 0.810
WBC - G/L (median & IQR) / 15.2
(9.6, 21.7) / 11.6
(5.7, 19.4) / <0.001 / 15.2
(10.1, 20.9) / 15.0
(9.1, 22.4) / 0.754 / 11.7
(5.9, 18.2) / 11.5
(5.3, 20.7) / 0.749
Bilirubin - umol/L (median & IQR) / 16.0
(9.0, 32.0) / 23.0
(12.0, 47.0) / <0.001 / 17.0
(8.0, 32.0) / 16.0
(9.0, 30.0) / 0.534 / 21.5
(12.0, 49.5) / 24.0
(14.0, 46.0) / 0.851
Serum lactate level — mmol/liter / 1.3 (0.4) / 5.1 (3.3) / <0.001 / 1.3 (0.4) / 1.4 (0.4) / 0.220 / 5.1 (3.5) / 5.1 (3.1) / 0.999
Vasoactive drug dosage at randomization (mean & SD)1
Norepinephrine / 14.9 (11.3) / 27.1 (25.1) / <0.001 / 14.2 (11.0) / 15.7 (11.6) / 0.305 / 28.0 (28.0) / 26.2 (21.8) / 0.529
Epinephrine / 6.3 (6.4) / 15.9 (16.7) / 0.086 / 9.5 (8.5) / 4.2 (4.1) / 0.214 / 19.4 (19.4) / 11.2 (11.2) / 0.183
Dopamine / 6.3 (5.3) / 7.9 (6.0) / 0.411 / 5.2 (5.2) / 7.8 (5.5) / 0.417 / 8.4 (7.0) / 7.5 (5.4) / 0.644
Dobutamine / 4.4 (3.8) / 6.9 (5.0) / 0.014 / 4.1 (2.9) / 4.7 (4.5) / 0.634 / 7.7 (5.8) / 5.7 (3.2) / 0.171
Milrinone / 0.4 (0.4) / 0.3 (0.1) / 0.298 / 0.3 (0.1) / 0.6 (0.6) / 0.333 / 0.3 (0.1) / 0.3 (0.2) / 0.450
Phenylephrine / 117.7 (70.5) / 183.6 (82.8) / <0.001 / 120.5 (81.0) / 115.2 (60.4) / 0.781 / 180.4 (90.5) / 188.3 (70.7) / 0.660
Vasoactive drug infusions, n (%)
Norepinephrine alone / 177 (61.0) / 184 (49.1) / 0.002 / 96 (64.9) / 81 (57.0) / 0.172 / 87 (45.1) / 97 (53.3) / 0.112
No norepinephrine / 48 (16.6) / 47 (12.5) / 0.142 / 21 (14.2) / 27 (19.0) / 0.269 / 27 (14.0) / 20 (11.0) / 0.380
Two or more vasopressors / 70 (24.1) / 144 (38.4) / <0.001 / 34 (23.0) / 36 (25.4) / 0.636 / 79 (40.9) / 65 (35.7) / 0.299
Baseline tidal volume / 6.9 (2.8) / 7.6 (2.4) / 0.006 / 6.8 (2.7) / 7.0 (2.8) / 0.638 / 7.5 (2.4) / 7.8 (2.3) / 0.447
Time from meeting inclusion criteria to study drug infusion, hours / 12.7 (10.6) / 10.4 (7.6) / 0.002 / 12.9 (10.3) / 12.4 (11.0) / 0.670 / 10.8 (7.2) / 10.1 (8.0) / 0.353
1. Restricted to those received at least some amount of the drug.
P value is based on t-test, Wilcoxon rank-sum test, Chi-square test or Fisher's exact test as appropriate. Continuous variables are presented using mean and standard deviation unless specified otherwise.
Supplemental Table 3. Groupings of cytokines based on PCA in patients in VASST
Lactate <=2 / Lactate >2Group 1 / GCSF / GCSF
IL10 / IL10
IL6 / IL6
IL8 / IL8
MCP1 / MCP1
MIP1A / MIP1A
MIP1B / MIP1B
TNFA / TNFA
IL2RA / EOTAXIN
IL3 / FLT3L
GMCSF
GRO
IL17
Group 2 / IL12P40 / IL12P40
IL13 / IL13
IL15 / IL15
IL1A / IL1A
IL1B / IL1B
IL1RA / IL1RA
IL2 / IL2
IL9 / IL9
MCP3 / MCP3
TNFB / TNFB
IL4 / EGF
TGFA / IL3
Group 3 / FRACTALKINE / FRACTALKINE
IFNA2 / IFNA2
IL12P70 / IL12P70
IL7 / IL7
VEGF / VEGF
EOTAXIN / IL4
FGF2
FLT3L
GMCSF
Group 4 / IFNG / IFNG
IP10 / IP10
MDC / MDC
IL17 / IL2RA
IL5
Group 5 / CD40L / CD40L
EGF / FGF2
GRO / IL5
TGFA
Supplemental Table 4. Plasma cytokine levels in patients in VASST who had lactate ≤2 or >2 mmol/L.
