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Hansen M, Gillespie J, Riddick T, Samatham R, Baker S, Filer S, Xin H, Sheridan D. Evaluation of electronic measurement of capillary refill for Sepsis screening at ED triage. Am J Emerg Med 2023; 70:61-65. [PMID: 37201452 DOI: 10.1016/j.ajem.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVE To evaluate the association between capillary refill time (CRT) measured by a medical device and sepsis among patients presenting to the Emergency Department (ED). METHODS This prospective observational study enrolled adult and pediatric patients during ED triage when sepsis was considered a potential diagnosis by the triage nurse. Patients were enrolled at an academic medical center between December 2020 and June 2022. CRT was measured by a research assistant using an investigational medical device. The outcomes included sepsis and septic shock defined using sep-3 criteria, septic shock defined as IV antibiotics and a vasopressor requirement, ICU admission, and hospital mortality. Other measures included patient demographics and vital signs at ED triage. We evaluated univariate associations between CRT and sepsis outcomes. RESULTS We enrolled 563 patients in the study, 48 met Sep-3 criteria, 5 met Sep-3 shock criteria, and 11 met prior septic shock criteria (IV antibiotics and vasopressors to maintain mean arterial pressure of 65). Sixteen patients were admitted to the ICU. The mean age was 49.1 years, and 51% of the cohort was female. The device measured CRT was significantly associated with the diagnosis of sepsis by sep-3 criteria (OR 1.23, 95% CI 1.06-1-43), septic shock by sep-3 criteria (OR 1.57, 95% CI 1.02-2.40), and septic shock defined as receipt of IV antibiotics and a vasopressor requirement (OR 1.37, 95% CI 1.03-1.82). Patients with CRT >3.5 s measured by the DCR device had an odds ratio of 4.67 (95%CI 1.31-16.1) of septic shock (prior definition), and an odds ratio of 3.97 (95% CI 1.99-7.92) of ICU admission, supporting the potential for the 3.5-s cutoff of the DCR measurement. CONCLUSIONS CRT measured by a medical device at ED triage was associated with the diagnosis of sepsis. Objective CRT measurement using a medical device may be a relatively simple way to improve sepsis diagnosis during ED triage.
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Affiliation(s)
- Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR, United States of America; School of Medicine, Oregon Health & Science University, Portland, OR, United States of America; Promedix Inc, Portland, OR.
| | - Jordan Gillespie
- School of Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Tyne Riddick
- School of Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Ravi Samatham
- Department of Dermatology, Oregon Health & Science University, Portland, OR, United States of America
| | | | | | - Haichang Xin
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - David Sheridan
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR, United States of America; School of Medicine, Oregon Health & Science University, Portland, OR, United States of America; Promedix Inc, Portland, OR
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2
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Ramgopal S, Horvat CM, Adler MD. Varying Estimates of Sepsis among Adults Presenting to US Emergency Departments: Estimates from a National Dataset from 2002-2018. J Intensive Care Med 2022; 37:1451-1459. [PMID: 35225727 PMCID: PMC9548922 DOI: 10.1177/08850666221080060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background A variety of approaches to defining sepsis using administrative datasets have been previously reported. We aimed to compare estimates, demographics, treatment factors, outcomes and longitudinal trends of patients identified with sepsis in United States emergency departments (EDs) using differing sets of sepsis criteria. Methods We performed a cross-sectional study using the National Healthcare Ambulatory Medical Care Survey, a complex survey of nonfederal US ED encounters between 2002 to 2018. We obtained survey-weighted population-adjusted encounters of sepsis using the following criteria: explicit sepsis, severe sepsis, and quick Sequential Organ Failure Assessment (qSOFA) score combined with the presence of infection. Results Age-adjusted for US adults, 18.6, 16.1 and 8.9 encounters per 10 000 population were identified when using the explicit, severe sepsis and qSOFA definitions, respectively. A higher proportion of the explicit cohort was hospitalized and had blood cultures performed, compared to cohorts ascertained using severe sepsis and qSOFA criteria, though confidence intervals overlapped. Antibiotic use was highest in encounters meeting qSOFA criteria. When inspecting unweighted encounters meeting each set of criteria, there was minimal overlap, with only 3% meeting all three. Encounters meeting the explicit and severe sepsis criteria were increasing over time. Conclusion The explicit, severe sepsis and qSOFA criteria generated similar annual rates of presentation when applied to US ED encounters, with some evidence of the explicit sepsis cohort being higher acuity. There was minimal overlap of cases and instability in estimates when assessed longitudinally. Our findings inform research efforts to accurately identify sepsis among ED encounters using administrative data.
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Affiliation(s)
- Sriram Ramgopal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christopher M Horvat
- University of Pittsburgh School of Medicine; UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Mark D Adler
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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3
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Peltan ID, McLean SR, Murnin E, Butler AM, Wilson EL, Samore MH, Hough CL, Dean NC, Bledsoe JR, Brown SM. Prevalence, Characteristics, and Outcomes of Emergency Department Discharge Among Patients With Sepsis. JAMA Netw Open 2022; 5:e2147882. [PMID: 35142831 PMCID: PMC8832179 DOI: 10.1001/jamanetworkopen.2021.47882] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Sepsis guidelines and research have focused on patients with sepsis who are admitted to the hospital, but the scope and implications of sepsis that is managed in an outpatient setting are largely unknown. OBJECTIVE To identify the prevalence, risk factors, practice variation, and outcomes for discharge to outpatient management of sepsis among patients presenting to the emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted at the EDs of 4 Utah hospitals, and data extraction and analysis were performed from 2017 to 2021. Participants were adult ED patients who presented to a participating ED from July 1, 2013, to December 31, 2016, and met sepsis criteria before departing the ED alive and not receiving hospice care. EXPOSURES Patient demographic and clinical characteristics, health system parameters, and ED attending physician. MAIN OUTCOMES AND MEASURES Information on ED disposition was obtained from electronic medical records, and 30-day mortality data were acquired from Utah state death records and the US Social Security Death Index. Factors associated with ED discharge rather than hospital admission were identified using penalized logistic regression. Variation in ED discharge rates between physicians was estimated after adjustment for potential confounders using generalized linear mixed models. Inverse probability of treatment weighting was used in the primary analysis to assess the noninferiority of outpatient management for 30-day mortality (noninferiority margin of 1.5%) while adjusting for multiple potential confounders. RESULTS Among 12 333 ED patients with sepsis (median [IQR] age, 62 [47-76] years; 7017 women [56.9%]) who were analyzed in the study, 1985 (16.1%) were discharged from the ED. After penalized regression, factors associated with ED discharge included age (adjusted odds ratio [aOR], 0.90 per 10-y increase; 95% CI, 0.87-0.93), arrival to ED by ambulance (aOR, 0.61; 95% CI, 0.52-0.71), organ failure severity (aOR, 0.58 per 1-point increase in the Sequential Organ Failure Assessment score; 95% CI, 0.54-0.60), and urinary tract (aOR, 4.56 [95% CI, 3.91-5.31] vs pneumonia), intra-abdominal (aOR, 0.51 [95% CI, 0.39-0.65] vs pneumonia), skin (aOR, 1.40 [95% CI, 1.14-1.72] vs pneumonia) or other source of infection (aOR, 1.67 [95% CI, 1.40-1.97] vs pneumonia). Among 89 ED attending physicians, adjusted ED discharge probability varied significantly (likelihood ratio test, P < .001), ranging from 8% to 40% for an average patient. The unadjusted 30-day mortality was lower in discharged patients than admitted patients (0.9% vs 8.3%; P < .001), and their adjusted 30-day mortality was noninferior (propensity-adjusted odds ratio, 0.21 [95% CI, 0.09-0.48]; adjusted risk difference, 5.8% [95% CI, 5.1%-6.5%]; P < .001). Alternative confounder adjustment strategies yielded odds ratios that ranged from 0.21 to 0.42. CONCLUSIONS AND RELEVANCE In this cohort study, discharge to outpatient treatment of patients who met sepsis criteria in the ED was more common than previously recognized and varied substantially between ED physicians, but it was not associated with higher mortality compared with hospital admission. Systematic, evidence-based strategies to optimize the triage of ED patients with sepsis are needed.
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Affiliation(s)
- Ithan D. Peltan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Sierra R. McLean
- University of Utah School of Medicine, Salt Lake City
- Department of Physical Medicine and Rehabilitation, University of North Carolina School of Medicine, Chapel Hill
| | - Emily Murnin
- University of Utah School of Medicine, Salt Lake City
- Department of Medicine, University of Wisconsin School of Medicine, Madison
| | | | - Emily L. Wilson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah
| | - Matthew H. Samore
- Divisions of Epidemiology and Infectious Disease, Department of Medicine, University of Utah School of Medicine, Salt Lake City
| | - Catherine L. Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Oregon Health and Sciences University, Portland
| | - Nathan C. Dean
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Joseph R. Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah
- Department of Emergency Medicine, Stanford University, Palo Alto, California
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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4
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Lewis JM, Abouyannis M, Katha G, Nyirenda M, Chatsika G, Feasey NA, Rylance J. Population Incidence and Mortality of Sepsis in an Urban African Setting, 2013-2016. Clin Infect Dis 2021; 71:2547-2552. [PMID: 31725849 PMCID: PMC7744994 DOI: 10.1093/cid/ciz1119] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/12/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Sepsis is an important cause of mortality globally, although population incidence estimates from low-income settings, including sub-Saharan Africa, are absent. We aimed to estimate sepsis incidence burden using routinely available data from a large urban hospital in Malawi. METHODS We linked routine-care databases at Queen Elizabeth Central Hospital, Blantyre, Malawi, to provide admission and discharge data for 217 149 adults from 2013-2016. Using a definition of sepsis based on systemic inflammatory response syndrome criteria and Blantyre census population data, we calculated population incidence estimates of sepsis and severe sepsis and used negative binomial regression to assess for trends over time. Missing data were multiply imputed with chained equations. RESULTS We estimate that the incidence rate of emergency department-attending sepsis and severe sepsis in adults was 1772 per 100 000 person-years (95% confidence interval [CI], 1754-1789) and 303 per 100 000 person-years (95% CI, 295-310), respectively, between 2013 and 2016, with a year-on-year decrease in incidence. In-hospital mortality for patients admitted to the hospital with sepsis and severe sepsis was 23.7% (95% CI, 22.7-24.7%) and 28.1% (95% CI, 26.1 - 30.0%), respectively, with no clear change over time. CONCLUSIONS Sepsis incidence is higher in Blantyre, Malawi, than in high-income settings, from where the majority of sepsis incidence data are derived. Worldwide sepsis burden is likely to be underestimated, and data from low-income countries are needed to inform the public health response.
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Affiliation(s)
- Joseph M Lewis
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Grace Katha
- Adult Emergency and Trauma Center, Queen Elizabeth Central Hospital, Blantyre, Malawi.,University of Malawi, College of Medicine, Blantyre, Malawi
| | - Mulinda Nyirenda
- Adult Emergency and Trauma Center, Queen Elizabeth Central Hospital, Blantyre, Malawi.,University of Malawi, College of Medicine, Blantyre, Malawi
| | - Grace Chatsika
- Adult Emergency and Trauma Center, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Nicholas A Feasey
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Jamie Rylance
- Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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5
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Anesi GL, Chelluri J, Qasim ZA, Chowdhury M, Kohn R, Weissman GE, Bayes B, Delgado MK, Abella BS, Halpern SD, Greenwood JC. Association of an Emergency Department-embedded Critical Care Unit with Hospital Outcomes and Intensive Care Unit Use. Ann Am Thorac Soc 2020; 17:1599-1609. [PMID: 32697602 PMCID: PMC7706601 DOI: 10.1513/annalsats.201912-912oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 07/22/2020] [Indexed: 12/15/2022] Open
Abstract
Rationale: A small but growing number of hospitals are experimenting with emergency department-embedded critical care units (CCUs) in an effort to improve the quality of care for critically ill patients with sepsis and acute respiratory failure (ARF).Objectives: To evaluate the potential impact of an emergency department-embedded CCU at the Hospital of the University of Pennsylvania among patients with sepsis and ARF admitted from the emergency department to a medical ward or intensive care unit (ICU) from January 2016 to December 2017.Methods: The exposure was eligibility for admission to the emergency department-embedded CCU, which was defined as meeting a clinical definition for sepsis or ARF and admission to the emergency department during the intervention period on a weekday. The primary outcome was hospital length of stay (LOS); secondary outcomes included total emergency department plus ICU LOS, hospital survival, direct admission to the ICU, and unplanned ICU admission. Primary interrupted time series analyses were performed using ordinary least squares regression comparing monthly means. Secondary retrospective cohort and before-after analyses used multivariable Cox proportional hazard and logistic regression.Results: In the baseline and intervention periods, 3,897 patients met the inclusion criteria for sepsis and 1,865 patients met the criteria for ARF. Among patients admitted with sepsis, opening of the emergency department-embedded CCU was not associated with hospital LOS (β = -1.82 d; 95% confidence interval [CI], -4.50 to 0.87; P = 0.17 for the first month after emergency department-embedded CCU opening compared with baseline; β = -0.26 d; 95% CI, -0.58 to 0.06; P = 0.10 for subsequent months). Among patients admitted with ARF, the emergency department-embedded CCU was not associated with a significant change in hospital LOS for the first month after emergency department-embedded CCU opening (β = -3.25 d; 95% CI, -7.86 to 1.36; P = 0.15) but was associated with a 0.64 d/mo shorter hospital LOS for subsequent months (β = -0.64 d; 95% CI, -1.12 to -0.17; P = 0.01). This result persisted among higher acuity patients requiring ventilatory support but was not supported by alternative analytic approaches. Among patients admitted with sepsis who did not require mechanical ventilation or vasopressors in the emergency department, the emergency department-embedded CCU was associated with an initial 9.9% reduction in direct ICU admissions in the first month (β = -0.099; 95% CI, -0.153 to -0.044; P = 0.002), followed by a 1.1% per month increase back toward baseline in subsequent months (β = 0.011; 95% CI, 0.003-0.019; P = 0.009). This relationship was supported by alternative analytic approaches and was not seen in ARF. No associations with emergency department plus ICU LOS, hospital survival, or unplanned ICU admission were observed among patients with sepsis or ARF.Conclusions: The emergency department-embedded CCU was not associated with clinical outcomes among patients admitted with sepsis or ARF. Among less sick patients with sepsis, the emergency department-embedded CCU was initially associated with reduced rates of direct ICU admission from the emergency department. Additional research is necessary to further evaluate the impact and utility of the emergency department-embedded CCU model.
