Predictors of early progression to severe sepsis or shock among emergency department patients with nonsevere sepsis

Abstract

BackgroundProgression from nonsevere sepsis—i.e., sepsis without organ failure or shock—to severe sepsis or shock among emergency department (ED) patients has been associated with significant mortality. Early recognition in the ED of those who progress to severe sepsis or shock during their hospital course may improve patient outcomes. We sought to identify clinical, demographic, and laboratory parameters that predict progression to severe sepsis, septic shock, or death within 96 h of ED triage among patients with initial presentation of nonsevere sepsis.MethodsThis is a retrospective cohort of patients presenting to a single urban academic ED from November 2008 to October 2010. Patients aged 18 years or older who met criteria for sepsis and had a lactate level measured in the ED were included. Patients were excluded if they had any combination of the following: a systolic blood pressure <90 mmHg upon triage, an initial whole blood lactate level ≥4 mmol/L, or one or more of a set of predefined signs of organ dysfunction upon initial assessment. Disease progression was defined as the development of any combination of the aforementioned conditions, initiation of vasopressors, or death within 96 h of ED presentation. Data on predefined potential predictors of disease progression and outcome measures of disease progression were collected by a query of the electronic medical record and via chart review. Logistic regression was used to assess associations of potential predictor variables with a composite outcome measure of sepsis progression to organ failure, hypotension, or death.ResultsIn this cohort of 582 ED patients with nonsevere sepsis, 108 (18.6 %) experienced disease progression. Initial serum albumin <3.5 mg/dL (OR 4.82; 95 % CI 2.40–9.69; p < 0.01) and a diastolic blood pressure <52 mmHg at ED triage (OR 4.59; 95 % CI 1.57–13.39; p < 0.01) were independently associated with disease progression to severe sepsis or shock within 96 h of ED presentation. There were no deaths within 96 h of ED presentation.ConclusionsIn our patient cohort, serum albumin <3.5 g/dL and an ED triage diastolic blood pressure <52 mmHg independently predict early progression to severe sepsis or shock among ED patients with presumed sepsis.

Increased Time to Initial Antimicrobial Administration Is Associated With Progression to Septic Shock in Severe Sepsis Patients

“…We found that for each hour that passed between ED triage and antimicrobial administration, the risk of progression to septic shock increased by 8.0%, highlighting the importance of early identification and treatment of patients with infection-induced organ dysfunction. The percentage of patients progressing to septic shock in our study was slightly higher than previously reported (6,7,8, 14,15). This is likely because we did not include patients with sepsis, defined as infection + SIRS (ICD-9 diagnosis code 995.91), and because our patients required the presence of an ICD-9 diagnosis code for severe sepsis or septic shock.…”

“…Holder et al investigated predictors of early progression to severe sepsis or septic shock in patients who presented to the ED with sepsis (infection + SIRS) but without signs of organ dysfunction(7). Their cohort excluded patients with severe sepsis at triage – the specific patient group that we desired to study.…”

“…Of patients presenting to the ED with sepsis but without organ dysfunction, progression to severe sepsis or septic shock occurred in 18.6% of patients and independent predictors of early progression to severe sepsis or septic shock included a serum albumin <3.5g/dL or triage diastolic blood pressure <52mmHg (7). Another study found that increased age, female sex, specific comorbid conditions, and vascular access site infections were associated with increased progression to septic shock; however, antimicrobial administration within 24 hours was similar among those who progressed to septic shock and those who did not (8).…”

Serum Albumin Is Independently Associated with Persistent Organ Failure in Acute Pancreatitis

“…Hypoalbuminemia has been proposed as a useful predictor of morbidity and mortality in many different clinical settings such as community-acquired pneumonia [12] and hemodialysis and coronary heart disease [13]. As a negative acute phase protein, initial serum albumin was also independently associated with disease progression to severe sepsis [14] and 30-day mortality in emergency medical patients, irrespective of the cause [15, 16]. …”

Intensive Care Medicine in 2050: toward an intensive care unit without waste

“…Such work will require highly granular adjustment for hospital- and patient-level risk factors. Ultimately, it may yield personalized triage approaches that are based not only on such formative work but also incorporate genetic predispositions [5] and real-time biomarkers [6] to help predict individual risk of clinical decompensation and ultimately “net ICU benefits”.…”