Trends in vital signs and routine biomarkers in patients with sepsis during resuscitation in the emergency department: a prospective observational pilot study

Quinten, Vincent M.; Meurs, Matijs van; Maaten, Jan C. ter; Ligtenberg, Jack J. M.

doi:10.1136/bmjopen-2015-009718

Cited by 21 publications

(23 citation statements)

References 16 publications

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“…To create this model, we study various predictive variables, like clinical scoring systems, biomarker levels and vital signs. 8 13 We have a special interest in patients with infection and sepsis without organ failure, since many of these patients deteriorate and they may benefit the most from early intervention. 3 4 14 …”

Section: Methods and Analysismentioning

confidence: 99%

Protocol of the sepsivit study: a prospective observational study to determine whether continuous heart rate variability measurement during the first 48 hours of hospitalisation provides an early warning for deterioration in patients presenting with infection or sepsis to the emergency department of a Dutch academic teaching hospital

et al. 2017

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IntroductionOne in five patients with sepsis deteriorates within 48 hours after hospital admission. Regrettably, a clear tool for the early detection of deterioration is still lacking. The SepsiVit study aims to determine whether continuous heart rate variability (HRV) measurement can provide an early warning for deterioration in patients presenting with suspected infection or sepsis to the emergency department (ED).Methods and analysisThe protocol of a prospective observational study in the ED. We will include 171 adult medical patients presenting with suspected infection or sepsis and at least two systemic inflammatory response syndrome criteria. Patients with known pregnancy, cardiac transplantation or not admitted to our hospital are excluded.High sample frequency ECG signals (500 Hz), respiratory rate, blood pressure and peripheral oxygen saturation will be recorded continuously during the first 48 hours of hospitalisation using a bedside patient monitor (Philips IntelliVue MP70). Primary endpoint is patient deterioration, defined as the development of organ dysfunction, unplanned intensive care unit admission or in-hospital mortality. The ECG data will be used for offline HRV analysis. We will compare the HRV between two groups (deterioration/no deterioration) and analyse whether HRV provides an early warning for deterioration. Furthermore, we will create a multivariate predictive model for deterioration based on heart rate, respiratory rate and HRV. As planned secondary analyses, we (1) perform a subgroup analysis for patients with pneumosepsis and urosepsis and (2) determine whether HRV using lower sample frequencies (1 Hz or less) suffices to predict deterioration.Ethics and disseminationThe Institutional Review Board of the University Medical Center Groningen granted a waiver for the study (METc 2015/164). Results will be disseminated through international peer-reviewed publications and conference presentations. A lay summary of the results will be provided to the study participants.Trial registration number NTR6168; Pre-results.

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Section: Methods and Analysismentioning

confidence: 99%

Protocol of the sepsivit study: a prospective observational study to determine whether continuous heart rate variability measurement during the first 48 hours of hospitalisation provides an early warning for deterioration in patients presenting with infection or sepsis to the emergency department of a Dutch academic teaching hospital

et al. 2017

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“…A larger study designed to compare clinical judgement with the PIRO and qSOFA scores is required to be conclusive on predicting indirect ICU admission. However, we speculate that changes over time in scores or vital signs might be more accurate at predicting indirect ICU admission (or patient deterioration) than scores or measurements on a single point in time 16 . Therefore, we plan further studies to assess changes in scores and vital signs over time.…”

Section: Discussionmentioning

confidence: 89%

“…These low mortality rates may be partially explained by the fact that we introduced a novel sepsis bundle in our ED in 2008. The aims of this bundle include earlier recognition of septic patients, immediate nurse/physician contact at admission, administration of antibiotics within 60 min and routine fluid resuscitation during the first 2 h (for as long as required) 16 . Furthermore, it should be noted that the recent literature reports considerably lower mortality rates compared with earlier publications.…”

Section: Discussionmentioning

confidence: 99%

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Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score?