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Affiliation(s)
- George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Zaffer A. Qasim
- Department of Emergency Medicine
- Department of Anesthesiology and Critical Care, and
| | | | - Rachel Kohn
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary E. Weissman
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian Bayes
- Palliative and Advanced Illness Research Center
| | - M. Kit Delgado
- Palliative and Advanced Illness Research Center
- Department of Emergency Medicine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin S. Abella
- Department of Emergency Medicine
- Center for Resuscitation Science, Perelman School of Medicine, and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John C. Greenwood
- Department of Emergency Medicine
- Center for Resuscitation Science, Perelman School of Medicine, and
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6
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Kayambankadzanja RK, Schell CO, Namboya F, Phiri T, Banda-Katha G, Mndolo SK, Bauleni A, Castegren M, Baker T. The Prevalence and Outcomes of Sepsis in Adult Patients in Two Hospitals in Malawi. Am J Trop Med Hyg 2020; 102:896-901. [PMID: 32043446 DOI: 10.4269/ajtmh.19-0320] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
There are an estimated 19.4 million sepsis cases every year, many of them in low-income countries. The newly adopted definition of sepsis uses Sequential Organ Failure Assessment Score (SOFA), a score which is not feasible in many low-resource settings. A simpler quick-SOFA (qSOFA) based solely on vital signs score has been devised for identification of suspected sepsis. This study aimed to determine in-hospital prevalence and outcomes of sepsis, as defined as suspected infection and a qSOFA score of 2 or more, in two hospitals in Malawi. The secondary aim was to evaluate qSOFA as a predictor of mortality. A cross-sectional study of adult in-patients in two hospitals in Malawi was conducted using prospectively collected single-day point-prevalence data and in-hospital follow-up. Of 1,135 participants, 81 (7.1%) had sepsis. Septic patients had a higher hospital mortality rate (17.5%) than non-septic infected patients (9.0%, p = 0.027, odds ratio 2.1 [1.1-4.3]), although the difference was not statistically significant after adjustment for baseline characteristics. For in-hospital mortality among patients with suspected infection, qSOFA ≥ 2 had a sensitivity of 31.8%, specificity of 82.1%, a positive predictive value of 17.5%, and a negative predictive value of 91.0%. In conclusion, sepsis is common and is associated with a high risk of death in admitted patients in hospitals in Malawi. In low-resource settings, qSOFA score that uses commonly available vital signs data may be a tool that could be used for identifying patients at risk-both for those with and without a suspected infection.
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Affiliation(s)
| | - Carl Otto Schell
- Department of Internal Medicine, Nyköping Hospital, Nyköping, Sweden.,Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.,Global Health, Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Felix Namboya
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Tamara Phiri
- Department of Internal Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Grace Banda-Katha
- Department of Emergency Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.,Adult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Samson Kwazizira Mndolo
- Department of Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Andy Bauleni
- Malaria Alert Centre, College of Medicine, Blantyre, Malawi
| | - Markus Castegren
- Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Tim Baker
- Department of Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi.,Global Health, Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Perioperative Medicine & Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,College of Medicine, University of Malawi, Blantyre, Malawi
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7
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Song J, Moon S, Park DW, Cho HJ, Kim JY, Park J, Cha JH. Biomarker combination and SOFA score for the prediction of mortality in sepsis and septic shock: A prospective observational study according to the Sepsis-3 definitions. Medicine (Baltimore) 2020; 99:e20495. [PMID: 32481464 DOI: 10.1097/md.0000000000020495] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Biomarkers are valuable tools for the prediction of mortality in patients with sepsis. However, the use of a single biomarker to predict patient outcomes is challenging owing to the complexity and redundancy of the immune response to infections.We aimed to conduct a prospective observational analysis to investigate the prognostic value of pentraxin 3, interleukin 6, procalcitonin, and lactate combined in predicting the 28-day mortality rate in patients with sepsis or septic shock (n = 160; sepsis, 78; sepsis shock, 82). Two methods (the frequency sum of values above the cutoff, and the multivariate logistic regression model) were used to assess the prognostic value of the biomarker combination.In the receiver operating characteristic curve analyses, the combination of the 4 biomarkers was better than the Sequential Organ Failure Assessment (SOFA) score in predicting the 28-day mortality rate, regardless of whether the frequency sum of values above the cutoff or the multivariate logistic model was used for the analysis. The addition of the SOFA score to the biomarker combination did not result in a better performance for the prediction of mortality.The combined biomarker approach showed good performance in predicting 28-day all-cause mortality among patients diagnosed with either sepsis or septic shock according to the Sepsis-3 definitions. Furthermore, it was superior to the SOFA score in predicting mortality.
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Affiliation(s)
- Juhyun Song
- Department of Emergency Medicine, Korea University Ansan Hospital
| | - Sungwoo Moon
- Department of Emergency Medicine, Korea University Ansan Hospital
- National Emergency Medical Center, National Medical Center, Seoul
| | - Dae Won Park
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Ansan
| | - Han-Jin Cho
- Department of Emergency Medicine, Korea University Ansan Hospital
| | - Joo Yeong Kim
- Department of Emergency Medicine, Korea University Ansan Hospital
| | - Jonghak Park
- Department of Emergency Medicine, Korea University Ansan Hospital
| | - Jae Hyung Cha
- Medical Science Research Center, Korea University Ansan Hospital, Ansan, Republic of Korea
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8
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Uffen JW, Oosterheert JJ, Schweitzer VA, Thursky K, Kaasjager HAH, Ekkelenkamp MB. Interventions for rapid recognition and treatment of sepsis in the emergency department: a narrative review. Clin Microbiol Infect 2020; 27:192-203. [PMID: 32120030 DOI: 10.1016/j.cmi.2020.02.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/17/2020] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sepsis is a major cause of morbidity and mortality worldwide. Early recognition and treatment of sepsis is associated with improved outcome. The emergency department (ED) is the department where patients with sepsis seek care. However, recognition of sepsis in the ED remains difficult. Different alert and triage systems, screening scores and intervention strategies have been developed to assist clinicians in early recognition of sepsis and to optimize management. OBJECTIVES This narrative review describes currently applied interventions or interventions we can start using today, such as screening scores, (automated) triage systems, sepsis teams and clinical pathways in sepsis care; and it summarizes evidence for the effect of implementation of these interventions in the ED on patient management and outcomes. SOURCES A systematic literature search was conducted in PubMed, resulting in 39 eligible studies. CONTENT The main sepsis interventions in the ED are (automated) triage systems, sepsis teams and clinical pathways, the most integrative being a clinical pathway. Implementation of any of these interventions in sepsis care will generally lead to increased protocol adherence. Presumably increased adherence to sepsis guidelines and bundles will lead to better patient outcomes, but the level of evidence to support this improvement is low, whereas implementation of interventions is often complex and costly. No studies comparing different interventions were identified. Two essential factors for success of interventions in the ED are obtaining the support from all professionals and providing ongoing education. The vulnerability of these interventions lies in the lack of accurate tools to identify sepsis; diagnosing sepsis ultimately still relies on clinical assessments. A lack of specificity or sepsis alerts may lead to alert fatigue and/or overtreatment. IMPLICATIONS The severity and poor outcome of sepsis as well as the frequency of its presentation in EDs make a structured, protocol-based approach towards these patients essential, preferably as part of a clinical pathway.
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Affiliation(s)
- J W Uffen
- Division of Acute Medicine, Department of Internal Medicine, University Medical Center Utrecht, the Netherlands.
| | - J J Oosterheert
- Division of Infectious Diseases, Department of Internal Medicine, University Medical Center Utrecht, the Netherlands
| | - V A Schweitzer
- Department of Microbiology, University Medical Center Utrecht, the Netherlands
| | - K Thursky
- Department of Infectious Disease, Royal Melbourne Hospital, Melbourne, Australia
| | - H A H Kaasjager
- Division of Acute Medicine, Department of Internal Medicine, University Medical Center Utrecht, the Netherlands
| | - M B Ekkelenkamp
- Department of Microbiology, University Medical Center Utrecht, the Netherlands
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9
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Associations of Intensive Care Unit Capacity Strain with Disposition and Outcomes of Patients with Sepsis Presenting to the Emergency Department. Ann Am Thorac Soc 2019; 15:1328-1335. [PMID: 30113865 DOI: 10.1513/annalsats.201804-241oc] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Intensive care unit (ICU) capacity strain refers to the potential limits placed on an ICU's ability to provide high-quality care for all patients who may need it at a given time. Few studies have investigated how fluctuations in ICU capacity strain might influence care outside the ICU. OBJECTIVES To determine whether ICU capacity strain is associated with initial level of inpatient care and outcomes for emergency department (ED) patients hospitalized for sepsis. METHODS We performed a retrospective cohort study of patients with sepsis admitted from the ED to a medical ward or ICU at three hospitals within the University of Pennsylvania Health System between 2012 and 2015. Patients were excluded if they required life support therapies, defined as invasive or noninvasive ventilatory support or vasopressors, at the time of admission. The exposures were four measures of ICU capacity strain at the time of the ED disposition decision: ICU occupancy, ICU turnover, ICU census acuity, and ward occupancy. The primary outcome was the decision to admit to a ward or to an ICU. Secondary analyses assessed the association of ICU capacity strain with in-hospital outcomes, including mortality. RESULTS Among 77,142 hospital admissions from the ED, 3,067 patients met the study's eligibility criteria. The ICU capacity strain metrics varied between and within study hospitals over time. In unadjusted analyses, ICU occupancy, ICU turnover, ICU census acuity, and ward occupancy were all negatively associated with ICU admission. In the fully adjusted model including patient-level covariates, only ICU occupancy remained associated with ICU admission (odds ratio, 0.87; 95% confidence interval, 0.79-0.96; P = 0.005), such that a 10% increase in ICU occupancy (e.g., one additional patient in a 10-bed ICU) was associated with a 13% decrease in the odds of ICU admission. Among the subset of patients admitted initially from the ED to a medical ward, ICU occupancy at the time of admission was associated with increased odds of hospital mortality (odds ratio, 1.61; 95% confidence interval, 1.21-2.14; P = 0.001). CONCLUSIONS The odds that patients in the ED with sepsis who do not require life support therapies will be admitted to the ICU are reduced when those ICUs experience high occupancy but not high levels of other previously explored measures of capacity strain. Patients with sepsis admitted to the wards during times of high ICU occupancy had increased odds of hospital mortality.
