d-dimer is a significant prognostic factor in patients with suspected infection and sepsis

Purpose

The aim of the study was to determine whether C-reactive protein (CRP), procalcitonin (PCT), and d-dimer (DD) are markers of mortality in patients admitted to the emergency department (ED) with suspected infection and sepsis.

Basic Procedures

We conducted a prospective cohort in a university hospital in Medellín, Colombia. Patients were admitted between August 1, 2007, and January 30, 2009. Clinical and demographic data and Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores as well as blood samples for CRP, PCT, and DD were collected within the first 24 hours of admission. Survival was determined on day 28 to establish its association with the proposed biomarkers using logistic regression and receiver operating characteristic curves.

Main Findings

We analyzed 684 patients. The median Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores were 10 (interquartile range [IQR], 6-15) and 2 (IQR, 1-4), respectively. The median CRP was 9.6 mg/dL (IQR, 3.5-20.4 mg/dL); PCT, 0.36 ng/mL (IQR, 0.1-3.7 ng/mL); and DD, 1612 ng/mL (IQR, 986-2801 ng/mL). The median DD in survivors was 1475 ng/mL (IQR, 955-2627 ng/mL) vs 2489 ng/mL (IQR, 1698-4573 ng/mL) in nonsurvivors (P = .0001). The discriminatory ability showed area under the curve–receiver operating characteristic for DD, 0.68; CRP, 0.55; and PCT, 0.59. After multivariate analysis, the only biomarker with a linear relation with mortality was DD, with an odds ratio of 2.07 (95% confidence interval, 0.93-4.62) for values more than 1180 and less than 2409 ng/mL and an odds ratio of 3.03 (95% confidence interval, 1.38-6.62) for values more than 2409 ng/mL.

Principal Conclusions

Our results suggest that high levels of DD are associated with 28-day mortality in patients with infection or sepsis identified in the emergency department.     

Incidence and risk factors for sepsis in surgical patients: a cohort study

Purpose

The aim of the study was to evaluate risk factors for infection and sepsis in surgical patients admitted to the intensive care unit (ICU).

Materials and Methods

Data were prospectively collected from a cohort of surgical patients from January 2005 to December 2007. We analyzed the incidence of infection and sepsis and certain other variables from the pre-, intra-, and postoperative periods as risk factors for infection and sepsis.

Results

We studied 625 surgical patients. The mortality rate was 18.2%, and the mean age of the subjects was 53.1 ± 18.8 years. The incidences of severe sepsis and septic shock were 5% and 11.5%, respectively. A multivariate analysis showed that the following variables were associated with sepsis in the postoperative period: urgent surgery (odds ratio, 2.63; 95% confidence interval [CI], 1.50-4.63), fluid resuscitation (odds ratio, 1.90; 95% CI, 1.18-3.05), vasoactive drugs (odds ratio, 2.58; 95% CI, 1.61-4.14), and mechanical ventilation (odds ratio, 5.51; 95% CI, 3.07-9.89). A Sequential Organ Failure Assessment was associated with infection or sepsis upon ICU admission (area under the curve, 0.737 ± 0.019; 95% CI, 0.748-0.825).

Conclusions

This study showed that sepsis has high incidence and mortality in surgical patients admitted to the ICU. Urgent surgeries, mechanical ventilation, fluid resuscitation, and vasoactive drugs in the postoperative period and Sequential Organ Failure Assessment at ICU admission were risk factors for sepsis.     

High concentrations of resistin in the peripheral blood of patients with acute basal ganglia hemorrhage are associated with poor outcome

Purpose

Resistin increases in peripheral blood of patients with intracerebral hemorrhage (ICH). We sought to evaluate its relation with disease outcome.

Materials and Methods

Thirty healthy controls and 86 patients with acute ICH were included. Plasma samples were obtained on admission. Its concentration was measured by enzyme-linked immunosorbent assay.

