Treatment variables associated with outcome in emergency department patients with suspected sepsis

Abstract

Background Early treatment is advocated in the management of patients with suspected sepsis in the emergency department (ED). We sought to understand the association between the ED treatments and outcome in patients admitted with suspected sepsis. The treatments studied were: (i) the time to antibiotics, where time zero is the time the patient was booked in which is also the triage time; (ii) the volume of intravenous fluid (IVF); (iii) mean arterial pressure (MAP) after 2000 ml of IVF and (iv) the final MAP in the ED. Methods We performed a retrospective analysis of the ED database of patients aged ≥ 18 year who met two SIRS criteria or one red flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted between 8th February 2016 and 31st August 2017. The primary outcome measure was all-cause in-hospital mortality. The four treatments stated above were controlled for severity of illness and subject to multivariate logistic regression and Cox proportional-hazard regression to identify independent predictors of mortality. Results Of the 2,066 patients studied 272 (13.2%) died in hospital. The median time to antibiotics was 48 (interquartile range 30–82) minutes. The time to antibiotics was an independent predictor of mortality only in those who developed refractory hypotension (RH); antibiotics administered more than 55 mins after arrival was associated with an odds ratio (OR) for mortality of 2.75 [95% confidence interval (CI) 1.22–6.14]. The number-needed-to-treat was 4. IVF > 2000 ml (95% CI > 500– > 2100), except in RH, and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality. The OR for mortality of IVF > 2,000 ml in non-RH was 1.80 (95% CI 1.15–2.82); Number-needed-to-harm was 14. The OR for morality for a MAP ≤ 66 mmHg after 2000 ml of IVF was 3.42 (95% CI 2.10–5.57). A final MAP < 75 mmHg in the ED was associated with, but not an independent predictor of mortality. An initial systolic blood pressure of < 100 mmHg has a sensitivity of 63.3% and specificity of 88.4% for the development of RH. Conclusion In this study, antibiotics were found to be time-critical in RH. Intravenous fluids > 2000 ml (except in RH) and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality.

Association between admission systemic immune-inflammation index and mortality in critically ill patients with sepsis: a retrospective cohort study based on MIMIC-IV database

“…The emergency department (ED) is often the first medical contact of patients with sepsis [3], but the medical conditions available are often quite limited. Therefore, the rapid screening of septic patients and identification of critically ill patients is a challenge that needs to be urgently addressed.…”

Early combination of albumin with crystalloids administration might be beneficial for the survival of septic patients: a retrospective analysis from MIMIC-IV database

“…Fluid therapy, which is a cornerstone in the treatment of sepsis and associated with outcome in emergency department patients, is commonly used to restore and maintain patients' tissue perfusion [9][10][11]. For many years, the types of fluid administration regarding "crystalloids" and "colloids" is under the heated debate [12,13].…”

Prognostic performance of the REDS score, SOFA score, NEWS2 score, and the red-flag, NICE high-risk, and SIRS criteria to predict survival at 180 days, in emergency department patients admitted with suspected sepsis – An observational cohort study

“…If shock is not present or the patient could have another condition, the recommendation is to perform investigations and if found to have an infection or sepsis, to deliver antibiotics within 3 h of recognition. We too have previously found that the time to antibiotics is critical in those with refractory hypotension, with a number needed to treat of four, but not in those without refractory hypotension ( 28 ). We have also suggested that a SBP of <100 mmHg could be used to identify patients who are likely to develop refractory hypotension.…”