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10
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Naderpour Z, Momeni M, Vahidi E, Safavi J, Saeedi M. Procalcitonin and D-dimer for Predicting 28-Day-Mortality Rate and Sepsis Severity based on SOFA Score; A Cross-sectional Study. Bull Emerg Trauma 2019; 7:361-365. [PMID: 31857998 PMCID: PMC6911710 DOI: 10.29252/beat-070404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: To determine the possible relationship of procalcitonin (PCT) and D-dimer with the 28-day-mortality rate and severity of sepsis based on sequential organ failure assessment (SOFA) score. Methods: In this cross-sectional study, patients were enrolled based on their signs and symptoms of sepsis confirmed by essential laboratory studies. Demographic data, Glasgow coma scale and vital signs, serum PCT and D-dimer levels, creatinine, bilirubin level, arterial blood gas analysis and platelet count were recorded. Disease severity index was assessed based on SOFA score. Patients’ 28-day-mortality rate and hospital length of stay were compared with the study variables. Results: Sixty-four patients with the mean age of 78.3±11.6 were included of whom 34 cases (53.1%) were male. The 28-day-mortality rate was 17%. The analysis showed that only patients’ age (p=0.01) and platelet count (p=0.02) had a statistically significant association with the mortality rate. SOFA score had no statistically significant correlation with PCT or D-dimer; and these two markers didn’t have any significant correlation in terms of predicting mortality due to the sepsis. Conclusion: In our study, PCT and D-dimer failed to show any significant correlation with 28-day-mortality rate of sepsis.
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Affiliation(s)
- Zeinab Naderpour
- Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Momeni
- Prehosptal and Hospital Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Elnaz Vahidi
- Prehosptal and Hospital Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Safavi
- Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Saeedi
- Prehosptal and Hospital Research Center, Tehran University of Medical Sciences, Tehran, Iran
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11
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Hunt A. Sepsis: an overview of the signs, symptoms, diagnosis, treatment and pathophysiology. Emerg Nurse 2019; 27:32-41. [PMID: 31475503 DOI: 10.7748/en.2019.e1926] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2019] [Indexed: 06/10/2023]
Abstract
Sepsis is a common phenomenon surrounded by uncertainty and misunderstanding. The urgency for treatment is complicated by the vagueness of signs and symptoms and lack of a conclusive diagnostic test. This article unpicks the signs and symptoms of sepsis with guidance for emergency department nurses who are responsible for assessing patients with potential sepsis. The article also relates monitoring, investigation and treatment expectations to the underlying pathophysiology and refers to the individual and global implications of the condition.
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Affiliation(s)
- Anne Hunt
- East and North Hertfordshire NHS Trust, Stevenage, England
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12
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Ndadane N, Maharaj RC. The epidemiology of sepsis in a district hospital emergency centre in Durban, KwaZulu natal. Afr J Emerg Med 2019; 9:123-126. [PMID: 31528529 PMCID: PMC6742595 DOI: 10.1016/j.afjem.2019.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/02/2018] [Accepted: 02/01/2019] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Sepsis is one of the leading causes of death worldwide. There is a paucity of data describing the epidemiology of sepsis in emergency centres in developing countries. This study aims to describe the clinical profile and management of patients presenting with sepsis in this setting. METHODS A retrospective chart review was conducted in an Emergency Centre (EC) of a district hospital in Durban from December 2015 to February 2016. All patients with a diagnosis of an infection that met the Surviving Sepsis Campaign criteria for sepsis syndrome were included in the study. RESULTS A total of 1195 patients who were diagnosed with an infection were screened. Of these, 52 of them met the inclusion criteria for the study. The criteria for severe sepsis was met in 40.3% (n 23) and 1.9% (n 1) met the criteria for septic shock. More than half of the patients were HIV positive and 30.7% did not know their HIV status. The most common sites of infection were respiratory tract, gastrointestinal and central nervous system respectively. Most patients were admitted to the general medical ward. The inpatient mortality rate was 15% for general medical ward admissions. CONCLUSION A better understanding of the demographic and clinical profile of sepsis syndrome in South African ECs is required to guide clinical and operational policy development.
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Emergency department charges may be associated with mortality in patients with severe sepsis and septic shock: a cohort study. BMC Emerg Med 2018; 18:62. [PMID: 30594140 PMCID: PMC6310923 DOI: 10.1186/s12873-018-0212-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 12/07/2018] [Indexed: 01/20/2023] Open
Abstract
Background Sepsis severity of illness is challenging to measure using claims, which makes sepsis difficult to study using administrative data. We hypothesized that emergency department (ED) charges may be associated with hospital mortality, and could be a surrogate marker of severity of illness for research purposes. The objective of this study was to measure concordance between ED charges and mortality in admitted patients with severe sepsis or septic shock. Methods Cohort study of all adult patients presenting to a 60,000-visit Midwestern academic ED with severe sepsis or septic shock (by ICD-9 codes) between July 1, 2008 and June 30, 2010. Data on demographics, admission APACHE-II score, and disposition was extracted from the medical record, and comorbidities were identified from diagnosis codes using the Elixhauser methodology. Summary statistics were reported and bivariate concordance was tested using Pearson correlation. Logistic regression models for 28-day mortality were developed to measure the independent association with mortality. Results We included a total of 294 patients in the analysis. We found that ED charges were inversely related to mortality (adjusted OR 0.829 per $1000 increase in total ED charges, 95%CI 0.702–0.980). ED charges were also independently associated with 28-day hospital-free and ICU-free days (0.74 days increase per $1000 additional ED charges, 95%CI 0.06–1.41 and 0.81 days increase per $1000 additional ED charges, 95%CI 0.05–1.56, respectively). ED charges were also associated with APACHE-II score ($34 total ED charges per point increase in APACHE-II score, 95%CI $6–62). Conclusions ED charges in administrative data sets are associated with in-hospital mortality and health care utilization, likely related to both illness severity and intensity of early sepsis resuscitation. ED charges may have a role in risk adjustment models using administrative data for acute care research.
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14
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Tokioka F, Okamoto H, Yamazaki A, Itou A, Ishida T. The prognostic performance of qSOFA for community-acquired pneumonia. J Intensive Care 2018; 6:46. [PMID: 30116532 PMCID: PMC6083584 DOI: 10.1186/s40560-018-0307-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/13/2018] [Indexed: 01/08/2023] Open
Abstract
Background Quick Sepsis-related Organ Failure Assessment (qSOFA) is a new screening system for sepsis. The prognostic performance of qSOFA for patients with suspected infections outside the intensive care unit (ICU) is similar to that of full SOFA; however, its performance for community-acquired pneumonia (CAP) has not yet been evaluated in detail. The objectives of the present study were to compare the prognostic performance of qSOFA with existing pneumonia severity scores, such as CURB-65 (confusion, blood urea nitrogen > 19 mg/dL, respiratory rate ≥ 30/min, systolic blood pressure < 90 mmHg, or diastolic blood pressure ≤ 60 mmHg, age ≥ 65 years) and the pneumonia severity index (PSI), and examine its usefulness for predicting mortality and ICU admission in patients with CAP of high severity and mortality that requires hospitalization. Methods We performed a secondary analysis of data from a prospective observational study of adult patients who were admitted to our hospital between October 2010 and June 2016. We compared the prognostic performance of qSOFA, CURB-65, and PSI for predicting in-hospital mortality and ICU admission using the C statistics. Results The median age of the 1045 enrolled patients was 77 (68–83) years, and 71.4% were males. The in-hospital mortality and ICU admission rates of the entire cohort were 6.1 and 7.9%, respectively. All scores were significantly higher in non-survivors and ICU admission patients than in survivors and non-ICU admission patients (p < 0.001). The C statistics of qSOFA for predicting in-hospital mortality was 0.69 (95% CI 0.63–0.75), and no significant differences were observed between CURB-65 (C statistics, 0.75; 95% CI 0.69–0.81) and PSI (C statistics, 0.74; 95% CI 0.69–0.80). The C statistics of qSOFA for predicting ICU admission was 0.76 (95% CI 0.71–0.80), and no significant differences were noted between CURB-65 (C statistics, 0.73; 95% CI 0.67–0.79) and PSI (C statistics, 0.72; 95% CI 0.66–0.78). Conclusions Regarding hospitalized CAP, the prognostic performance of qSOFA for in-hospital mortality and ICU admission was not significantly different from those of CURB-65 and PSI. qSOFA only requires a few items and vital signs, and, thus, may be particularly useful for emergency department or non-respiratory specialists. Electronic supplementary material The online version of this article (10.1186/s40560-018-0307-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fumiaki Tokioka
- 1Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602 Japan
| | - Hiroshi Okamoto
- 2Center for Clinical Epidemiology, St. Luke's International University, Tokyo, Japan
| | - Akio Yamazaki
- 1Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602 Japan
| | - Akihiro Itou
- 1Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602 Japan
| | - Tadashi Ishida
- 1Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602 Japan
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15
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Liu XW, Ma T, Liu W, Cai Q, Wang L, Song HW, Yuan L, Liu Z. Sustained increase in angiopoietin-2, heparin-binding protein, and procalcitonin is associated with severe sepsis. J Crit Care 2018; 45:14-19. [PMID: 29413717 DOI: 10.1016/j.jcrc.2018.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/27/2017] [Accepted: 01/10/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE The identification of infection at its early stage in vulnerable patients is challenging. This study aimed to investigate potential biomarkers to distinguish patients progressing to severe sepsis from those with uncomplicated sepsis. MATERIALS AND METHODS Serum samples were collected from sepsis patients admitted to the emergency department. The mRNA and protein levels of angiopoietin-2 (Ang-2), interleukin-10 (IL-10), heparin-binding protein (HBP), procalcitonin (PCT), adrenomedullin (ADM), and interleukin-6 (IL-6) were evaluated. RESULTS Compared to those of healthy individuals (n = 47), mRNA levels of ANG2, IL10, HBP, PCT, and ADM were increased in patients who eventually developed sepsis. ANG2 was the only gene whose expression was significantly increased in patients developing severe sepsis than in those with uncomplicated sepsis. Serum levels of Ang-2, IL-10, HBP, PCT, and IL-6 were also increased in sepsis patients, but only Ang-2, HBP, and PCT were elevated in the serum of patients developing severe septic shock than in those with uncomplicated sepsis. Serum levels of Ang-2, HBP, and PCT were closely associated with the sequential organ failure assessment (SOFA) score of the patients. CONCLUSIONS These findings indicated that sustained elevation of Ang-2, HBP, and PCT were associated with severe infection in critically ill patients.
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Affiliation(s)
- Xiao-Wei Liu
- Department of Emergency, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Tao Ma
- Department of Emergency, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wei Liu
- Department of Emergency, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Quan Cai
- Department of Emergency, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Li Wang
- Department of Emergency, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Hong-Wei Song
- Department of Emergency, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Liao Yuan
- Department of Emergency, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhi Liu
- Department of Emergency, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.
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16
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Lu X, Xue L, Sun W, Ye J, Zhu Z, Mei H. Identification of key pathogenic genes of sepsis based on the Gene Expression Omnibus database. Mol Med Rep 2017; 17:3042-3054. [PMID: 29257295 PMCID: PMC5783525 DOI: 10.3892/mmr.2017.8258] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/10/2017] [Indexed: 12/20/2022] Open
Abstract
Sepsis is a life-threatening condition in which an uncontrolled inflammatory host response is triggered. The exact pathogenesis of sepsis remains unclear. The aim of the present study was to identify key genes that may aid in the diagnosis and treatment of sepsis. mRNA expression data from blood samples taken from patients with sepsis and healthy individuals was downloaded from the Gene Expression Omnibus database and differentially expressed genes (DEGs) between the two groups were identified. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis, and protein-protein interaction (PPI) network construction, was performed to investigate the function of the identified DEGs. Furthermore, for validation of these results, the expression levels of several DEGs were analyzed by reverse transcription quantitative-polymerase chain reaction (RT-qPCR) in three patients with sepsis and three healthy blood samples to support the results obtained from the bioinformatics analysis. Receiver operating characteristic analyses were also used to analyze the diagnostic ability of the identified DEGs for sepsis. The results demonstrated that a total of 4,402 DEGs, including 1,960 upregulated and 2,442 downregulated genes, were identified between patients with sepsis and healthy individuals. KEGG pathway analysis revealed that 39 DEGs were significantly enriched in toll-like receptor signaling pathways. The top 20 upregulated and downregulated DEGs were used to construct the PPI network. Hub genes with high degrees, including interleukin 1 receptor-associated kinase 3 (IRAK3), S100 calcium-binding protein (S100)A8, angiotensin II receptor-associated protein (AGTRAP) and S100A9, were demonstrated to be associated sepsis. Furthermore, RT-qPCR results demonstrated that IRAK3, adrenomedullin (ADM), arachidonate 5-lipoxygenase (ALOX5), matrix metallopeptidase 9 (MMP9) and S100A8 were significantly upregulated, while ectonucleoside triphosphate diphosphohydrolase 1 (ENTPD1) was upregulated but not significantly, in blood samples from patients with sepsis compared with healthy individuals, which was consistent with bioinformatics analysis results. Therefore, AGTRAP, IRAK3, ADM, ALOX5, MMP9, S100A8 and ENTPD1 were identified to have potential diagnostic value in sepsis. In conclusion, dysregulated levels of the AGTRAP, IRAK3, ADM, ALOX5, MMP9, S100A8 and ENTPD1 genes may be involved in sepsis pathophysiology and may be utilized as potential diagnostic biomarkers or therapeutic targets.
