Early identification and management of patients with severe sepsis and septic shock in the emergency department

Prognostic role of albumin, lactate-to-albumin ratio and C-reactive protein-to-albumin ratio in infected patients

INTRODUCTION

The prognostic evaluation of the septic patient has recently been enriched by some predictive indices such as albumin concentration, lactate/albumin ratio (LAR) and C-reactive protein/albumin ratio (CAR). The performance of these indices has been evaluated in septic patients in intensive care, but until now their performance in infected patients in the Emergency Department (ED) has not been evaluated.

AIM

To investigate the potential prognostic role of albumin, LAR and CAR in patients with infection in the ED.

METHODS

Single-centre prospective study performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital (Italy). All patients with infection were enrolled. The study outcome was death within 30 days. The predictive ability of albumin, LAR and CAR was assessed by area under the receiver operating characteristic curves (AUROCs). A multivariate logistic regression model was used to examine the association of the indices with 30-day mortality, with comorbidity, acute urgency and severity of infection as covariates.

RESULTS

The study enrolled 962 patients with an infectious status. The overall 30-day mortality rate was 8.9% (86/962). The AUROC of albumin was 0.831 (95% CI 0.795-868), while for LAR this was 0.773 (CI95% 0.719-0.827) and for CAR 0.718 (CI95% 0.664-0.771). The odds ratio for 30-day mortality for albumin was 3.362 (95% CI 1.904-5.936), for ln(LAR) 2.651 (95% CI 1.646-4.270) and for ln(CAR) 1.739 (95% CI 1.326-2.281).

CONCLUSIONS

All three indices had a good discriminatory ability for the risk of short-term death in patients with infection, indicating their promising use in the ED as well as in the ICU. Further studies are needed to confirm the better performance of albumin compared to LAR and CAR.

Impact of a Coordinated Sepsis Response on Time to Treatment in a Pediatric Emergency Department

BACKGROUND

Sepsis is responsible for 75 000 pediatric hospitalizations annually, with an associated mortality rate estimated between 11% and 19%. Evidence supports the use of timely fluid resuscitation and antibiotics to decrease morbidity and mortality. Our emergency department did not meet the timeliness goals for fluid and antibiotic administration suggested by the 2012 Surviving Sepsis Campaign.

METHODS

In November 2018, we implemented a sepsis response team utilizing a scripted communication tool and a dedicated sepsis supply cart to address timeliness barriers. Performance was evaluated using statistical process control charts. We conducted observations to evaluate adherence to the new process. Our aim was to meet the Surviving Sepsis Campaign's timeliness goals for first fluid and antibiotic administration (20 and 60 minutes, respectively) within 8 months of our intervention.

RESULTS

We observed sustained decreases in mean time to fluids. We also observed a shift in the proportion of patients receiving fluids within 20 minutes. No shifts were observed for timely antibiotic administration.

CONCLUSIONS

The implementation of a dedicated emergency department sepsis response team with designated roles and responsibilities, directed communication, and easily accessible supplies can lead to improvements in the timeliness of fluid administration in the pediatric population.

Development and validation of a nomogram for predicting the prognosis in cancer patients with sepsis

BACKGROUND

To develop a multiparameter-based, easy-to-use nomogram and to predict the prognosis of cancer patients with sepsis in the intensive care unit (ICU).

METHODS

Clinical data on cancer patients with sepsis who met the definition of sepsis 3.0 admitted to the ICU from January 2016 to October 2021 were collected. All patients were randomly entered into the development cohort or validation cohort according to the ratio of 7:3. Patients in the development cohort were divided into the survivors and the nonsurvivors according to the outcome of 28 days in ICU. The independent risk factors of mortality due to sepsis were screened out from the two groups (the survivors and the nonsurvivors) in the development cohort through multivariate logistic regression analysis. A nomogram was established with these independent risk factors, and the calibration plot was subsequently evaluated. Finally, the predictive power of the nomogram was verified in the validation cohort.

RESULTS

A total of 317 cancer patients with sepsis who met the requirements were enrolled in this study, of which 229 entered into the development cohort and 88 entered into the validation cohort. The 28-day mortality rates of the two cohorts were 17.5% and 20.5%, respectively. The neutrophil-to-lymphocyte ratio (NLR) on day 3 (d3), brain natriuretic peptide (BNP) d3, fluid accumulation at 72 hours (h), and Sequential Organ Failure Assessment (SOFA) score were independent risk factors for the 28-day mortality between the survivors and the nonsurvivors in the development cohort. A nomogram was established on the above variables. The calibration plots fit well with the nomogram and had good statistical consistency in predicting the 28-day mortality of sepsis (the C value was 0.938 and 0.968 in the two cohorts, respectively). With a nomogram score of 83.8 points, the diagnostic accuracy was 90.8% vs 92.0%, the sensitivity was 72.5% vs 77.7%, the specificity was 94.7% vs 95.7%, the positive predictive value was 72.3% vs 82.4%, and the negative predictive value was 94.2% vs 94.4% for predicting the 28-day mortality in the development cohort and the validation cohort, respectively.

