Diagnostic Characteristics of a Clinical Screening Tool in Combination With Measuring Bedside Lactate Level in Emergency Department Patients With Suspected Sepsis

Singer, Adam J.; Taylor, Merry; Domingo, Anna; Ghazipura, Saad; Khorasonchi, Adam; Thode, Henry C.; Shapiro, Nathan I.

doi:10.1111/acem.12444

Cited by 65 publications

(56 citation statements)

References 18 publications

(26 reference statements)

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“…Keywords related to symptom presentation are not included in the existing screening tools for sepsis identification within emergency care [17, 18], which should be reconsidered. However, before this is done, prospective studies evaluating the sensitivity and specificity of these keywords needs to be evaluated.…”

Section: Discussionmentioning

confidence: 99%

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Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis

Wallgren

Bohm

Kurland

2017

Scand J Trauma Resusc Emerg Med

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BackgroundCurrent sepsis screening tools rely on vital parameters which are, however, normal in one third of patients with serious infections. Therefore, there is a need to include other variables than vital parameters to identify septic patients. Our primary aim was to identify and quantify keywords related to the septic patients’ symptom presentation in the prehospital setting. The secondary aims were to compare keywords in relation to in-hospital mortality and the distribution of keywords in relation to age categories, survivors/ deceased and severe/ non-severe sepsis.MethodsA mixed methods analysis using a sequential exploratory design was performed, starting with a content analysis of presentations of septic patients as documented in Emergency Medical Services (EMS) records (n = 80) from 2012, to identify keywords related to sepsis presentation. Thereafter, the identified keywords were quantified among 359 septic patients from 2013. All patients were adults, admitted to Södersjukhuset and discharged with an ICD-10-code (International Classification of Diseases, Tenth Revision) compatible with sepsis.ResultsThe most common keywords related to septic patients’ symptom presentation were: abnormal/ suspected abnormal temperature (64.1.%), pain (38.4%), acute altered mental status (38.2%), weakness of the legs (35.1%), breathing difficulties (30.4%), loss of energy (26.2%) and gastrointestinal symptoms (24.0%). There was an association between keywords and in-hospital mortality. Symptoms varied between age categories, survivors/ deceased and severe/ non-severe sepsis.DiscussionThis is, to the best of our knowledge, the first study exploring the symptom presentation as documented by EMS, of septic patients in the prehospital setting. Keywords related to patients´ symptom presentation recurred in the EMS records of septic patients, so that a pattern was discernible. In addition, certain symptom presentations were associated with increased in-hospital mortalityConclusionsInformation relating to symptom presentation is not included in current sepsis screening tools. We suggest that keywords related to patients´ symptom presentation could be integrated into screening tools and may thus increase the identification of sepsis, and potentially also identify high-risk patients. However, as a first step, the specificity of these keywords, with respect to sepsis, needs to be examined.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-017-0367-z) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

“…The inadequate sensitivity and specificity of the SIRS criteria has been a contributing factor to a recently suggested revision of the sepsis definition [1]. Nevertheless, existing sepsis screening tools are still based mainly on SIRS criteria [17, 18]. …”

Section: Introductionmentioning

confidence: 99%

Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis

Wallgren

Bohm

Kurland

2017

Scand J Trauma Resusc Emerg Med

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“…[16] The use of lactic acid assays in the ED and procalcitonin and c-reactive protein assays in the intensive care unit have been studied as screening modalities to aid in sepsis recognition. [22-24] Management strategies in the ED have focused on time-based bundles created to help direct resuscitation, while inpatient sepsis management strategies have focused on appropriate antibiotic stewardships, lung-protective ventilation strategies and the use of hospital rapid response teams. [9, 16, 25]…”

Section: Discussionmentioning

confidence: 99%

Community-, Healthcare-, and Hospital-Acquired Severe Sepsis Hospitalizations in the University HealthSystem Consortium