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Affiliation(s)
- Xinxing Lu
- Department of Intensive Medicine, Taizhou People's Hospital, Taizhou, Jiangsu 225300, P.R. China
| | - Lu Xue
- Department of Intensive Medicine, Taizhou People's Hospital, Taizhou, Jiangsu 225300, P.R. China
| | - Wenbin Sun
- Department of Intensive Medicine, Taizhou People's Hospital, Taizhou, Jiangsu 225300, P.R. China
| | - Jilu Ye
- Department of Intensive Medicine, Taizhou People's Hospital, Taizhou, Jiangsu 225300, P.R. China
| | - Zhiyun Zhu
- Department of Intensive Medicine, Taizhou People's Hospital, Taizhou, Jiangsu 225300, P.R. China
| | - Haifeng Mei
- Department of Intensive Medicine, Taizhou People's Hospital, Taizhou, Jiangsu 225300, P.R. China
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17
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Abstract
OBJECTIVES Sepsis is a life-threatening condition that arises when the response of the body to infection injures its own tissues and organs. The early prediction of sepsis by current clinical and laboratory methods remains inadequate. Serum neutrophil gelatinase-associated lipocalin level is increased in sepsis irrespective of renal dysfunction. Therefore, we aimed to correlate the serum neutrophil gelatinase-associated lipocalin value determined at admission with clinical progression and severity of disease in critically ill children and to declare its role as a potential diagnostic and prognostic marker for sepsis in critically ill children in the emergency department. DESIGN A prospective cohort study. SETTING The study carried out at the PICU of Menoufia University Hospital. PATIENTS We serially enrolled 120 critically ill children admitted to the PICU at 2 fixed days per week in addition to 40 healthy children served as controls. INTERVENTIONS Clinical examination was performed including calculation of the Pediatric Risk of Mortality and Pediatric Index of Mortality 2. Serum neutrophil gelatinase-associated lipocalin measurement was performed for patients at admission and for the controls. Patients were followed up for 30 days. The discriminatory power of neutrophil gelatinase- associated lipocalin was determined using the receiver-operating characteristic and other predictive likelihood values. MEASUREMENTS AND MAIN RESULTS Serum neutrophil gelatinase-associated lipocalin level was significantly higher among the total patient cohort and those with sepsis than among the controls (p < 0.001), also in patients with systemic inflammatory response syndrome without sepsis and patients without systemic inflammatory response syndrome (p = 0.04 and <0.001). Furthermore, plasma level of neutrophil gelatinase-associated lipocalin was significantly elevated in nonsurvivors compared with survivors (p < 0. 001). Receiver-operating characteristic curve analysis exhibited an area under the curve of 0.84 for neutrophil gelatinase-associated lipocalin for diagnosis of sepsis, whereas C-reactive protein had an area under the curve of 0.79. Regarding the prognosis, neutrophil gelatinase-associated lipocalin had an area under the curve of 0.74 for prediction of mortality, whereas the area under the curve for Pediatric Risk of Mortality, Pediatric Index of Mortality 2, and C-reactive protein were 0.59, 0.58, and 0.62, respectively. CONCLUSION Overall, the data support the view that measurement at admission, serum neutrophil gelatinase-associated lipocalin results in substantial added value for early diagnosis and prognostication of sepsis in critically sick children.
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18
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Nygård ST, Skrede S, Langeland N, Flaatten HK. An observational study of community-acquired severe sepsis comparing intensive care and non-intensive care patients. Acta Anaesthesiol Scand 2017; 61:194-204. [PMID: 28058720 DOI: 10.1111/aas.12848] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Most studies of sepsis are from intensive care units (ICUs). We aimed to investigate community-acquired severe sepsis in a broader population, in order to compare patients treated in or outside an ICU . METHODS We performed a 1-year prospective observational study with enrollment of patients from three units; a general ICU, a combined ICU/non-ICU and a medical ward with limited surveillance facilities. Hospital survivors were followed up for 5 years. RESULTS Overall, 220 patients were included, of which 107 received ICU treatment. The majority of abdominal (77%, P = 0.003) and genitourinary (81%, P < 0.001) infections were found in ICU and non-ICU patients, respectively. Time to first antibiotic administration was longer in ICU-patients (median 3.5 vs. 2.0 h in non-ICU patients, P = 0.011). ICU developed more organ dysfunctions than non-ICU patients (P < 0.001), nevertheless supportive therapy with vasoactive drugs and non-invasive ventilation was documented in 22% and 27% of the latter. Median hospital length of stay was 15 vs. 9 days (P = 0.001), and hospital and 5-year mortality rates 35% vs. 16% (P = 0.002) and 57% vs. 58% (P = 0.892) among ICU and non-ICU patients, respectively. Increasing age (HR 1.06 (1.04, 1.07) per year, P < 0.001), not care level during hospitalization (HR 1.19 (0.70, 2.02), P = 0.514), influenced long-term survival. CONCLUSION Half of the subjects with community-acquired severe sepsis never received ICU treatment. Still, use of organ supportive therapy outside the ICU was considerable. Hospital mortality was higher, whereas 5-year survival was similar when comparing ICU with non-ICU patients.
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Affiliation(s)
- S. T. Nygård
- Department of Medicine; Haukeland University Hospital; Bergen Norway
| | - S. Skrede
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - N. Langeland
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - H. K. Flaatten
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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19
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Abstract
Sepsis is a common condition managed in the emergency department. Current diagnosis relies on physiologic criteria and suspicion of a source of infection using history, physical examination, laboratory studies, and imaging studies. The infection triggers a host response with the aim to destroy the pathogen, and this response can be measured. A reliable biomarker for sepsis should assist with earlier diagnosis, improve risk stratification, or improve clinical decision making. Current biomarkers for sepsis include lactate, troponin, and procalcitonin. This article discusses the use of lactate, procalcitonin, troponin, and novel biomarkers for use in sepsis.
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20
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Long B, Koyfman A, Modisett KL, Woods CJ. Practical Considerations in Sepsis Resuscitation. J Emerg Med 2016; 52:472-483. [PMID: 27823892 DOI: 10.1016/j.jemermed.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/27/2016] [Accepted: 10/03/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment. OBJECTIVE This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment. DISCUSSION Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario. CONCLUSIONS The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katharine L Modisett
- Department of Pulmonary and Critical Care Medicine, MedStar Georgetown University/MedStar Washington Hospital Center, Washington, District of Columbia
| | - Christian J Woods
- Sections of Infectious Diseases and Pulmonary Critical Care, MedStar Washington Hospital Center, Washington, District of Columbia
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21
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Stoneking L, Denninghoff K, DeLuca L, Keim SM, Munger B. Sepsis Bundles and Compliance With Clinical Guidelines. J Intensive Care Med 2016; 26:172-82. [DOI: 10.1177/0885066610387988] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Realizing the vast medical benefits of validated protocols, recommendations and practice guidelines requires acceptance and implementation by frontline care providers. Knowledge translation is the science of accelerating the transfer of knowledge to practice by understanding and creatively addressing the barriers that prevent adoption of new professional standards. In an attempt to improve patient care and reduce mortality, the Surviving Sepsis Campaign and The Institute for Healthcare Improvement created the resuscitation and management bundles for patients with severe sepsis and septic shock. These bundles have been accepted as best practice by many clinicians since multiple clinical trials have produced similar positive results when they were implemented. However, transferring these research outcomes-based guidelines to the clinical practice arena has been associated with poor compliance due to important barriers to implementation. Delays in the adoption of sepsis bundles are not surprising since the time from validation to implementation of a new clinical practice is typically 17 years. Using sepsis bundles as a model, this article explores why guidelines are important, examines physician adherence to protocols, and reviews the literature on strategies to improve clinical compliance and enhance knowledge translation.
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Affiliation(s)
- Lisa Stoneking
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA,
| | - Kurt Denninghoff
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Lawrence DeLuca
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Samuel M. Keim
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Benson Munger
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
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22
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Fleischmann C, Scherag A, Adhikari NKJ, Hartog CS, Tsaganos T, Schlattmann P, Angus DC, Reinhart K. Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. Am J Respir Crit Care Med 2016; 193:259-72. [PMID: 26414292 DOI: 10.1164/rccm.201504-0781oc] [Citation(s) in RCA: 2074] [Impact Index Per Article: 259.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Reducing the global burden of sepsis, a recognized global health challenge, requires comprehensive data on the incidence and mortality on a global scale. OBJECTIVES To estimate the worldwide incidence and mortality of sepsis and identify knowledge gaps based on available evidence from observational studies. METHODS We systematically searched 15 international citation databases for population-level estimates of sepsis incidence rates and fatality in adult populations using consensus criteria and published in the last 36 years. MEASUREMENTS AND MAIN RESULTS The search yielded 1,553 reports from 1979 to 2015, of which 45 met our criteria. A total of 27 studies from seven high-income countries provided data for metaanalysis. For these countries, the population incidence rate was 288 (95% confidence interval [CI], 215-386; τ = 0.55) for hospital-treated sepsis cases and 148 (95% CI, 98-226; τ = 0.99) for hospital-treated severe sepsis cases per 100,000 person-years. Restricted to the last decade, the incidence rate was 437 (95% CI, 334-571; τ = 0.38) for sepsis and 270 (95% CI, 176-412; τ = 0.60) for severe sepsis cases per 100,000 person-years. Hospital mortality was 17% for sepsis and 26% for severe sepsis during this period. There were no population-level sepsis incidence estimates from lower-income countries, which limits the prediction of global cases and deaths. However, a tentative extrapolation from high-income country data suggests global estimates of 31.5 million sepsis and 19.4 million severe sepsis cases, with potentially 5.3 million deaths annually. CONCLUSIONS Population-level epidemiologic data for sepsis are scarce and nonexistent for low- and middle-income countries. Our analyses underline the urgent need to implement global strategies to measure sepsis morbidity and mortality, particularly in low- and middle-income countries.
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Affiliation(s)
- Carolin Fleischmann
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
| | - André Scherag
- 3 Clinical Epidemiology, Integrated Research and Treatment Center, Center for Sepsis Control and Care, and
| | - Neill K J Adhikari
- 4 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Christiane S Hartog
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
| | - Thomas Tsaganos
- 5 4th Department of Internal Medicine, University of Athens, Medical School, Athens, Greece; and
| | - Peter Schlattmann
- 6 Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Jena, Germany
| | - Derek C Angus
- 7 Critical Care Medicine Division, Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Konrad Reinhart
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
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Sepsis patients' renal manifestation on contrast-enhanced CT. Clin Radiol 2016; 71:617.e1-7. [PMID: 27017479 DOI: 10.1016/j.crad.2016.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 01/14/2016] [Accepted: 02/22/2016] [Indexed: 11/22/2022]
Abstract
AIM To evaluate renal volume and attenuation changes in patients with sepsis on contrast-enhanced computed tomography (CT) with respect to the severity of sepsis. MATERIALS AND METHODS Forty-four patients with sepsis who underwent CT before and after the onset of sepsis were retrospectively analysed. Renal volume and CT attenuation value of the renal cortex on contrast-enhanced CT were measured for each patient and changes in renal volume and CT attenuation value from before to after the onset of sepsis were calculated. The changes were correlated with the severity of sepsis (Sepsis-related Organ Failure Assessment [SOFA] score). The time course of the renal volume and CT attenuation changes were also evaluated. RESULTS Renal volume increased by 17.6% and CT attenuation value decreased by 19% after the onset of sepsis with statistically significant differences (p<0.001 for both renal volume and CT attenuation changes). The renal volume and CT attenuation changes had significant correlations with the SOFA score (r=0.36, p=0.018 and -0.43, p=0.005, respectively). The time course of the renal volume and CT attenuation changes seemed to be gradual compared to that of the SOFA score and to lag behind the peak of the SOFA score. CONCLUSION In patients with sepsis, the renal volume increases and the CT attenuation value decreases in proportion to the severity of sepsis. The changes may lag behind the peak of severity of sepsis and can be observed for a relatively long time after a patient's recovery from sepsis.