Cytokine - Mean (SD) / Lactate ≤ 2 / Lactate > 2 / P1 / FDR P2EGF / -0.10 (0.95) / 0.45 (0.88) / <0.001 / <0.001
FGF2 / -0.15 (0.98) / 0.33 (0.96) / <0.001 / <0.001
EOTAXIN / -0.10 (0.89) / 0.47 (0.96) / <0.001 / <0.001
TGFA / -0.10 (0.98) / 0.43 (0.89) / <0.001 / <0.001
GCSF / -0.22 (0.84) / 0.63 (1.03) / <0.001 / <0.001
FLT3L / -0.09 (0.93) / 0.34 (1.07) / <0.001 / <0.001
GMCSF / -0.17 (0.91) / 0.56 (0.91) / <0.001 / <0.001
FRACTALKINE / -0.13 (0.85) / 0.52 (0.93) / <0.001 / <0.001
IFNA2 / -0.11 (0.96) / 0.49 (0.86) / <0.001 / <0.001
IFNG / -0.14 (0.87) / 0.35 (1.17) / <0.001 / <0.001
GRO / -0.02 (0.84) / 0.40 (1.16) / <0.001 / <0.001
IL10 / -0.20 (0.88) / 0.62 (0.90) / <0.001 / <0.001
MCP3 / -0.19 (0.86) / 0.53 (1.04) / <0.001 / <0.001
IL12P40 / -0.19 (1.01) / 0.48 (0.90) / <0.001 / <0.001
MDC / -0.08 (0.88) / 0.12 (1.15) / 0.087 / 0.089
IL12P70 / -0.12 (0.95) / 0.41 (0.99) / <0.001 / <0.001
IL13 / -0.22 (0.94) / 0.42 (0.96) / <0.001 / <0.001
IL15 / -0.23 (0.95) / 0.41 (0.85) / <0.001 / <0.001
CD40L / 0.08 (0.96) / 0.10 (1.02) / 0.876 / 0.876
IL17 / -0.21 (1.17) / 0.32 (0.96) / <0.001 / <0.001
IL1RA / -0.20 (0.98) / 0.65 (0.86) / <0.001 / <0.001
IL2RA / -0.09 (0.95) / 0.30 (0.88) / <0.001 / <0.001
IL1A / -0.19 (1.00) / 0.42 (0.95) / <0.001 / <0.001
IL9 / -0.27 (0.91) / 0.51 (0.92) / <0.001 / <0.001
IL1B / -0.23 (0.89) / 0.54 (1.07) / <0.001 / <0.001
IL2 / -0.21 (0.95) / 0.47 (0.94) / <0.001 / <0.001
IL3 / -0.08 (0.97) / 0.34 (0.88) / <0.001 / <0.001
IL4 / -0.15 (0.91) / 0.46 (1.02) / <0.001 / <0.001
IL5 / -0.12 (0.99) / 0.26 (1.04) / 0.001 / 0.001
IL6 / -0.09 (0.81) / 0.71 (0.95) / <0.001 / <0.001
IL7 / -0.10 (0.89) / 0.45 (0.90) / <0.001 / <0.001
IL8 / -0.25 (0.76) / 0.70 (1.11) / <0.001 / <0.001
IP10 / -0.11 (0.88) / 0.34 (1.15) / <0.001 / <0.001
MCP1 / -0.17 (0.83) / 0.57 (1.06) / <0.001 / <0.001
MIP1A / -0.19 (0.96) / 0.45 (0.98) / <0.001 / <0.001
MIP1B / -0.17 (0.90) / 0.53 (1.07) / <0.001 / <0.001
TNFA / -0.20 (0.89) / 0.59 (1.09) / <0.001 / <0.001
TNFB / -0.25 (0.94) / 0.43 (1.06) / <0.001 / <0.001
VEGF / -0.12 (0.91) / 0.41 (0.87) / <0.001 / <0.001
Table 4 Legend.
1. P value: Based on two-sample t-test.
2. FDR P value: False discovery rate controlling adjustment has been made to the p-values.