Identify Sepsis Patients Research Articles

Serum anion gap predicts lactate poorly, but may be used to identify sepsis patients at risk for death: A cohort study

Purpose(1) To test whether serum bicarbonate or anion gap can be used to predict elevated lactate or mortality in emergency department (ED) patients with sepsis, and (2) to define thresholds that may predict elevated lactate and mortality. MethodsRetrospective diagnostic-validation study of adults with sepsis treated in a 60,000-visit Midwestern university ED (2010–2015). In the derivation sample, 8 experts selected thresholds based on objective measures to optimize clinical utility. Test performance was reported using likelihood ratios (LR +/−) in the validation cohort. ResultsWe included 4159 patients. Anion gap predicted lactate>2 better than bicarbonate [ROC AUC 0.680 vs. 0.609], and anion gap predicted lactate>4 better than lactate>2 [ROC AUC 0.816 vs. 0.680]. In the validation cohort, anion gap ≥20mEq/L had LR+ for lactate>2 of 3.670 (2.630–5.122), lactate>4 of 7.019 (5.310–9.278), and mortality of 2.768 (1.922–3.986). Anion gap predicted mortality similar to lactate>2 [LR+ 2.768 vs. LR+ 2.09; LR− 0.823 vs. 0.447]. ConclusionsAnion gap and serum bicarbonate poorly predict changes in lactate and mortality. In resource-limited settings where lactate is unavailable, anion gap ≥20mEq/L may be used to further risk-stratify patients for ongoing sepsis care, but lactate remains a preferred biomarker.

Comparative effectiveness of physician diagnosis and guideline definitions in identifying sepsis patients in the emergency department

PurposeThe purpose of our study was to compare the agreement of emergency physician diagnoses relative to the 1991 American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) and 2001 ACCP/SCCM/European Society of Intensive Care Medicine/American Thoracic Society/Surgical Infection Society internationally accepted definitions of sepsis, severe sepsis, and septic shock. Materials and methodsThis study was an observational cohort study of adult patients presenting to the emergency department (ED) with a chief complaint suggestive of infection over a 6-week period, during a daily enrollment schedule from 7:00 am to 10:00 pm. Patients were categorized as having “no sepsis,” “sepsis,” “severe sepsis,” or “septic shock” based on ED physician diagnosis, the 1991 definitions, or 2001 definitions. Agreement statistics were performed. ResultsA total of 1275 patients were enrolled with age 50.1 ± 21.7 years and 59.1% were female. Among the enrolled patients, 228 were identified as having a source of infection. Temperature, heart rate, and white blood cell count were significantly higher in patients with infection, compared with those without (P < .001). The odds ratio for disagreement between a physician-designated no sepsis diagnosis and the 1991 definitions was 4.47 (95% confidence interval, 3.01-7.53) and 5.96 (3.78-9.46) between the same physician-designated diagnosis and the 2001 definitions. The odds ratios for disagreement of a severe sepsis physician diagnosis in relation to the 1991 and 2001 definitions were 0.06 (0.01-0.19) and 0.06 (0.01-0.20), respectively. The 1991 and 2001 consensus definitions had strong agreement, with κ = 0.86 and 91.2% agreement. No agreement was found between the physician diagnosis and 1991 consensus sepsis definitions (κ = 0.11 and 52.2% agreement) or between the physician diagnosis and the 2001 consensus sepsis definitions (κ = 0.13 and 50.0% agreement). ConclusionsOur study showed that ED physician diagnosis of sepsis may disagree with the international definitions such that severe sepsis is underrecognized by clinical judgment alone. Although these results are limited to a single center, we raise concern that early treatments for these high-risk patients may be delayed due to inaccurate clinical diagnosis. Efforts are needed to increase the application of sepsis guideline definitions to better identify ED patients with this potentially deadly condition.

Diagnostic characteristics of a clinical screening tool in combination with measuring bedside lactate level in emergency department patients with suspected sepsis.