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Shankar-Hari M, Phillips GS, Levy ML, Seymour CW, Liu VX, Deutschman CS, Angus DC, Rubenfeld GD, Singer M. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:775-87. [PMID: 26903336 PMCID: PMC4910392 DOI: 10.1001/jama.2016.0289] [Citation(s) in RCA: 1376] [Impact Index Per Article: 172.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Septic shock currently refers to a state of acute circulatory failure associated with infection. Emerging biological insights and reported variation in epidemiology challenge the validity of this definition. OBJECTIVE To develop a new definition and clinical criteria for identifying septic shock in adults. DESIGN, SETTING, AND PARTICIPANTS The Society of Critical Care Medicine and the European Society of Intensive Care Medicine convened a task force (19 participants) to revise current sepsis/septic shock definitions. Three sets of studies were conducted: (1) a systematic review and meta-analysis of observational studies in adults published between January 1, 1992, and December 25, 2015, to determine clinical criteria currently reported to identify septic shock and inform the Delphi process; (2) a Delphi study among the task force comprising 3 surveys and discussions of results from the systematic review, surveys, and cohort studies to achieve consensus on a new septic shock definition and clinical criteria; and (3) cohort studies to test variables identified by the Delphi process using Surviving Sepsis Campaign (SSC) (2005-2010; n = 28,150), University of Pittsburgh Medical Center (UPMC) (2010-2012; n = 1,309,025), and Kaiser Permanente Northern California (KPNC) (2009-2013; n = 1,847,165) electronic health record (EHR) data sets. MAIN OUTCOMES AND MEASURES Evidence for and agreement on septic shock definitions and criteria. RESULTS The systematic review identified 44 studies reporting septic shock outcomes (total of 166,479 patients) from a total of 92 sepsis epidemiology studies reporting different cutoffs and combinations for blood pressure (BP), fluid resuscitation, vasopressors, serum lactate level, and base deficit to identify septic shock. The septic shock-associated crude mortality was 46.5% (95% CI, 42.7%-50.3%), with significant between-study statistical heterogeneity (I2 = 99.5%; τ2 = 182.5; P < .001). The Delphi process identified hypotension, serum lactate level, and vasopressor therapy as variables to test using cohort studies. Based on these 3 variables alone or in combination, 6 patient groups were generated. Examination of the SSC database demonstrated that the patient group requiring vasopressors to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L (18 mg/dL) after fluid resuscitation had a significantly higher mortality (42.3% [95% CI, 41.2%-43.3%]) in risk-adjusted comparisons with the other 5 groups derived using either serum lactate level greater than 2 mmol/L alone or combinations of hypotension, vasopressors, and serum lactate level 2 mmol/L or lower. These findings were validated in the UPMC and KPNC data sets. CONCLUSIONS AND RELEVANCE Based on a consensus process using results from a systematic review, surveys, and cohort studies, septic shock is defined as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone. Adult patients with septic shock can be identified using the clinical criteria of hypotension requiring vasopressor therapy to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L after adequate fluid resuscitation.
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Affiliation(s)
- Manu Shankar-Hari
- Division of Asthma, Allergy, and Lung Biology, King's College London, London, United Kingdom2Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE17EH, United Kingdom
| | - Gary S Phillips
- The Ohio State University College of Medicine, Department of Biomedical Informatics, Center for Biostatistics, Columbus
| | - Mitchell L Levy
- Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island
| | - Christopher W Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vincent X Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Clifford S Deutschman
- Department of Pediatrics, Hofstra-North Shore-Long Island Jewish-Hofstra School of Medicine, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York8Department of Molecular Medicine, Hofstra-North Shore-Long Island Jewish-Hofstra Sch
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania10Associate Editor, JAMA
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada12Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom
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Hong DY, Kim JW, Paik JH, Jung HM, Baek KJ, Park SO, Lee KR. Value of plasma neutrophil gelatinase-associated lipocalin in predicting the mortality of patients with sepsis at the emergency department. Clin Chim Acta 2015; 452:177-81. [PMID: 26626454 DOI: 10.1016/j.cca.2015.11.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/22/2015] [Accepted: 11/24/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sepsis is a major cause of morbidity and mortality in the emergency department. This study aimed to evaluate the assessment of severity of sepsis by and prognostic value of plasma neutrophil gelatinase-associated lipocalin (NGAL) compared with other widely used biological markers of inflammation in patients with sepsis. METHODS NGAL, procalcitonin, and C-reactive protein values were measured in 470 patients with suspected sepsis, and the Mortality in Emergency Department Sepsis (MEDS) score was obtained for all enrolled subjects, who were followed for up to 28days. RESULTS The median plasma NGAL value was increased with sepsis severity according to the MEDS score. The plasma NGAL value was higher in nonsurvivors than in survivors. The area under the receiver operating characteristic curve of NGAL (0.797) was greater than that of procalcitonin (0.599) and MEDS score (0.774) in predicting 28-day hospital mortality. Multivariable logistic regression found that the plasma NGAL value was an independent predictor for hospital mortality in patients with sepsis. The plasma NGAL values were positively correlated with C-reactive protein and procalcitonin levels, and MEDS scores. CONCLUSIONS Plasma NGAL is a valuable biological marker in the assessment of severity and prediction of prognosis of patients with sepsis in the emergency department.
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Affiliation(s)
- Dae Young Hong
- Department of Emergency Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jong Won Kim
- Department of Emergency Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jin Hui Paik
- Department of Emergency Medicine, College of Medicine, Inha University, Incheon, Republic of Korea
| | - Hyun Min Jung
- Department of Emergency Medicine, College of Medicine, Inha University, Incheon, Republic of Korea
| | - Kwang Je Baek
- Department of Emergency Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Sang O Park
- Department of Emergency Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Kyeong Ryong Lee
- Department of Emergency Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea.
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Edman-Wallér J, Ljungström L, Jacobsson G, Andersson R, Werner M. Systemic symptoms predict presence or development of severe sepsis and septic shock. Infect Dis (Lond) 2015; 48:209-14. [PMID: 26492354 DOI: 10.3109/23744235.2015.1104719] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Severe sepsis is a major cause of mortality and morbidity globally. As the time to adequate treatment is directly linked to outcome, early recognition is of critical importance. Early, accessible markers for severe sepsis are desirable. The systemic inflammatory response in sepsis leads to changes in vital signs and biomarkers and to symptoms unrelated to the focus of infection. This study investigated whether the occurrence of any of six systemic symptoms could predict severe sepsis in a cohort of patients admitted to hospital for suspected bacterial infections. METHODS A retrospective, consecutive study was conducted. All adult patients admitted during 1 month to a 550-bed secondary care hospital in western Sweden and given intravenous antibiotics for suspected community-acquired infection were included (n = 289). Symptoms (fever/chills, muscle weakness, localised pain, dyspnea, altered mental status and gastrointestinal symptoms) were registered along with age, sex, vital signs and laboratory values. Patients who fulfilled criteria of severe sepsis within 48 h were compared with patients who did not. Odds ratios for severe sepsis were calculated, adjusted for age, sex and comorbidities. RESULTS Criteria for severe sepsis were fulfilled by 90/289 patients (31.1%). Altered mental status (OR = 4.29, 95% CI = 2.03-9.08), dyspnea (OR = 2.92, 95% CI = 1.69-5.02), gastrointestinal symptoms (OR = 2.31, 95% CI = 1.14-4.69) and muscle weakness (OR = 2.24, 95% CI = 1.06-4.75) were more common in patients who had or later developed severe sepsis. CONCLUSIONS Systemic symptoms in combination with other signs of infection should be considered warning signs of severe sepsis.
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Affiliation(s)
- Jon Edman-Wallér
- a Department for Infectious Diseases , Södra Älvsborgs Sjukhus , Borås , Sweden
| | - Lars Ljungström
- b Department for Infectious Diseases , Skaraborgs Sjukhus , Skövde , Sweden
| | - Gunnar Jacobsson
- b Department for Infectious Diseases , Skaraborgs Sjukhus , Skövde , Sweden
| | - Rune Andersson
- c Department for Infectious Diseases , Institute of Biomedicine, University of Gothenburg , Sweden
| | - Maria Werner
- a Department for Infectious Diseases , Södra Älvsborgs Sjukhus , Borås , Sweden
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Prognostic value of B-type natriuretic peptide with the sequential organ failure assessment score in septic shock. Am J Med Sci 2015; 349:287-91. [PMID: 25651369 DOI: 10.1097/maj.0000000000000422] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the prognostic value of B-type natriuretic peptide (BNP) in combination with the sequential organ failure assessment (SOFA) score in patients with septic shock at the time of emergency department (ED). METHODS Study subjects included all consecutive patients with septic shock who were treated with resuscitation bundle therapy between January 2010 and July 2012. SOFA scores and BNP were measured at ED recognition. The primary outcome was 28-day mortality. The area under the receiver operating characteristic curve was used to compare the predictive ability of SOFA score alone and in combination with BNP. RESULTS A total of 290 patients with septic shock admitted to ED were included. The BNP and SOFA score were higher in nonsurvival group compared with survival group (1,156.0 versus 469.1 pg/mL, P < 0.01; 9.9 versus 8.0, P < 0.01). In the receiver operating characteristic curves for predicting 28-day mortality, the area under the curves of SOFA score combined with BNP was 0.728 (95% confidence interval [CI]: 0.658-0.798) and SOFA score alone was 0.682 (95% CI: 0.610-0.755). Although the predictive ability of SOFA with BNP was statistically higher than that of SOFA alone (P = 0.02), it could not increase prognostic accuracy clinically significantly. SOFA with BNP was an independent predictor of 28-day mortality (odds ratio: 1.40, 95% CI: 1.15-1.71). CONCLUSIONS The combination of SOFA with BNP at the time of ED presentation may provide superior prognostic accuracy to the patients with septic shock. However, further studies need to validate the prognostic usefulness of SOFA with BNP.
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Gao S, Yang Y, Fu Y, Guo W, Liu G. Diagnostic and prognostic value of myeloid-related protein complex 8/14 for sepsis. Am J Emerg Med 2015. [PMID: 26206243 DOI: 10.1016/j.ajem.2015.06.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The objective of this study is to evaluate the diagnostic and prognostic value of myeloid-related protein complex 8/14 (MRP8/14) in septic patients in intensive care units. METHODS Fifty-three cases of healthy people, 72 cases of systemic inflammatory response syndrome patients, 74 cases of sepsis patients, 78 cases of severe sepsis patients, and 76 cases of septic shock patients were enrolled in our hospital. Serum MRP8/14 was detected by enzyme-linked immunosorbent assay, and Mortality in Emergency Department Sepsis (MEDS) score was calculated at enrollment. The receiver operating characteristic curve was used to analyze the diagnostic value of MRP8/14 for sepsis. The prognostic values of MRP8/14 were compared with MEDS score. A 28-day follow-up was performed for all patients. RESULTS Serum MRP8/14 level of control group, systemic inflammatory response syndrome group, sepsis group, severe sepsis group, and septic shock group was (834.135 ± 251.662), (2343.213 ± 901.850), (3163.617 ± 912.821), (3941.326 ± 850.490), and (4131.326 ± 950.439) ng/mL, respectively. Myeloid-related protein complex 8/14 level increased with sepsis severity. The area under the receiver operating characteristic curves of MRP8/14 for sepsis was 0.901 (95% confidence interval, 0.852-0.942).The area under the receiver operating characteristic curves of MRP8/14 was greater than that of MEDS score in predicting 28-day mortality. Serum MRP8/14 level was significantly higher in nonsurvivors than survivors at 28 days' follow-up. In addition, the level of MRP8/14 was much higher in septic patients with acute kidney injury (AKI) than those without AKI. CONCLUSIONS Myeloid-related protein complex 8/14 is valuable for diagnosis and prognostication of sepsis and septic patients with AKI in the intensive care unit.
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Affiliation(s)
- Shanglan Gao
- Department of Critical Care Medicine, the Central Hospital of Xinxiang City, Xinxiang, China.
| | - Yan Yang
- Department of Critical Care Medicine, the Central Hospital of Xinxiang City, Xinxiang, China
| | - Yun Fu
- Department of Critical Care Medicine, the Central Hospital of Xinxiang City, Xinxiang, China
| | - Weidong Guo
- Department of Critical Care Medicine, the Central Hospital of Xinxiang City, Xinxiang, China
| | - Guowei Liu
- Department of Critical Care Medicine, the Central Hospital of Xinxiang City, Xinxiang, China
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Henriksen DP, Pottegård A, Laursen CB, Jensen TG, Hallas J, Pedersen C, Lassen AT. Risk factors for hospitalization due to community-acquired sepsis - a population-based case-control study. PLoS One 2015; 10:e0124838. [PMID: 25898024 PMCID: PMC4405362 DOI: 10.1371/journal.pone.0124838] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 03/17/2015] [Indexed: 01/20/2023] Open
Abstract
Background The aim of the study was to estimate risk factors for hospitalization due to sepsis and to determine whether these risk factors vary by age and gender. Methods We performed a population-based case-control study of all adult patients admitted to a medical ED from September 2010 to August 2011. Controls were sampled within the hospital catchment-area. All potential cases were manually validated using a structured protocol. Vital signs and laboratory values measured at arrival were registered to define systemic inflammatory response syndrome and organ dysfunction. Multivariable logistic regression was used to elucidate which predefined risk factors were associated with an increased or decreased risk hospitalization due to sepsis. Results A total of 1713 patients were admitted with sepsis of any severity. The median age was 72 years (interquartile range: 57–81 years) and 793 (46.3%) were male. 621 (36.3%) patients were admitted with sepsis, 1071 (62.5%) with severe sepsis and 21 (1.2%) with septic shock. Episodes with sepsis of any severity were associated with older age (85+ years adjusted OR 6.02 [95%CI: 5.09–7.12]), immunosuppression (4.41 [3.83–5.09]), alcoholism-related conditions (2.90 [2.41–3.50]), and certain comorbidities: psychotic disorder (1.90 [1.58–2.27]), neurological (1.98 [1.73–2.26]), respiratory (3.58 [3.16–4.06]), cardiovascular (1.62 [1.41–1.85]), diabetes (1.82 [1.57–2.12]), cancer (1.44 [1.22–1.68]), gastrointestinal (1.71 [1.44–2.05]) and renal (1.46 [1.13–1.89]). The strength of the observed associations for comorbid factors was strongest among younger individuals. Conclusions Hospitalization due to sepsis of any severity was associated with several independent risk factors, including age and comorbid factors.
