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.
Highlights
Progression 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
The goal of this study is to identify specific parameters that are associated with a composite outcome of progression to severe sepsis, shock, or death within 96 h of ED triage among ED patients who initially present with nonsevere sepsis
After applying the exclusion criteria and subsequently excluding three patients who signed out of the hospital against medical advice, there were 582 eligible patients found in our chart review who had nonsevere sepsis in the emergency department
Summary
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. Recent literature suggests that patients with sepsis who develop organ dysfunction represent approximately 25 % of those who initially present to the emergency department (ED) with sepsis [1, 2]. One study demonstrated a 20 % higher absolute hospital mortality among septic patients who developed shock late in their hospital course compared to those who had shock early [4]. Identification of patients with nonsevere sepsis—i.e., those without organ dysfunction or shock—who later develop severe sepsis may impact patient morbidity and mortality. Prediction of disease progression in sepsis could be used for timely triage to a higher level of care upon admission
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