CONCLUSION

This easy-to-use nomogram based on NLR d3, BNP d3, and fluid accumulation at 72 h and SOFA score provides an accurate 28-day prognosis prediction for cancer patients with sepsis admitted to the ICU.

Helpful Only When Elevated: Initial Serum Lactate in Stable Emergency Department Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration

BACKGROUND

Early emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration.

OBJECTIVE

Our aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis.

METHODS

We conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission > 24 h, intubation, vasoactive medications for > 1 h, or noninvasive positive pressure ventilation for > 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded.

RESULTS

Nine hundred and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97% (95% confidence interval [CI] 94-100%), but a sensitivity of 27% (95% CI 18-37%) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95% CI 6.3-18.3) and 0.8 (95% CI 0.7-0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI 55-76%) and specificity of 66% (95% CI 63-69%), with corresponding positive and negative likelihood ratios of 2.0 (95% CI 1.7-2.3) and 0.5 (95% CI 0.4-0.7).

CONCLUSIONS

High ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration.

IGF-1 may predict the severity and outcome of patients with sepsis and be associated with microRNA-1 level changes

IGF-1 functions as an anti-oxidative stress molecule and some critical patients with sepsis have a lower level of serum IGF-1. However, the association between IGF-1 and the severity or prognosis of sepsis remains unclear. This study aimed to elucidate the relationship between serum IGF-1 levels and the severity and prognosis of sepsis, and the possible mechanism was analyzed. Clinical characteristics of patients with sepsis were recorded and analyzed. Serum IGF-1 levels and micro (mi)RNA-1 levels were tested using radioimmunoassay and reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analysis, respectively. The A549 cell line and HKC cell line were cultured in vitro and exposed to H₂O₂ with or without IGF-1 treatment. Cell death was detected by analyzing cell death markers via ELISA kits, and miRNA-1 levels were detected after H₂O₂ exposure using RT-qPCR analysis. miRNA-1 in cells was upregulated by transfection and IGF-1 mRNA was detected to determine its relationship with miRNA-1. Once again, cell ELISA kits were used to analyze cell death markers after transfection. Serum IGF-1 levels were reduced in patients with sepsis, whereas miRNA-1 levels were higher (P<0.05 vs. healthy control). Patients in the septic shock subgroup or dead patients had the lowest IGF-1 levels and the highest miRNA-1 levels (P<0.05 vs. sepsis and severe sepsis). IGF-1 levels were inversely proportional to the miRNA-1 level. In vitro, IGF-1 reduced the cell death caused by H₂O₂. miRNA-1 transfection effectively increased the sensitivity of cells to H₂O₂ damage by reducing the expression of IGF-1, which was able to prevent cells from injury caused by H₂O₂. The transfection of negative control miRNA did not influence the level of IGF-1 miRNA and the sensitivity to H₂O₂ damage. In conclusion, low IGF-1 levels in patients with sepsis may predict increased severity of the condition and poor prognosis. The possible mechanism is that the excessive miRNA-1 levels reduce IGF-1 levels, resulting in insufficient anti-oxidative action by IGF-1 which increases the injury caused by oxidative stress in patients with sepsis.

Prognostic value of extravascular lung water and its potential role in guiding fluid therapy in septic shock after initial resuscitation

PURPOSES

To explore whether extravascular lung water (EVLW) provides a valuable prognostic tool guiding fluid therapy in septic shock patients after initial resuscitation.

MATERIALS AND METHODS

We performed a retrospective study of septic shock patients who achieved adequate initial fluid resuscitation with extended hemodynamic monitoring, analyzing the prognostic value of EVLW and whether fluid therapy for 24 (T24) or 24-48 hours (T24-48) after initial resuscitation with a recommended value of EVLW yielded a 28-day mortality advantage.