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Affiliation(s)
| | - Anton Pottegård
- Clinical Pharmacology, Department of Public Health, University of Southern Denmark, DK-5000 Odense C, Denmark
| | - Christian B. Laursen
- Department of Respiratory Medicine, Odense University Hospital, DK-5000 Odense C, Denmark
| | - Thøger Gorm Jensen
- Department of Clinical Microbiology, Odense University Hospital, DK-5000 Odense C, Denmark
| | - Jesper Hallas
- Clinical Pharmacology, Department of Public Health, University of Southern Denmark, DK-5000 Odense C, Denmark
- Department of Clinical Chemistry & Pharmacology, Odense University Hospital, DK-5000 Odense C, Denmark
| | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital, DK-5000 Odense C, Denmark
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Hu Z, Gu Z, Sun M, Zhang K, Gao P, Yang Q, Yuan Y. Ursolic acid improves survival and attenuates lung injury in septic rats induced by cecal ligation and puncture. J Surg Res 2015; 194:528-536. [PMID: 25454976 DOI: 10.1016/j.jss.2014.10.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/16/2014] [Accepted: 10/17/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Sepsis is characterized as a systemic inflammatory response syndrome during infection, which can result in multiple organ dysfunction and death. Ursolic acid (UA), a pentacyclic triterpene acid, has been reported to have potent anti-inflammatory and antioxidant properties. The aim of this study was to detect the possible protective effects of UA on sepsis-evoked acute lung injury. MATERIALS AND METHODS A rat model of sepsis induced by cecal ligation and puncture (CLP) was used. Rats were injected intraperitoneally with UA (10 mg/kg) after CLP, and then the survival was determined twice a day for 4 d. The protective effects of UA on CLP-induced acute lung injury were assayed at 24 h after CLP. RESULTS The results revealed that UA treatment markedly improved the survival of septic rats, and attenuated CLP-induced lung injury, including reduction of lung wet/dry weight ratio, infiltration of leukocytes and proteins, myeloperoxidase activity, and malondialdehyde content. In addition, UA significantly decreased the serum levels of tumor necrosis factor-α, interleukin-6, and interleukin-1β, inhibited the expression of inducible nitric oxide synthase and cyclooxygenase-2 in the lung, which are involved in the productions of nitric oxide and prostaglandin E2. CONCLUSIONS These findings indicate that UA exerts protective effects on CLP-induced septic rats. UA may be a potential therapeutic agent against sepsis.
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Affiliation(s)
- Zhansheng Hu
- Department of Critical Care Medicine, The First Affiliated Hospital of Liaoning Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Zhilong Gu
- Department of Critical Care Medicine, The First Affiliated Hospital of Liaoning Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Meina Sun
- Department of Critical Care Medicine, Graduate School of Liaoning Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Ke Zhang
- Department of Critical Care Medicine, Graduate School of Liaoning Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Penghui Gao
- Department of Critical Care Medicine, Graduate School of Liaoning Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Qinwu Yang
- Department of Critical Care Medicine, Graduate School of Liaoning Medical University, Jinzhou, Liaoning, People's Republic of China
| | - Yuan Yuan
- Department of Pharmacy, Jinzhou Central Hospital, Jinzhou, Liaoning, People's Republic of China.
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Rodrigo C, Bewick T, Sheppard C, Greenwood S, Mckeever TM, Trotter CL, Slack M, George R, Lim WS. Impact of infant 13-valent pneumococcal conjugate vaccine on serotypes in adult pneumonia. Eur Respir J 2015; 45:1632-41. [PMID: 25792633 DOI: 10.1183/09031936.00183614] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 12/16/2014] [Indexed: 11/05/2022]
Abstract
Infant 13-valent pneumococcal conjugate vaccination (PCV13) was introduced to the UK in 2010. Its impact on serotypes implicated in adult non-bacteraemic pneumococcal pneumonia is not known. Beginning in 2008, a 5-year prospective cohort study of adults admitted to hospital with community-acquired pneumonia (CAP) was conducted. Pneumococcal serotype was established using a validated multiplex immunoassay (Bio-Plex; Bio-Rad, Hercules, CA, USA). The overall incidence for hospitalised CAP and pneumococcal CAP was 79.9 (95% CI 76.6-83.3) and 23.4 (95% CI 21.6-25.3) per 100,000 population, respectively. A decline in CAP (incidence rate ratio (IRR) per year 0.96, 95% CI 0.94-0.99; p=0.016) and pneumococcal CAP (IRR per year 0.84, 95% CI 0.80-0.89; p<0.001) was observed over the 5-year period of the study. Between the pre- and post-PCV13 periods of the study, the incidence of CAP due to serotypes included in the PCV7 declined by 88% (IRR 0.12, 95% CI 0.08-0.20; p<0.001), and CAP due to the additional 6 serotypes in PCV13 declined by 30% (IRR 0.70, 95% CI 0.51-0.96; p=0.024). Incidence of adult pneumococcal pneumonia declined over the last 5 years, with serotypes included in PCV13 declining post-PCV13 introduction, indicating early herd protection effects from PCV13 infant vaccination on adult non-bacteraemic disease. These effects may accrue over the coming years with implications for national pneumococcal vaccination policies in adults.
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Affiliation(s)
- Chamira Rodrigo
- Dept of Respiratory Medicine, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Thomas Bewick
- Dept of Respiratory Medicine, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Carmen Sheppard
- Respiratory and Vaccine Preventable Bacteria Reference Unit, Public Health England, Microbiology Services Division, London, UK
| | - Sonia Greenwood
- Dept of Respiratory Medicine, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tricia M Mckeever
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Caroline L Trotter
- Disease Dynamics Unit, Dept of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Mary Slack
- Respiratory and Vaccine Preventable Bacteria Reference Unit, Public Health England, Microbiology Services Division, London, UK
| | - Robert George
- Respiratory and Vaccine Preventable Bacteria Reference Unit, Public Health England, Microbiology Services Division, London, UK
| | - Wei Shen Lim
- Dept of Respiratory Medicine, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Ballester JCA, Ballester F, Sánchez AG, Quilis AA, Rubio EC, Otero CP. Epidemiology of Sepsis in the Valencian Community (Spain), 1995–2004. Infect Control Hosp Epidemiol 2015; 29:630-4. [DOI: 10.1086/589583] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To study the incidence of sepsis in the Valencian Community (Spain) during a period of 10 years (1995–2004).Methods.We downloaded data on discharge diagnoses of septicemia in all 26 public hospitals in the Valencian Community during the 10-year study period, as well as the additional discharge diagnoses of each patient.Results.We identified 33,767 cases of sepsis during the study period. The age-standardized incidence rates among men increased from 64.11 (95% confidence interval [CI], 60.37–67.85) cases per 100,000 population in 1995 to 114.02 (95% CI, 109.02–118.50) cases per 100,000 population in 2004 (P < .001), and those among women increased from 45.08 (95% CI, 42.01–48.15) cases per 100,000 population in 1995 to 83.62 (95% CI, 79.85–87.39) cases per 100,000 population in 2004 (P < .001). Gram-negative bacteria were the most frequently involved microorganisms (in 21.4% of cases), and there was a significant increase in the number of sepsis cases caused by these organisms from 1999 onward. The mortality rate was approximately 42.5% among patients hospitalized for sepsis, and mortality was associated with organ failure. In addition, mortality was associated with the microorganism responsible not being known, with infection due to fungi, and with polymicrobial sepsis.Conclusions.The rates of hospitalization both for sepsis overall and for severe sepsis in the Valencian Community (Spain) are lower than those in other countries but are increasing, by 5% each year. The increase in the number of cases in which gram-negative bacteria are the cause of sepsis is notable.
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Wang M, Zhang Q, Zhao X, Dong G, Li C. Diagnostic and prognostic value of neutrophil gelatinase-associated lipocalin, matrix metalloproteinase-9, and tissue inhibitor of matrix metalloproteinases-1 for sepsis in the Emergency Department: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:634. [PMID: 25407832 PMCID: PMC4258267 DOI: 10.1186/s13054-014-0634-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 11/03/2014] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate the early diagnostic, risk stratification and prognostic value of neutrophil gelatinase-associated lipocalin (NGAL), matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of matrix metalloproteinases-1 (TIMP-1), compared with procalcitonin (PCT) and the Mortality in Emergency Department Sepsis (MEDS) score in septic patients in the emergency department (ED). METHODS In total, 480 consecutive adult patients were enrolled in this study. They fulfilled the systemic inflammatory response syndrome (SIRS) criteria and were admitted to the ED of Beijing Chaoyang Hospital from February 2013 to August 2013. A total of 40 healthy controls comprised the control group. The patients were classified into four groups: SIRS, sepsis, severe sepsis, and septic shock. Serum NGAL, MMP-9, TIMP-1 and PCT were measured, and MEDS score was calculated at enrollment. The prognostic values of NGAL, MMP-9 and TIMP-1 were compared with PCT and MEDS score. A 28-day follow-up was performed for all patients. RESULTS The median levels of serum NGAL and TIMP-1 increased with sepsis severity. The areas under the receiver operating characteristic (AUC) curves of NGAL or TIMP-1 were greater than those of PCT and MEDS score in diagnosing and predicting 28-day mortality, and the AUC of a combination of NGAL and MEDS score or TIMP-1 and MEDS score was more significant. Serum NGAL, MMP-9 and TIMP-1 levels were significantly higher in non-survivors than survivors at 28 days' follow-up. In addition, the level of NGAL was much higher in septic patients with acute kidney injury (AKI) than those without AKI. NGAL, TIMP-1, MMP-9 and MEDS score were found to be independent predictors of 28-day mortality in septic patients. The levels of serum NGAL and TIMP-1 were positively correlated with PCT and MEDS score in every septic group. CONCLUSIONS NGAL and TIMP-1 are valuable for the risk stratification, early diagnosis and prognostication of sepsis in the ED. NGAL is also a valuable biomarker for prognosis of septic patients with AKI in the ED.
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Affiliation(s)
- Miaomiao Wang
- Emergency Department, Beijing Chao-yang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Beijing, Chao-yang District, 100020, China.
| | - Qian Zhang
- Emergency Department, Beijing Chao-yang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Beijing, Chao-yang District, 100020, China.
| | - Xin Zhao
- Emergency Department, Beijing Chao-yang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Beijing, Chao-yang District, 100020, China.
| | - Guijuan Dong
- Emergency Department, Beijing Chao-yang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Beijing, Chao-yang District, 100020, China.
| | - Chunsheng Li
- Emergency Department, Beijing Chao-yang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Beijing, Chao-yang District, 100020, China.