Results

Thirty-two patients (37.2%) died from ICH in a week. The plasma resistin level (24.2 ± 9.7 ng/mL) in patients was significantly higher than that (8.8 ± 2.4 ng/mL) in healthy controls after adjustment by age, sex, hypertension, diabetes mellitus, hyperlipidemia, and body mass index using analysis of covariate (F = 9.507, P = .003).A univariate correlation analysis found Glasgow Coma Scale (GCS) score and ICH volume, but a multivariate linear regression only selected GCS score (t = −4.587, P < .001) to be related to plasma resistin level. On a multivariate logistic regression, plasma resistin level (odds ratio = 1.257, 95% confidence interval = 1.058-1.492, P = .009) was an independent variable predicting 1-week mortality. A receiver operating characteristic curve identified that a plasma resistin level greater than 26.3 ng/mL predicted 1-week mortality of patients with 81.2% sensitivity and 81.5% specificity (P < .001). Areas under curves of GCS score and ICH volume were not statistically significantly larger than that of plasma resistin level (P > .05).

Conclusions

Increased resistin level is found after ICH, in association with a poor clinical outcome.     

Initial fractal exponent of heart rate variability is associated with success of early resuscitation in patients with severe sepsis or septic shock: a prospective cohort study

Introduction

Heart rate variability (HRV) reflects autonomic nervous system tone as well as the overall health of the baroreflex system. We hypothesized that loss of complexity in HRV upon intensive care unit (ICU) admission would be associated with unsuccessful early resuscitation of sepsis.

Methods

We prospectively enrolled patients admitted to ICUs with severe sepsis or septic shock from 2009 to 2011. We studied 30 minutes of electrocardiogram, sampled at 500 Hz, at ICU admission and calculated heart rate complexity via detrended fluctuation analysis. Primary outcome was vasopressor independence at 24 hours after ICU admission. Secondary outcome was 28-day mortality.

Results

We studied 48 patients, of whom 60% were vasopressor independent at 24 hours. Five (10%) died within 28 days. The ratio of fractal alpha parameters was associated with both vasopressor independence and 28-day mortality (P = .04) after controlling for mean heart rate. In the optimal model, Sequential Organ Failure Assessment score and the long-term fractal α parameter were associated with vasopressor independence.

Conclusions

Loss of complexity in HRV is associated with worse outcome early in severe sepsis and septic shock. Further work should evaluate whether complexity of HRV could guide treatment in sepsis.     

Safety of research bronchoscopy in critically ill patients

Objective

Bronchoscopy and bronchoalveolar lavage (BAL) are common procedures in intensive care units; however, no contemporaneous safety and outcomes data have been reported, particularly for critically ill patients.

Design

This is a retrospective analysis of prospectively collected data from teaching hospital adult intensive care units.

Interventions

One hundred mechanically ventilated patients with severe sepsis, septic shock, acute lung injury (ALI), and/or acute respiratory distress syndrome underwent bronchoscopy with unilateral BAL. Data collected included demographics, presence of sepsis or ALI, Pao₂ to Fio₂ ratio, positive end-expiratory pressure, Acute Physiology and Chronic Health Evaluation score, Sequential Organ Failure Assessment score, and peri- or postprocedural complications.

Results

Men comprised 51% of the patients; 81% of the patients were black, and 15% were white. The mean age was 52 (SD, ± 16) years. The mean Acute Physiology and Chronic Health Evaluation score was 22 (± 7.5), whereas the median Sequential Organ Failure Assessment score was 9 (interquartile range, 5-12). Ten patients (10%) had complications during or immediately after the procedure. Hypoxemia during or immediately after the BAL was the most common complication. Ninety percent of the complications were related to transient hypoxemia, whereas bradycardia and hypotension each occurred in 1 patient. Age, female sex, and higher positive end-expiratory pressure were associated with complications.

Conclusions

Bronchoscopy with BAL in critically ill patients with sepsis and ALI is well tolerated with low risk of complications, primarily related to manageable hypoxemia.     

Plasma neutrophil gelatinase-associated lipocalin as a biomarker for acute kidney injury in critically ill patients with suspected sepsis

Objectives

The aim of this study was to investigate the diagnostic utility of plasma neutrophil gelatinase-associated lipocalin (NGAL) as an early objective biomarker to predict acute kidney injury (AKI) in critically ill patients with suspected sepsis, for whom procalcitonin (PCT) was used for the diagnosis and staging of sepsis.

Design and methods

Plasma NGAL was measured using the Triage NGAL Test (Alere, Inc., San Diego, CA, USA) in 231 samples obtained from patients with suspected sepsis. The results of NGAL were compared with those of Elecsys BRAHMS PCT (Roche Diagnostics, Basel, Switzerland). Renal failure was assessed using the renal subscore of Sepsis-related Organ Failure Assessment (SOFA) score. AKI was defined according to the Acute Kidney Injury Network criteria.