Quinten¹,

Meurs

Wolffensperger

et al. 2018

European Journal of Emergency Medicine

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ObjectiveThe aim of this study was to compare the stratification of sepsis patients in the emergency department (ED) for ICU admission and mortality using the Predisposition, Infection, Response and Organ dysfunction (PIRO) and quick Sequential Organ Failure Assessment (qSOFA) scores with clinical judgement assessed by the ED staff.Patients and methodsThis was a prospective observational study in the ED of a tertiary care teaching hospital. Adult nontrauma patients with suspected infection and at least two Systemic Inflammatory Response Syndrome criteria were included. The primary outcome was direct ED to ICU admission. The secondary outcomes were in-hospital, 28-day and 6-month mortality, indirect ICU admission and length of stay. Clinical judgement was recorded using the Clinical Impression Scores (CIS), appraised by a nurse and the attending physician. The PIRO and qSOFA scores were calculated from medical records.ResultsWe included 193 patients: 103 presented with sepsis, 81 with severe sepsis and nine with septic shock. Fifteen patients required direct ICU admission. The CIS scores of nurse [area under the curve (AUC)=0.896] and the attending physician (AUC=0.861), in conjunction with PIRO (AUC=0.876) and qSOFA scores (AUC=0.849), predicted direct ICU admission. The CIS scores did not predict any of the mortality endpoints. The PIRO score predicted in-hospital (AUC=0.764), 28-day (AUC=0.784) and 6-month mortality (AUC=0.695). The qSOFA score also predicted in-hospital (AUC=0.823), 28-day (AUC=0.848) and 6-month mortality (AUC=0.620).ConclusionClinical judgement is a fast and reliable method to stratify between ICU and general ward admission in ED patients with sepsis. The PIRO and qSOFA scores do not add value to this stratification, but perform better on the prediction of mortality. In sepsis patients, therefore, the principle of ‘treat first what kills first’ can be supplemented with ‘judge first and calculate later’.

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“…While clinical deterioration can, to a certain degree, be predicted with the use of clinical judgment, clinical scoring systems and repeated vital sign measurements, clinical improvement, on the other hand, cannot. [11,13,[16][17][18][19][20][21][22][23] Length of in-hospital stay of patients presenting to the ED with an infection varies, with an average of 1 to 7 days (range 0-38 days). [24][25][26] Which of these patients will develop sepsis and, in turn, need prolonged hospitalization, remains a complex and not well understood process.…”

Section: Introductionmentioning

confidence: 99%

Development and Internal Validation of a Model Predicting Safe, Early Discharge Among Patients Presenting to the Emergency Department with an Infection.

Mulders

Maaten

Boekhoud

et al. 2020

Preprint

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Background: Prolonged hospitalization is associated with high costs and mortality, and increases the chance of adverse events. This study aimed to identify predictors of safe, early discharge in patients presenting to the Emergency Department (ED) with an infection. Methods: This prospective observational study was performed in the ED of a tertiary care teaching hospital. Adult non-trauma patients with suspected infection and at least two Systemic Inflammatory Response Syndrome (SIRS) criteria were included. Exclusion criteria were intensive care unit admission and transfer to another hospital. Safe, early discharge was defined as hospital-discharge within 24 hours without disease-related death or readmission to our hospital during the first 7 days. A prediction model for safe, early discharge was created using a multivariate logistic regression analysis and validated with k-fold cross-validation. Results: 1381 patients were included, of whom 354 (25.6%) met the safe, early discharge criteria. Parameters associated with safe, early discharge were younger age, absence of co-morbidities, living independently, yellow or green triage urgency, absence of ambulance transport, absence of general practitioner referral, normal clinical impression, (q)SOFA, PIRO, MEDS, NEWS and SIRS scores, absence of abnormal vital sign measurements and absence of kidney and respiratory failure. A prediction model for safe, early discharge was developed with an area under the curve (AUC) of 0.824. Internal validation generated a minimal drop in performance, indicating a good fit. Conclusion: By identifying predictors of clinical improvement and combining several readily available parameters in the ED setting, a model for safe, early discharge with good prognostic performance was created.

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Trends in vital signs and routine biomarkers in patients with sepsis during resuscitation in the emergency department: a prospective observational pilot study

Cited by 21 publications

References 16 publications

Sepsis patients in the emergency department: stratification using the Clinical Impression Score, Predisposition, Infection, Response and Organ dysfunction score or quick Sequential Organ Failure Assessment score?

Development and Internal Validation of a Model Predicting Safe, Early Discharge Among Patients Presenting to the Emergency Department with an Infection.

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