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Guirgis FW, Williams DJ, Kalynych CJ, Hardy ME, Jones AE, Dodani S, Wears RL. End-tidal carbon dioxide as a goal of early sepsis therapy. Am J Emerg Med 2014; 32:1351-6. [DOI: 10.1016/j.ajem.2014.08.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 08/12/2014] [Accepted: 08/14/2014] [Indexed: 12/01/2022] Open
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Macdonald SPJ, Stone SF, Neil CL, van Eeden PE, Fatovich DM, Arendts G, Brown SGA. Sustained elevation of resistin, NGAL and IL-8 are associated with severe sepsis/septic shock in the emergency department. PLoS One 2014; 9:e110678. [PMID: 25343379 PMCID: PMC4208806 DOI: 10.1371/journal.pone.0110678] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/28/2014] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To identify biomarkers which distinguish severe sepsis/septic shock from uncomplicated sepsis in the Emergency Department (ED). METHODS Patients with sepsis underwent serial blood sampling, including arrival in the ED and up to three subsequent time points over the first 24 hours. Messenger RNA (mRNA) levels of 13 genes representing arms of the innate immune response, organ dysfunction or shock were measured in peripheral blood leucocytes using quantitative PCR, and compared with healthy controls. Serum protein concentrations of targets differentially expressed between uncomplicated sepsis and severe sepsis/septic shock were then measured at each time point and compared between the two patient groups. RESULTS Of 27 participants (median age 66 years, (IQR 35, 78)), 10 had uncomplicated sepsis and 17 had sepsis with organ failure (14 septic shock; 3 had other sepsis-related organ failures). At the time of first sample collection in the ED, gene expression of Interleukin (IL)-10 and Neutrophil Gelatinase Associated Lipocalin (NGAL) were significantly higher in severe sepsis than uncomplicated sepsis. Expression did not significantly change over time for any target gene. Serum concentrations of IL-6, IL-8, IL-10, NGAL and Resistin were significantly higher in severe sepsis than uncomplicated sepsis at the time of first sample collection in the ED, but only IL-8, NGAL and Resistin were consistently higher in severe sepsis compared to uncomplicated sepsis at all time points up to 24 h after presentation. CONCLUSIONS These mediators, produced by both damaged tissues and circulating leukocytes, may have important roles in the development of severe sepsis. Further work will determine whether they have any value, in addition to clinical risk parameters, for the early identification of patients that will subsequently deteriorate and/or have a higher risk of death.
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Affiliation(s)
- Stephen P. J. Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
- Emergency Department, Armadale Health Service, Perth, Australia
| | - Shelley F. Stone
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
- * E-mail:
| | - Claire L. Neil
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
| | - Pauline E. van Eeden
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
| | - Daniel M. Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
| | - Simon G. A. Brown
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
- Emergency Department, Royal Perth Hospital, Perth, Australia
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Green RS, Gorman SK. Emergency department antimicrobial considerations in severe sepsis. Emerg Med Clin North Am 2014; 32:835-49. [PMID: 25441038 DOI: 10.1016/j.emc.2014.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Severe sepsis and septic shock are common problems in the emergency department patient population and require expert clinical skill by members of the emergency department team to maximize optimal patient outcomes. Although various guidelines have been developed for the management of these patients, issues around antimicrobial-related considerations in critically ill patients require further evidence-based attention. In this review article, important factors related to patient illness, microorganism, timing of antimicrobial administration, and source control are discussed.
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Affiliation(s)
- Robert S Green
- Division of Critical Care Medicine, Department of Anesthesia, Faculty of Medicine, Trauma Nova Scotia, Dalhousie University, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada; Department of Emergency Medicine, Faculty of Medicine, Trauma Nova Scotia, Dalhousie University, Room 377 Bethune Building, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada.
| | - Sean K Gorman
- Clinical Quality & Research, Critical Care, Pharmacy Services, Interior Health Authority, Faculty of Pharmaceutical Sciences, The University of British Columbia, #200-1835 Gordon Drive, Kelowna, British Columbia V1Y3H5, Canada
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Brown T, Ghelani-Allen A, Yeung D, Nguyen HB. Comparative effectiveness of physician diagnosis and guideline definitions in identifying sepsis patients in the emergency department. J Crit Care 2014; 30:71-7. [PMID: 25241088 DOI: 10.1016/j.jcrc.2014.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/23/2014] [Accepted: 08/17/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of our study was to compare the agreement of emergency physician diagnoses relative to the 1991 American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) and 2001 ACCP/SCCM/European Society of Intensive Care Medicine/American Thoracic Society/Surgical Infection Society internationally accepted definitions of sepsis, severe sepsis, and septic shock. MATERIALS AND METHODS This study was an observational cohort study of adult patients presenting to the emergency department (ED) with a chief complaint suggestive of infection over a 6-week period, during a daily enrollment schedule from 7:00 am to 10:00 pm. Patients were categorized as having "no sepsis," "sepsis," "severe sepsis," or "septic shock" based on ED physician diagnosis, the 1991 definitions, or 2001 definitions. Agreement statistics were performed. RESULTS A total of 1275 patients were enrolled with age 50.1 ± 21.7 years and 59.1% were female. Among the enrolled patients, 228 were identified as having a source of infection. Temperature, heart rate, and white blood cell count were significantly higher in patients with infection, compared with those without (P < .001). The odds ratio for disagreement between a physician-designated no sepsis diagnosis and the 1991 definitions was 4.47 (95% confidence interval, 3.01-7.53) and 5.96 (3.78-9.46) between the same physician-designated diagnosis and the 2001 definitions. The odds ratios for disagreement of a severe sepsis physician diagnosis in relation to the 1991 and 2001 definitions were 0.06 (0.01-0.19) and 0.06 (0.01-0.20), respectively. The 1991 and 2001 consensus definitions had strong agreement, with κ = 0.86 and 91.2% agreement. No agreement was found between the physician diagnosis and 1991 consensus sepsis definitions (κ = 0.11 and 52.2% agreement) or between the physician diagnosis and the 2001 consensus sepsis definitions (κ = 0.13 and 50.0% agreement). CONCLUSIONS Our study showed that ED physician diagnosis of sepsis may disagree with the international definitions such that severe sepsis is underrecognized by clinical judgment alone. Although these results are limited to a single center, we raise concern that early treatments for these high-risk patients may be delayed due to inaccurate clinical diagnosis. Efforts are needed to increase the application of sepsis guideline definitions to better identify ED patients with this potentially deadly condition.
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Affiliation(s)
- Tyler Brown
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Azmina Ghelani-Allen
- Department of Medicine, Loma Linda University, Loma Linda, CA, USA; Center for Comparative Effectiveness and Outcomes Research, Loma Linda University, Loma Linda, CA, USA
| | - Denise Yeung
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - H Bryant Nguyen
- Department of Medicine, Loma Linda University, Loma Linda, CA, USA; Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA; Center for Comparative Effectiveness and Outcomes Research, Loma Linda University, Loma Linda, CA, USA.
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Admission via the emergency department in relation to mortality of adults hospitalised with community-acquired pneumonia: an analysis of the British Thoracic Society national community-acquired pneumonia audit. Emerg Med J 2014; 32:55-9. [DOI: 10.1136/emermed-2013-203494] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Persistent organ dysfunction after severe sepsis: A systematic review. J Crit Care 2014; 29:320-6. [DOI: 10.1016/j.jcrc.2013.10.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 09/13/2013] [Accepted: 10/24/2013] [Indexed: 12/30/2022]
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Robbins T, Linney L, Nicholson T, Stein A. Characterising the acute medical take: foundation for planning future care. Future Hosp J 2014; 1:28-32. [DOI: 10.7861/futurehosp.14.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nygård ST, Langeland N, Flaatten HK, Fanebust R, Haugen O, Skrede S. Aetiology, antimicrobial therapy and outcome of patients with community acquired severe sepsis: a prospective study in a Norwegian university hospital. BMC Infect Dis 2014; 14:121. [PMID: 24588984 PMCID: PMC3975934 DOI: 10.1186/1471-2334-14-121] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 02/21/2014] [Indexed: 01/20/2023] Open
Abstract
Background Severe sepsis is recognized as an inflammatory response causing organ dysfunction in patients with infection. Antimicrobial therapy is the mainstay of treatment. There is an ongoing demand for local surveillance of sepsis aetiology and monitoring of empirical treatment recommendations. The present study was established to describe the characteristics, quality of handling and outcome of patients with severe sepsis admitted to a Norwegian university hospital. Methods A one year prospective, observational study of adult community acquired case-defined severe sepsis was undertaken. Demographics, focus of infection, microbiological findings, timing and adequacy of empirical antimicrobial agents were recorded. Clinical diagnostic practice was evaluated. Differences between categorical groups were analysed with Pearson’s chi-squared test. Predictors of in-hospital mortality were identified in a multivariate stepwise backward logistic regression model. Results In total 220 patients were identified, yielding an estimated annual incidence of 0.5/1000 inhabitants. The focus of infection was established at admission in 69%. Respiratory tract infection was present in 52%, while genitourinary, soft tissue and abdominal infections each were found in 12-14%. Microbiological aetiology was identified in 61%; most prevalent were Streptococcus pneumoniae, Escherichia coli and Staphylococcus aureus. Independent predictors of in-hospital mortality were malignancy, cardiovascular disease, endocarditis, abdominal infections, undefined microbiological aetiology, delay in administration of empirical antimicrobial agents ≥ 6 hours and use of inadequate antimicrobial agents. In patients ≥ 75 years, antimicrobial therapy was less in compliance with current recommendations and more delayed. Conclusions Community acquired severe sepsis is common. Initial clinical aetiology is often revised. Compliance with recommendations for empirical antimicrobial treatment is lowest in elderly patients. Our results emphasizes that quick identification of correct source of infection, proper sampling for microbiological analyses, and fast administration of adequate antimicrobial agents are crucial points in the management of severe sepsis.
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Affiliation(s)
| | | | | | | | | | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway.
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Theodoro D, Owens PL, Olsen MA, Fraser V. Rates and timing of central venous cannulation among patients with sepsis and respiratory arrest admitted by the emergency department*. Crit Care Med 2014; 42:554-64. [PMID: 24145846 PMCID: PMC3944374 DOI: 10.1097/ccm.0b013e3182a66a2a] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Clinical guidelines for the acute management of emergency department patients with severe sepsis encourage the placement of central venous catheters. Data examining the timing of central venous catheter insertion among critically ill patients admitted from the emergency department are limited. We examined the hypothesis that prompt central venous catheter insertion during hospitalization among patients admitted from the emergency department acts as a surrogate marker for early aggressive care in the management of critically ill patients. DESIGN Retrospective cross-sectional analysis of emergency department visits using 2003-2006 discharge data from California, State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. SETTING General medical or general surgical hospitals (n = 310). PATIENTS Patient hospitalizations beginning in the emergency department with the two most common diagnoses associated with central venous catheter (sepsis and respiratory arrest). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified the occurrence and timing of central venous catheter using International Classification of Diseases, 9th Revision, Clinical Modifications procedure codes. The primary outcomes measured were annual central venous catheters per 1,000 hospitalizations that began in the emergency department occurring emergently (procedure day 0), urgently (procedure day 1-2), or late (procedure day 3 or later). A total of 129,288 hospital discharges had evidence of central venous catheter. In 2003, 5,759 central venous catheters were placed emergently compared with 10,469 in 2006. The rate of emergent central venous catheter/1,000 increased annually from 228 in 2003, 239 in 2004, 257 in 2005, up to 269 in 2006. Urgent and late central venous catheter rates trended down (p < 0.001). In a multilevel model, the odds of undergoing emergent central venous catheter relative to 2003 increased annually: 1.08 (95% CI, 1.03-1.12) in 2004, 1.19 (95% CI, 1.14-1.23) in 2005, and 1.28 (95% CI, 1.23-1.33) in 2006. CONCLUSIONS Central venous catheters are inserted earlier and more frequently among critically ill patients admitted from the emergency department. Earlier central venous catheter insertion may require systematic changes to meet increasing utilization and enhanced mechanisms to measure central venous catheter outcomes.
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Affiliation(s)
- Daniel Theodoro
- 1Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO. 2Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO. 3Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
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Yin Q, Liu B, Chen Y, Zhao Y, Li C. Prognostic value of the International Society on Thrombosis and Haemostasis scoring system for overt disseminated intravascular coagulation in emergency department sepsis. Infection 2014; 42:629-37. [PMID: 24557707 DOI: 10.1007/s15010-014-0600-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 02/03/2014] [Indexed: 01/16/2023]
Abstract
PURPOSE The International Society on Thrombosis and Haemostasis (ISTH) scoring system is a useful tool to diagnosis overt disseminated intravascular coagulation in clinical practice. The main purposes of this study were to investigate the prognostic value of the ISTH score in emergency department (ED) sepsis and compare the ISTH score with two established scoring systems, the Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and two biomarkers,procalcitonin (PCT) and C-reactive protein (CRP). METHODS Septic patients were consecutively enrolled from the ED of Beijing Chaoyang Hospital, China. The ISTH score, SOFA score and APACHE II score were calculated, and PCT and CRP levels were measured on enrollment. A 30-day follow-up was performed. RESULTS A total of 680 septic patients were enrolled in this study. The Cox regression analysis showed that the ISTH score had a greater effect on 30-day mortality prediction, and the receiver operating characteristic curve analysis showed that the accuracy of the ISTH score in prediction of 30-day mortality was better than the SOFA score, the APACHE II score, PCT and CRP. Combination of the ISTH score and CRP can enhance the predictive accuracy of 30-day mortality. CONCLUSION The ISTH score is a valuable scoring system in the prognosis evaluation in ED sepsis.
