Predictors of Patients Who Present to the Emergency Department With Sepsis and Progress to Septic Shock Between 4 and 48 Hours of Emergency Department Arrival*

Capp, Roberta; Horton, Cheryl Lynn; Takhar, Sukhjit S.; Ginde, Adit A.; Peak, David A.; Zane, Richard D.; Marill, Keith A.

doi:10.1097/ccm.0000000000000861

Cited by 44 publications

(38 citation statements)

References 17 publications

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“…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.…”

Section: Discussioncontrasting

confidence: 89%

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

Whiles

Deis

Simpson

2017

Critical Care Medicine

154

101

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Objective To determine if time to initial antimicrobial is associated with progression of severe sepsis to septic shock. Design Retrospective cohort Setting 656 bed urban academic medical center Patients Emergency department patients ≥18 years of age with severe sepsis and/or septic shock and antimicrobial administration within 24 hours. Patients with shock on presentation were excluded. Interventions N/A. Measurements and Main Results We identified 3,929 severe sepsis patients, with overall mortality 12.8%. 984 (25.0%) patients progressed to septic shock. The median time to antimicrobial was 3.77 hours (IQR = 1.96 – 6.42) in those who progressed vs 2.76 hours (IQR = 1.60 – 4.82) in those who did not (p < 0.001). Multivariate logistic regression demonstrated that male sex (OR = 1.18; 95% CI, 1.01–1.36), Charlson Comorbidity Index (OR = 1.18; 95% CI, 1.11–1.27), number of infections (OR = 1.05; 95% CI, 1.02–1.08), and time to first antimicrobial (OR = 1.08; 95% CI, 1.06–1.10) were associated with progression. Each hour until initial antimicrobial administration was associated with a 8.0% increase in progression to septic shock. Additionally, time to broad spectrum antimicrobial was associated with progression (OR = 1.06; 95% CI, 1.05–1.08). Time to initial antimicrobial was also associated with in-hospital mortality (OR = 1.05; 95% CI, 1.03–1.07). Conclusions This study emphasizes the importance of early, broad spectrum antimicrobial administration in severe sepsis patients admitted through the emergency department, as longer time to initial antimicrobial administration is associated with increased progression of severe sepsis to septic shock and increased mortality.

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Section: Discussioncontrasting

confidence: 89%

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

Whiles

Deis

Simpson

2017

Critical Care Medicine

154

101

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“…A 48-h window was selected based on prior studies have found that significant progression and potential decompensation of septic patients in the ED typically occurs by this point [11, 12]. Patients were classified as “needing early escalation” if admitted to a non-ICU level of care from the ED but subsequently upgraded to ICU level within the first 48 h or if they died in the wards within 48 h of admission.…”

Section: Methodsmentioning

confidence: 99%

“…The following 8 variables were considered in the forward selection model-building process: serum lactate ≥4 mmol/L, presence of pneumonia, time to antibiotic administration, nighttime admission, Charlson co-morbidity index, shock index, quantity of fluid administered, and age. These variables were selected based upon prior studies that have shown that these are risk factors for unexpected ICU transfer, significant biological plausibility, or significant findings in the univariate analysis [10–12, 14]. A separate multivariable logistic model was used to determine if unexpected ICU transfer was an independent risk factor for death and included the following four variables: serum lactate ≥4 mmol/L, time to antibiotic administration, volume of fluids resuscitation, and shock index.…”

Section: Methodsmentioning

confidence: 99%

“…However, identification of these patients remains a challenge. Prior research has evaluated general patient characteristics for all-comers admitted from the ED at risk of delayed escalation to the ICU, and this includes tachypnea, sepsis, elevated lactate, non-sustained hypotension, and fever [9–12]. However, risk factors for unexpected decompensation and ICU transfer in patients admitted with severe sepsis have not been specifically examined.…”

Section: Introductionmentioning

confidence: 99%

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Unexpected intensive care transfer of admitted patients with severe sepsis

et al. 2017

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BackgroundPatients with severe sepsis generally respond well to initial therapy administered in the emergency department (ED), but a subset later decompensate and require unexpected transfer to the intensive care unit (ICU). This study aimed to identify clinical factors that can predict patients at increased risk for delayed transfer to the ICU and the association of delayed ICU transfer with mortality.MethodsThis is a nested case-control study in a prospectively collected registry of patients with severe sepsis and septic shock at two EDs. Cases had severe sepsis and unexpected ICU transfer within 48 h of admission from the ED; controls had severe sepsis but remained in a non-ICU level of care. Univariate and multivariate regression analyses were used to identify predictors of unexpected transfer to the ICU, which was the primary outcome. Differences in mortality between these two groups as well as a cohort of patients directly admitted to the ICU were also calculated.ResultsOf the 914 patients in our registry, 358 patients with severe sepsis were admitted from the ED to non-ICU level of care; 84 (23.5%) had unexpected ICU transfer within 48 h. Demographics and baseline co-morbidity burden were similar for patients requiring versus not requiring delayed ICU transfer. In unadjusted analysis, lactate ≥4 mmol/L and infection site were significantly associated with unexpected ICU upgrade. In forward selection multivariate logistic regression analysis, lactate ≥4 mmol/L (OR 2.0, 95% CI 1.03, 3.73; p = 0.041) and night (5 PM to 7 AM) admission (OR 1.9, 95% CI 1.07, 3.33; p = 0.029) were independent predictors of unexpected ICU transfer. Mortality of patients who were not upgraded to the ICU was 8.0%. Patients with unexpected ICU upgrade had similar mortality (25.0%) to those patients with severe sepsis/septic shock (24.6%) who were initially admitted to the ICU, despite less severe indices of illness at presentation.ConclusionsSerum lactate ≥4 mmol/L and nighttime admissions are associated with unexpected ICU transfer in patients with severe sepsis. Mortality among patients with delayed ICU upgrade was similar to that for patients initially admitted directly to the ICU.

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“…A significant proportion (~18%) of ED patients develops shock within the first 72 hours of admission, although many give scant clinical indication of this impending event during the initial 3–4 hours of their evaluation, making it difficult to risk-stratify these patients 4–6. In one study, one-third of patients presenting to the ED with sepsis who developed septic shock during the first 2 days of hospitalisation were not initially admitted to an ICU 6. Importantly, unplanned transfer to a critical care unit following initial admission to a medical ward has been associated with poorer outcomes 7 8…”

Section: Introductionmentioning

confidence: 99%

Use of the low-frequency/high-frequency ratio of heart rate variability to predict short-term deterioration in emergency department patients with sepsis

et al. 2017

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Predictors of Patients Who Present to the Emergency Department With Sepsis and Progress to Septic Shock Between 4 and 48 Hours of Emergency Department Arrival*

Cited by 44 publications

References 17 publications

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

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

Unexpected intensive care transfer of admitted patients with severe sepsis

Use of the low-frequency/high-frequency ratio of heart rate variability to predict short-term deterioration in emergency department patients with sepsis

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