Early identification of sepsis and initiation of aggressive treatment saves lives. However, the diagnosis of sepsis may be delayed in patients without overt deterioration. Clinical screening tools and lactate levels may help identify sepsis patients at risk for adverse outcomes. The objective was to determine the diagnostic characteristics of a clinical screening tool in combination with measuring early bedside point-of-care (POC) lactate levels in emergency department (ED) patients with suspected sepsis. This was a prospective, observational study set at a suburban academic ED with an annual census of 90,000. A convenience sample of adult ED patients with suspected infection were screened with a sepsis screening tool for the presence of at least one of the following: temperature greater than 38°C or less than 36°C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min, or altered mental status. Patients meeting criteria had bedside POC lactate testing following triage, which was immediately reported to the treating physician if ≥2.0 mmol/L. Demographic and clinical information, including lactate levels, ED interventions, and final diagnosis, were recorded. Outcomes included presence or absence of sepsis using the American College of Chest Physicians/Society of Critical Care Medicine consensus conference definitions and intensive care unit (ICU) admissions, use of vasopressors, and mortality. Diagnostic test characteristics were calculated using 2-by-2 tables with their 95% confidence intervals (CIs). The association between bedside lactate and ICU admissions, use of vasopressors, and mortality was determined using logistic regression. A total of 258 patients were screened for sepsis. Their mean (± standard deviation [SD]) age was 64 (±19) years; 46% were female, and 82% were white. Lactate levels were 2.0 mmol/L or greater in 80 (31%) patients. Patients were confirmed to meet sepsis criteria in 208 patients (81%). The diagnostic characteristics for sepsis of the combined clinical screening tool and bedside lactates were sensitivity 34% (95% CI = 28% to 41%), specificity 82% (95% CI = 69% to 90%), positive predictive value 89% (95% CI = 80% to 94%), and negative predictive value 23% (95% CI = 17% to 30%). Bedside lactate levels were associated with sepsis severity (p < 0.001), ICU admission (odds ratio [OR] = 2.01; 95% CI = 1.53 to 2.63), and need for vasopressors (OR = 1.54; 95% CI = 1.13 to 2.12). Use of a clinical screening tool in combination with early bedside POC lactates has moderate to good specificity but low sensitivity in adult ED patients with suspected sepsis. Elevated bedside lactate levels are associated with poor outcomes.

1034

Introduction: Sepsis is a morbid cause of hospitalization, however, little is known about the relative proportion of hospital deaths that result from sepsis. We evaluated a multi-center sample of hospitalizations at 21 community medical centers in the Kaiser Permanente Northern California integrated healthcare delivery system between September 2010 and September 2012 to determine the proportion of all hospital deaths associated with sepsis. Methods: We retrospectively analyzed all hospitalizations that included non-obstetrical patients aged ≥18 years with overnight stays (or death at any time). We identified sepsis patients based on diagnosis coding and manually-collected data from regional sepsis quality improvement (QI) initiatives. We used QI data-available for 83.9% of sepsis patients-to categorize patients based on sepsis severity and their eligibility for, or use of, early goal-directed therapy (EGDT). Results: Over two years, a total of 345,264 patients met the study criteria including 42,457 (12.3%) hospitalized for sepsis-85.7% with the 038 ICD-9 diagnosis code. Mean age was 69.5 ± 16.9 for sepsis patients and 64.1 ± 17.5 years for others. Sepsis patients had higher comorbid disease burden, acute severity of illness, and predicted mortality (9.3% ± 12.6% versus 2.4% ± 5.5%, p<0.001) when compared with non-sepsis patients. They also had higher ICU utilization (31.8% versus 13.5%) and length of stay (6.7 versus 3.8 days) than other inpatients. Sepsis hospital mortality was 10.5%; 30-day mortality was 15.2%. Hospital mortality otherwise was 1.9%. More than 43% (n = 4,463) of all inpatient deaths were among sepsis patients. Most had sepsis present on admission (93.8%) and nearly 40% had severe sepsis or septic shock. Hospital mortality varied by severity strata; for example, 6.6% of patients with non-severe sepsis died compared with 17.8% of patients receiving EGDT. Hospital mortality was 26.2% to 33.6% among EGDT-eligible patients who did not receive EGDT (either based on clinician judgment, contraindications, patient refusal, or comfort care status). In terms of all sepsis deaths, each sepsis strata (non-severe sepsis, sepsis with intermediate lactate, and EGDT-eligible sepsis) contributed roughly equal numbers of deaths. This included 1,225 (31.9%) deaths among non-severe, 1,213 (31.6%) among intermediate lactate, and 1,397 (36.4%) among EGDT-eligible sepsis patients. Conclusions: In a multi-center study of community hospitals, >43% of patients dying in the hospital had sepsis. These sepsis deaths were roughly equally distributed across severity strata.

A Computerized Alert Screening For Severe Sepsis In Emergency Department Patients Increases Lactate Testing But Does Not Improve Inpatient Mortality

