Disease Progression in Hemodynamically Stable Patients Presenting to the Emergency Department With Sepsis

Abstract

Background Aggressive diagnosis and treatment of patients presenting to the emergency department (ED) with septic shock has been shown to reduce mortality. To enhance the ability to intervene in patients with lesser illness severity, a better understanding of the natural history of the early progression from simple infection to more severe illness is needed. Objectives The objectives were to 1) describe the clinical presentation of ED sepsis, including types of infection and causative microorganisms, and 2) determine the incidence, patient characteristics, and mortality associated with early progression to septic shock among ED patients with infection. Methods This was a multicenter study of adult ED patients with sepsis but no evidence of shock. Multivariable logistic regression was used to identify patient factors for early progression to shock and its association with 30-day mortality. Results Of 472 patients not in shock at ED presentation (systolic blood pressure > 90 mm Hg and lactate < 4 mmol / L), 84 (17.8%) progressed to shock within 72 hours. Independent factors associated with early progression to shock included older age, female sex, hyperthermia, anemia, comorbid lung disease, and vascular access device infection. Early progression to shock (vs. no progression) was associated with higher 30-day mortality (13.1% vs. 3.1%, odds ratio [OR] = 4.72, 95% confidence interval [CI] = 2.01 to 11.1; p ≤ 0.001). Among 379 patients with uncomplicated sepsis (i.e., no evidence of shock or any end-organ dysfunction), 86 (22.7%) progressed to severe sepsis or shock within 72 hours of hospital admission. Conclusions A significant portion of ED patients with less severe sepsis progress to severe sepsis or shock within 72 hours. Additional diagnostic approaches are needed to risk stratify and more effectively treat ED patients with sepsis.

The spectrum and outcome of surgical sepsis in Pietermaritzburg, South Africa

“…In addition to operative management, these patients require aggressive resuscitation and organ support. [5][6][7][8][9][10][11] In the resource-limited environment in low-and middle-income countries (LMICs), the management of SS continues to represent a significant portion of the workload for most general surgeons.…”

Integrative “Omic” Analysis of Experimental Bacteremia Identifies a Metabolic Signature That Distinguishes Human Sepsis from Systemic Inflammatory Response Syndromes

“…The Community-acquired Pneumonia and Sepsis Outcomes Diagnostic (CAPSOD) study was approved by the Institutional Review Boards of the National Center for Genome Resources, Duke University Medical Center, Durham Veterans Affairs Medical Center, and Henry Ford Health Systems and filed at ClinicalTrials.gov (NCT00258869) (8,(11)(12)(13). The Registry of Critical Illness (RoCI) is approved by the Partners Human Research Committee under IRB protocol 2008-P-000495 (14,15).…”

“…We next tested the four-metabolite training model on the RoCI and CAPSOD clinical cohorts, which had similar metabolomic measurements (8,15). Noninfected SIRS and sepsis differentiation of the CAPSOD and RoCI cohorts has been described in detail (8,(11)(12)(13)15). Sepsis included all patients regardless of final outcome (sepsis, severe sepsis, septic shock, and sepsis nonsurvivors).…”

Fluid Volume, Lactate Values, and Mortality in Sepsis Patients with Intermediate Lactate Values

“…We believe that this is an important consideration that should be addressed by future prospective study. Finally, this study did not address clinical changes after index lactate values (e.g., incident hypotension or organ failure) that might have altered lactate values or fluid administration practice independently of our observed variables (14,18,29,41).…”

“…Even those with normal blood pressure and "intermediate" lactate levels (>2.0 and ,4.0 mmol/L) have hospital mortality exceeding 10% (14)(15)(16)(17)(18), and, although their mortality rate is lower, their contribution to hospital deaths is on par with that of patients with the most severe sepsis, because they represent a larger fraction of all patients with sepsis (1,19). Despite this, there are limited data and no established guidelines for treating patients with sepsis with intermediate lactate values (10).…”