RESULTS

One hundred five patients with septic shock were included in this study, 60 (57.1%) of whom died after 28 days. For 48 hours after initial resuscitation, the daily fluid balance (DFB; T24: 2494 ± 1091 vs 1965 ± 964 mL [P = .011] and T24-48: 2127 ± 783 vs 1588 ± 665 mL [P < .001]) and daily maximum values of the EVLW index (EVLWImax; T24: 13.9 ± 3.7 vs 11.5 ± 3.2 mL/kg [P < .001] and T24-48: 14.4 ± 5.3 vs 12.0 ± 4.4 mL/kg [P < .001]) were significantly higher in nonsurvivors than in survivors. In multivariate regression analysis, the DFB (T24: odds ratio [OR] 1.001 [P = .016] and T24-48: OR 1.001 [P = .008]), EVLWImax (T24: OR 2.158 [P = .002] and T24-48: OR 3.277 [P = .001]), blood lactate (T24: OR 1.368 [P = .021] and T24-48: OR 4.112 [P < .001]), and central venous blood oxygen saturation (T24: OR 0.893 [P = .013] and T24-48: OR 0.780 [P = .004]) were all independently associated with the 28-day mortality. A receiver operating characteristic analysis revealed that area under the curve values of 0.82 (95% confidence interval, 0.74-0.91; P < .001) and 0.90 (95% confidence interval, 0.83-0.96; P < .001) for EVLWImax ≥ 12.5 mL/kg (T24 and T24-48) predicted a 28-day mortality with sensitivities of 88% (80%-96%) and 95% (90%-100%) and specificities of 60% (46%-74%) and 76% (63%-89%).The EVLWImax was correlated with DFB with Spearman ρ values of 0.497 (T24: P < .001) and 0.650 (T24-48: P < .001). Cox survival and regression analyses demonstrated that EVLWImax ≥ 12.5 mL/kg (T24 and T24-48) was associated with higher risk and increased mortality, with adjusted ORs of 4.77 (P < .001) and 10.86 (P < .001).

CONCLUSIONS

A higher EVLW in septic shock patients after initial resuscitation was associated with a more positive fluid balance and increased mortality, which is an independent predictor of the 28-day mortality in septic shock patients after initial resuscitation.

Application strategy of PiCCO in septic shock patients

Septic shock, also known as infectious or toxic shock, is a medical condition caused by severe infection and sepsis. Early identification, timely diagnosis and effective treatments are imperative to prevent this medical condition. The aim of the present study was to examine the application of pulse index continuous cardiac output (PiCCO) technique in the treatment of septic shock patients. Fifty septic shock patients were randomly divided into the conventional detection group (group C, n=25) and the PiCCO detection group (group P, n=25). A central venous catheter and radial artery catheter were placed into the patients of group C and a central venous catheter and PiCCO catheter (through femoral artery) were placed in the patients of group P to detect haemodynamics, which was managed and treated according to early goal-directed therapy (EGDT). PiCCO was applied to monitor and guide the application of fluid resuscitation, vasoconstriction drugs (dopamine) and positive inotropic drugs (dobutamine). The EGDT qualified rate of patients from the two groups at the 6th h of treatment, changes of post-resuscitation relevant parameters [blood lactate level, central venous oxygen saturation (ScvO₂), central venous pressure (CVP), mean arterial pressure (MAP) and urine volume], positive fluid balance quantity and the dosage of dopamine and dobutamine at the 6th, 24th and 48th h were observed. In comparison to group C, group P showed an increase in the EGDT qualified rate and ScvO₂ at the 6th h of treatment while the blood lactate level was decreased. The positive fluid balance quantity at the 6th and 24th h and the dosage of dobutamine were increased while the dosage of dopamine was reduced (P<0.05). There was no statistical significance in terms of the differences of positive fluid balance quantity and the dosage of dopamine and dobutamine in the two groups at the 48th h of treatment (P>0.05). There was also no statistical significance in terms of the differences of CVP, MAP and urine volume in the two groups (P>0.05). In conclusion, under the monitoring and guidance of the PiCCO technique, EGDT treatment should be applied to septic shock patients together with early fluid resuscitation and positive inotropic drugs instead of using only vasoconstriction drug, which cause elevation of blood pressure.

Acute kidney injury in septic patients admitted to emergency clinical room: risk factors and outcome

PURPOSE

Acute kidney injury (AKI) is a common source of morbidity in sepsis. We sought to determine risk factors for AKI, by acute kidney injury network (AKIN) criteria, in septic patients admitted in emergency clinical room (ER).

MATERIALS AND METHODS

Prospective cohort study of 200 patients admitted to the ER of a University Hospital, followed for development of AKI over 5 days.

RESULTS

AKI developed in 144/200 (72 %) patients. In multivariable regression analysis, independent risk factors for AKI included age over 65 years (OR 1.28; 95 % CI 1.12-1.89; p = 0.04), mean blood pressure (MBP) lower than 65 mmHg at moment of admission (OR 1.89; 95 % CI 1.43-2.64, p = 0.003) and diabetes mellitus (OR 1.66; 95 % CI 1.30-3.20; p = 0.012). Mortality rate was 51.4 % in AKI patients compared with 26.8 % for those without AKI (p = 0.002). Septic shock (OR = 1.83, 95 % CI 1.23-2.74, p = 0.007), AKIN 3 (OR = 1.64; 95 % CI 1.19-1.89, p = 0.02), APACHE 2 > 20 (OR 1.92, 95 % CI 1.34-2.02, p = 0.009) and need for dialysis (OR = 1.26, 95 % CI 1.13-1.75, p = 0.03) were identified as independent risk factors for death in multivariable regression analysis.

CONCLUSIONS

AKI severity in septic patients admitted in ER is associated with mortality. Diabetes, age over 65 years, and low MBP are independent risk factors for AKI and deserve further study to prevent AKI and, consequently, decreasing mortality.