This study tested the hypothesis that lactate testing in ED sepsis patients could be increased using a computer alert that automatically recognizes systemic inflammatory response syndrome (SIRS) criteria and recommends lactate testing in cases of sepsis defined as ≥2 SIRS criteria plus physician suspicion of infection. Secondary outcomes included the effect of the alert on lactate testing among admitted sepsis patients, the proportion of admitted patients with lactate ≥4.0 mmol/L identified and the in-patient mortality difference before and after alert implementation. After a 6 month pre-alert phase, a computer alert was implemented that computed and displayed abnormal vital signs and white blood cell counts for all patients with >2 SIRS criteria and recommended testing lactate if an infection was suspected. Data for admitted patients was collected electronically on consecutive patients meeting sepsis criteria for 6 months before and 6 months after implementation of the alert. There were a total of 5,796 subjects enrolled. Among all septic patients, lactate testing increased from 5.2% in the pre-alert phase to 12.7% in the alert phase, a 7.5% (95% CI 6.0 to 9.0%) absolute increase in lactate testing, p<0.001. Among the 1,798 admitted patients with sepsis, lactate testing increased from 15.3% to 34.2%, an 18.9% (95% CI 15.0 to 22.8%) absolute increase, p<0.001. Among admitted patients with sepsis, there was a 1.9% (95% CI 0.03 to 3.8%, p = 0.05) increase in absolute number of patients with elevated lactate levels identified and a 0.5% (95% CI -1.6 to 2.6%, p=0.64) decrease in mortality. The proportion of ED patients who had lactate tested and the number of admitted patients identified with a lactate level ≥4.0 mmol/L improved significantly after the implementation of a computer alert identifying sepsis patients with >2 SIRS criteria while mortality among admitted sepsis patients remained unchanged.

Presymptomatic Prediction of Sepsis in Intensive Care Unit Patients

Postoperative or posttraumatic sepsis remains one of the leading causes of morbidity and mortality in hospital populations, especially in populations in intensive care units (ICUs). Central to the successful control of sepsis-associated infections is the ability to rapidly diagnose and treat disease. The ability to identify sepsis patients before they show any symptoms would have major benefits for the health care of ICU patients. For this study, 92 ICU patients who had undergone procedures that increased the risk of developing sepsis were recruited upon admission. Blood samples were taken daily until either a clinical diagnosis of sepsis was made or until the patient was discharged from the ICU. In addition to standard clinical and laboratory parameter testing, the levels of expression of interleukin-1beta (IL-1beta), IL-6, IL-8, and IL-10, tumor necrosis factor-alpha, FasL, and CCL2 mRNA were also measured by real-time reverse transcriptase PCR. The results of the analysis of the data using a nonlinear technique (neural network analysis) demonstrated discernible differences prior to the onset of overt sepsis. Neural networks using cytokine and chemokine data were able to correctly predict patient outcomes in an average of 83.09% of patient cases between 4 and 1 days before clinical diagnosis with high sensitivity and selectivity (91.43% and 80.20%, respectively). The neural network also had a predictive accuracy of 94.55% when data from 22 healthy volunteers was analyzed in conjunction with the ICU patient data. Our observations from this pilot study indicate that it may be possible to predict the onset of sepsis in a mixed patient population by using a panel of just seven biomarkers.

CENTRALIZED, REMOTE CARE IMPROVES SEPSIS IDENTIFICATION, BUNDLE COMPLIANCE AND OUTCOMES

PURPOSE: Sepsis is responsible for 215,000 deaths per year and the Surviving Sepsis Campaign was initiated to standardize care and improve outcomes in this patient population. We previously reported on reduced sepsis mortality (CCM 2006, Vol. 34, A2 & A108) in our ICU patients and we hypothesized that the improvement in outcomes correlated with the development of a centralized process for identifying sepsis patients and implementing the sepsis bundle in a more timely fashion during the same time period.

Markers of systemic inflammation predicting organ failure in community-acquired septic shock

To obtain predictors of organ failure (OF), we studied markers of systemic inflammation [circulating levels of interleukin-6 (IL-6), IL-8, soluble IL-2 receptor (sIL-2R), soluble E-selectin and C-reactive protein, and neutrophil and monocyte CD11b expression] and routine blood cell counts in 20 patients with systemic inflammatory response syndrome and positive blood culture. Eight patients with shock due to community-acquired infection developed OF, whereas 11 normotensive patients and one patient with shock did not (NOF group). The first blood sample was collected within 48 h after taking the blood culture (T1). OF patients, as compared with NOF patients, had at T1 a lower monocyte count, a lower platelet count, higher levels of CD11b expression on both neutrophils and monocytes, and higher concentrations of IL-6, IL-8 and sIL-2R. C-reactive protein and soluble E-selectin concentrations did not differ between groups. No parameter alone identified all patients that subsequently developed OF. However, a sepsis-related inflammation severity score (SISS), developed on the basis of the presence or absence of shock and on the levels of markers at T1, identified each patient that developed OF. The maximum SISS value was 7. The range of SISS values in OF patients was 2-5, and that in NOF patients was 0-1. In conclusion, high levels of CD11b expression, depressed platelet and monocyte counts, and high concentrations of IL-6, IL-8 and sIL-2R predict OF in patients with community-acquired septic shock, and the combination of these markers may provide the means to identify sepsis patients who will develop OF.