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Affiliation(s)
- Q Yin
- Emergency Department of Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Beijing, 100020, China
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Horeczko T, Green JP, Panacek EA. Epidemiology of the Systemic Inflammatory Response Syndrome (SIRS) in the emergency department. West J Emerg Med 2014; 15:329-36. [PMID: 24868313 PMCID: PMC4025532 DOI: 10.5811/westjem.2013.9.18064] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/24/2013] [Accepted: 09/30/2013] [Indexed: 11/24/2022] Open
Abstract
Introduction: Consensus guidelines recommend sepsis screening for adults with systemic inflammatory response syndrome (SIRS), but the epidemiology of SIRS among adult emergency department (ED) patients is poorly understood. Recent emphasis on cost-effective, outcomes-based healthcare prompts the evaluation of the performance of large-scale efforts such as sepsis screening. We studied a nationally representative sample to clarify the epidemiology of SIRS in the ED and subsequent category of illness. Methods: This was a retrospective analysis of ED visits by adults from 2007 to 2010 in the National Hospital Ambulatory Medical Care Survey (NHAMCS). We estimated the incidence of SIRS using initial ED vital signs and a Bayesian construct to estimate white blood cell count based on test ordering. We report estimates with Bayesian modified credible intervals (mCIs). Results: We used 103,701 raw patient encounters in NHAMCS to estimate 372,844,465 ED visits over the 4-year period. The moderate estimate of SIRS in the ED was 17.8% (95% mCI: 9.7 to 26%). This yields a national moderate estimate of approximately 16.6 million adult ED visits with SIRS per year. Adults with and without SIRS had similar demographic characteristics, but those with SIRS were more likely to be categorized as emergent in triage (17.7% versus 9.9%, p<0.001), stay longer in the ED (210 minutes versus 153 minutes, p<0.0001), and were more likely to be admitted (31.5% versus 12.5%, p<0.0001). Infection accounted for only 26% of SIRS patients. Traumatic causes of SIRS comprised 10% of presentations; other traditional categories of SIRS were rare. Conclusion: SIRS is very common in the ED. Infectious etiologies make up only a quarter of adult SIRS cases. SIRS may be more useful if modified by clinician judgment when used as a screening test in the rapid identification and assessment of patients with the potential for sepsis. [West J Emerg Med. 2014;15(3):329–336.]
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Affiliation(s)
- Timothy Horeczko
- University of California Los Angeles, Department of Emergency Medicine, Torrance, California
| | - Jeffrey P Green
- University of California Davis, Department of Emergency Medicine, Sacramento, California
| | - Edward A Panacek
- University of California Davis, Department of Emergency Medicine, Sacramento, California
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Ibrahim I. Sepsis: the need for epidemiological studies in the emergency department. J Emerg Med 2013; 46:e93-4. [PMID: 24188602 DOI: 10.1016/j.jemermed.2013.08.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 08/20/2013] [Indexed: 11/24/2022]
Affiliation(s)
- Irwani Ibrahim
- Emergency Medicine Department and Department of Surgery, National University Health Systems, Singapore
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Abstract
OBJECTIVES The epidemiology of the systemic inflammatory response syndrome (SIRS) in children is poorly understood. We sought to determine national estimates of the incidence of pediatric SIRS and its corresponding clinical etiologies presenting to US emergency departments (EDs) using current definitions. METHODS We analyzed ED visits by children younger than 18 years from 2007 to 2010 in the National Hospital Ambulatory Medical Care Survey. We used a Bayesian logical framework of prior probability distributions for white blood cell count result to make minimum, moderate, and maximum estimates for pediatric SIRS. RESULTS Taking the minimum and maximum estimates as modified credible intervals, we report an overall incidence of pediatric SIRS presenting to the ED to be 21.7% (95% modified credible interval, 18.1%-25.4%). The national moderate estimate of pediatric ED visits presenting with SIRS was approximately 6.2 million per year. Children with SIRS and without SIRS had similar baseline characteristics, but SIRS patients were younger (2.9 vs 5.5 years; P < 0.0001), had higher triage acuity (emergent, 9.0 vs 6.3%; P < 0.0001), and were more often admitted (7.0 vs 2.4%; P < 0.0001) than children without SIRS. Based on the moderate estimate, infection was the most common (53%) associated etiology, followed by trauma (10%). Other traditional categories of SIRS were extremely rare. Of note, 35% of children with SIRS did not fall into any of the previously established categories. CONCLUSIONS Pediatric SIRS is common; its associated clinical contexts include potentially dangerous etiologies; many cases of pediatric SIRS can be recognized in triage; and there is significant heterogeneity in the etiology of pediatric SIRS.
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Macdonald SPJ, Brown SGA. Near-infrared spectroscopy in the assessment of suspected sepsis in the emergency department. Emerg Med J 2013; 32:404-8. [PMID: 24154943 DOI: 10.1136/emermed-2013-202956] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 10/06/2013] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIMS The conventional approach to sepsis resuscitation involves early interventions targeting global oxygenation and macro-haemodynamic variables such as central venous and systemic arterial pressures. There is increasing recognition of the importance of microcirculatory changes in shock states, including sepsis, and the relationship of these to outcome. Near-infrared spectroscopy (NIRS) is a recently developed non-invasive technology that measures tissue oxygen saturations (StO2), which may be an indirect measure of the adequacy of the microcirculation. StO2 measurements, therefore, have the potential to identify patients who are at risk of progressing to organ dysfunction and could be used to guide resuscitation. This article reviews the current state of knowledge of NIRS in the setting of sepsis, examining its application, validity and prognostic value. METHODS A search of the relevant literature was performed using Medline, Embase and Cochrane databases, and a qualitative analysis was undertaken. RESULTS A limited number of observational studies, mostly conducted among patients with severe sepsis, have shown that NIRS may correlate with severity of illness but demonstrate a variable relationship between StO2 and outcome. CONCLUSIONS Outstanding questions still remain as to whether NIRS can help to risk-stratify patients with suspected sepsis in the emergency department and the utility of StO2 as a resuscitation target.
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Affiliation(s)
- Stephen P J Macdonald
- Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia Centre for Clinical Research in Emergency Medicine, Western Australian Institute for Medical Research, Perth, Western Australia, Australia Department of Emergency Medicine, Armadale Health Service, Armadale, Western Australia, Australia
| | - Simon G A Brown
- Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia Centre for Clinical Research in Emergency Medicine, Western Australian Institute for Medical Research, Perth, Western Australia, Australia Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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Chiu CW, Li MC, Ko WC, Li CW, Chen PL, Chang CM, Lee NY, Lee CC. Clinical impact of Gram-negative nonfermenters on adults with community-onset bacteremia in the emergency department. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 48:92-100. [PMID: 24060496 DOI: 10.1016/j.jmii.2013.08.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/10/2013] [Accepted: 08/08/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND To determine clinical predictors and impact of Gram-negative nonfermenters (GNNFs) infections among adults with community-onset bacteremia in the emergency department (ED). METHODS Adults with bacteremia visiting the ED from January 2007 to June 2008 were identified retrospectively. Demographic characteristics, underlying illnesses, clinical conditions, bacteremic pathogens, antimicrobial agents, and outcome, were retrieved from chart records. RESULTS After the exclusion of 261 patients with contamination of blood cultures and 24 patients referred from other hospitals, 518 adults with community-onset bacteremia were eligible; their mean age was 65.1 years, with slight predominance of female (262 patients, 50.6%). Of a total of 565 bacteremic isolates, Escherichia coli (228 isolates, 40.4%) and Klebsiella pneumoniae (100, 17.7%) were the major microorganisms. GNNFs caused bacteremia in 31 (6.0%) patients. A higher proportion of inappropriate antibiotic therapy in the ED (87.1% vs. 26.5%, p < 0.001) and higher 28-day crude mortality rate (19.4% vs. 8.4%, p = 0.05) were observed in bacteremic patients caused by GNNFs than those not caused by GNNFs. In further analysis of Kaplan-Meier survival curve, patients with GNNF bacteremia had a worse outcome than those due to other pathogens (p = 0.04). Multivariate analysis revealed that the independent predictors related to GNNF bacteremia included surgery during previous 4 weeks prior to ED arrival [odds ratio (OR), 10.79; 95% confidence interval (CI), 1.84-63.24; p = 0.01], residents in long-term healthcare facilities (OR, 4.62; 95% CI, 2.08-10.29; p < 0.001), and malignancy (OR, 2.24; 95% CI, 1.10-5.40; p = 0.02). CONCLUSION For adults with bacteremia visiting the ED, GNNF is associated with a higher mortality rate and more inappropriate empirical antibiotic therapy in the ED. To allow early administration of empirical antibiotics, several clinical predictors of GNNF infections were identified.
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Affiliation(s)
- Chun-Wei Chiu
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Chia-Wen Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Ming Chang
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
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Yin Q, Liu B, Chen Y, Zhao Y, Li C. The role of soluble thrombomodulin in the risk stratification and prognosis evaluation of septic patients in the emergency department. Thromb Res 2013; 132:471-6. [PMID: 24035044 DOI: 10.1016/j.thromres.2013.08.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/13/2013] [Accepted: 08/14/2013] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Soluble thrombomodulin (sTM) is a sensitive marker of endothelial damage. In this study we investigated the role of sTM in the evaluation of the severity and prognosis of septic patients in the emergency department (ED). MATERIALS AND METHODS A prospective, observational cohort study was performed in the ED of an urban, university hospital. Patients who had suspected infection with two or more criteria of systemic inflammatory response syndrome were consecutively enrolled. sTM, D-Dimer and procalcitonin levels were measured on enrollment, and the Mortality in Emergency Department Sepsis (MEDS) score was calculated. A 30-day follow-up was performed for all patients. RESULTS A total of 372 patients with sepsis, 210 patients with severe sepsis and 98 patients with septic shock were enrolled in this study. According to the disease severity, patients were divided into sepsis subgroup and severe sepsis subgroup (including septic shock). In addition, patients were divided into survivors subgroup and non-survivors subgroup according to the 30-day mortality. Plasma sTM levels in patients with severe sepsis were higher than those with sepsis (P<0.001). Compared with survivors, non-survivors has higher plasma sTM levels (P<0.001). Multivariate logistic regression analysis showed that sTM was an independent predictor of severe sepsis (odds ratio 1.11) and 30-day mortality (odds ratio 1.059). Receiver operating characteristic curve analysis showed that sTM was a useful parameter in prediction of severe sepsis (0.859) and 30-day mortality (0.78). Compared with the MEDS score alone, combination of sTM and the MEDS score can improve the accuracy in prediction of severe sepsis and 30-day mortality. CONCLUSIONS sTM is a valuable biomarker in the risk stratification and prognosis evaluation of ED sepsis. Furthermore, sTM can enhance the ability of the MEDS score in prediction of severe sepsis and 30-day mortality.
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Affiliation(s)
- Qin Yin
- Emergency Department of Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Beijing, 100020, China
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Abstract
BACKGROUND In 1992, the first consensus definition of severe sepsis was published. Subsequent epidemiologic estimates were collected using administrative data, but ongoing discrepancies in the definition of severe sepsis produced large differences in estimates. OBJECTIVES We seek to describe the variations in incidence and mortality of severe sepsis in the United States using four methods of database abstraction. We hypothesized that different methodologies of capturing cases of severe sepsis would result in disparate estimates of incidence and mortality. DESIGN, SETTING, PARTICIPANTS Using a nationally representative sample, four previously published methods (Angus et al, Martin et al, Dombrovskiy et al, and Wang et al) were used to gather cases of severe sepsis over a 6-year period (2004-2009). In addition, the use of new International Statistical Classification of Diseases, 9th Edition (ICD-9), sepsis codes was compared with previous methods. MEASUREMENTS Annual national incidence and in-hospital mortality of severe sepsis. RESULTS The average annual incidence varied by as much as 3.5-fold depending on method used and ranged from 894,013 (300/100,000 population) to 3,110,630 (1,031/100,000) using the methods of Dombrovskiy et al and Wang et al, respectively. Average annual increase in the incidence of severe sepsis was similar (13.0% to 13.3%) across all methods. In-hospital mortality ranged from 14.7% to 29.9% using abstraction methods of Wang et al and Dombrovskiy et al. Using all methods, there was a decrease in in-hospital mortality across the 6-year period (35.2% to 25.6% [Dombrovskiy et al] and 17.8% to 12.1% [Wang et al]). Use of ICD-9 sepsis codes more than doubled over the 6-year period (158,722 - 489,632 [995.92 severe sepsis], 131,719 - 303,615 [785.52 septic shock]). CONCLUSION There is substantial variability in incidence and mortality of severe sepsis depending on the method of database abstraction used. A uniform, consistent method is needed for use in national registries to facilitate accurate assessment of clinical interventions and outcome comparisons between hospitals and regions.
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