Page

Donnelly

Wang

2015

Critical Care Medicine

120

119

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Objectives Severe sepsis poses a major burden on the U.S. healthcare system. Previous epidemiologic studies have not differentiated community-acquired severe sepsis from healthcare-associated severe sepsis or hospital-acquired severe sepsis hospitalizations. We sought to compare and contrast community-acquired severe sepsis, healthcare-associated severe sepsis, and hospital-acquired severe sepsis hospitalizations in a national hospital sample. Setting United States Interventions None Measurements & Main Results Prevalence of community-acquired severe sepsis, healthcare-associated severe sepsis, and hospital-acquired severe sepsis, adjusted hospital mortality, length of hospitalization, length of stay in an ICU, and hospital costs. Among 3,355,753 hospital discharges, there were 307,491 with severe sepsis, including 193,081 (62.8%) community-acquired severe sepsis, 79,581 (25.9%) healthcare-associated severe sepsis, and 34,829 (11.3%) hospital-acquired severe sepsis. Hospital-acquired severe sepsis and healthcare-associated severe sepsis exhibited higher in-hospital mortality than community-acquired severe sepsis (hospital-acquired [19.2%] vs healthcare-associated [12.8%] vs community-acquired [8.6%]). Hospital-acquired severe sepsis had greater resource utilization than both healthcare-associated severe sepsis and community-acquired severe sepsis, with higher median length of hospital stay (hospital acquired [17 d] vs healthcare associated [7 d] vs community-acquired [6 d]), median length of ICU stay (hospital-acquired [8 d] vs healthcare-associated [3 d] vs community-acquired [3 d]), and median hospital costs (hospital-acquired [$38,369] vs healthcare-associated [$8,796] vs community-acquired [$7,024]). Conclusions In this series, severe sepsis hospitalizations included CA-SS (62.8%), HCA-SS (25.9%) and HA-SS (11.3%) cases. HA-SS was associated with both higher mortality and resource utilization than CA-SS and HCA-SS.

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“…Several studies (17,18) found that about one-third to one-half of patients with vasopressor-dependent septic shock did not express lactate on presentation and that lactate remained below 2.0 mmoL L À1 . More recently, Singer et al (19) demonstrated that a lactate level of !2 mmoL L À1 is associated with an increased need for vasopressors (odds ratio [OR] 1.54, 95% CI 1.13-2.12).…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Perfusion Index as a Predictor of Vasopressor Requirement in Patients with Severe Sepsis

Rasmy

Mohamed

Nabil

et al. 2015

Shock

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We evaluated the ability of perfusion index (PI) to predict vasopressor requirement during early resuscitation in patients with severe sepsis. All consecutive patients with clinically suspected severe sepsis as defined by the criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference were included. Perfusion variables included PI, arterial lactate level, central venous oxygen saturation, and the difference between central venous carbon dioxide and arterial carbon dioxide pressures, and were recorded before resuscitation and 6 h thereafter. We enrolled 36 patients with severe sepsis. Twenty-one patients required vasopressors, whereas 15 did not. The cut-off of the PI value for predicting vasopressor requirement was ≤0.3. This cut-off value had a sensitivity of 100% and a specificity of 93%; the area under the curve was 0.96 (95% confidence interval 0.8-0.99, P < 0.0001). The cut-off of the arterial lactate level for predicting vasopressor requirement was ≥1.8 mg dL. This cut-off value had a sensitivity of 82% and a specificity of 80%; the area under the curve was 0.84 (95% confidence interval 0.68-0.94, P < 0.0001). Other perfusion variables failed to predict vasopressor requirement in patients with severe sepsis. We concluded that PI and arterial lactate level are good predictors of vasopressor requirement during early resuscitation in patients with severe sepsis. Further studies are warranted to investigate whether monitoring PI during resuscitation improves the outcome of patients with septic shock.

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Diagnostic Characteristics of a Clinical Screening Tool in Combination With Measuring Bedside Lactate Level in Emergency Department Patients With Suspected Sepsis

Cited by 65 publications

References 18 publications

Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis

Presentations of adult septic patients in the prehospital setting as recorded by emergency medical services: a mixed methods analysis

Community-, Healthcare-, and Hospital-Acquired Severe Sepsis Hospitalizations in the University HealthSystem Consortium

Evaluation of Perfusion Index as a Predictor of Vasopressor Requirement in Patients with Severe Sepsis

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