Results

The concentrations of plasma NGAL were significantly different according to the five groups of PCT concentration (P < 0.0001) and the renal subscore of SOFA score (P < 0.0001). Plasma NGAL was significantly increased in the patients with AKI compared with those without AKI (416.5 ng/mL vs. 181.0 ng/mL, P = 0.0223).

Conclusion

Plasma NGAL seems to be a highly sensitive and objective predictor of AKI in patients with sepsis. Plasma NGAL can be added for the diagnosis and staging of renal failure in sepsis.     

Soluble urokinase–type plasminogen activator receptor as a prognostic biomarker in critically ill patients

Purpose

The aim of this study was to assess the role of blood soluble urokinase–type plasminogen activator receptor (suPAR) levels in the diagnosis and prognostication of sepsis in critically ill patients.

Methods

Serum suPAR levels were measured prospectively in adult intensive care unit (ICU) patients on admission and then daily until ICU discharge (maximum of 14 days) using an enzyme-linked immunosorbent assay kit. Normal levels were established in 31 healthy controls.

Results

We included 258 patients (161 men); median admission Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were 17 (9-23) and 6 (3-9), respectively. The mortality rate was 13.6%. Sepsis was diagnosed on admission in 94 patients (36%), of whom 23 had severe sepsis and 49 had septic shock. On admission, septic patients had higher suPAR levels than did nonseptic patients (8.9 [5.9-12.7] vs 3.7 [2.7-5.4] ng/mL), but the predictive value of suPAR for diagnosing sepsis was weaker than that of C-reactive protein. During the week after ICU admission, serum suPAR concentrations correlated with Sequential Organ Failure Assessment scores over time. High suPAR levels on admission were a strong independent predictor for ICU and 28-day mortality. In the global population, a suPAR level higher than 6.15 ng/mL had 66% sensitivity and 64% specificity for prediction of ICU mortality, with a receiver operating characteristic area under the curve of 0.726 (95% confidence interval, 0.645-0.808).

Conclusions

In ICU patients, serum suPAR concentrations have limited use for identifying sepsis, but their time course correlated with the degree of organ dysfunction, and they have prognostic value in septic and nonseptic populations.     

Stress hyperglycemia may not be harmful in critically ill patients with sepsis

Background

Stress hyperglycemia (SH) is commonly seen in critically ill patients. It has been shown to be associated with adverse outcomes in some groups of patients. The effects of SH on critically ill patients with sepsis have not been well studied. We aimed to evaluate the effects of SH in critically ill patients with sepsis.

Methods

In this retrospective study, patients with sepsis admitted to intensive care unit (ICU) over a 5-year period were included.

Results

Of 297 patients, 204 (68.7%) had SH during the study period. The mean blood glucose level in patients with SH was 8.7 mmol/L compared with 5.9 mmol/L in those without SH (P < .05). There were no statistically significant differences in age; sex; sepsis severity; cardiovascular, respiratory, and renal comorbidities; requirement of mechanical ventilation; inotropes; and Acute Physiology, Age, and Chronic Health Evaluation III and Simplified Acute Physiology 2 scores on ICU admission. Intensive care unit mortality was significantly lower in patients who had SH. The median duration of ICU and hospital length of stay was longer in patients with SH. On logistic regression analysis, the presence of SH was associated with reduced ICU mortality. Subgroup analysis revealed SH to be protective in patients with septic shock.

Conclusion

Stress hyperglycemia may not be harmful in critically ill patients with sepsis. Patients with SH had lower ICU mortality.     

Outcome of patients with liver cirrhosis admitted to a specialty liver intensive care unit in India

Purpose

The study aimed to describe the clinical outcome of patients with liver cirrhosis admitted to intensive care unit (ICU) and to compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) in predicting mortality.

Methods

In this prospective study of patients with cirrhosis admitted to the ICU, demographic data, APACHE II score, SOFA score, presence of acute renal failure (ARF), need for organ support, and mortality were collected.

Results

The observed mortality in ICU and at 30 days among 104 patients was 42.3% (95% confidence interval [CI], 32.7%-52.0%) and 56.7% (95% CI, 47.0%-66.4%), respectively. Area under the receiver operating characteristic curve for first-day APACHE II in predicting 30-day mortality was 0.90 (95% CI, 0.83-0.96) and 0.93 (95% CI, 0.88-0.98) for SOFA score (P = .24). On multivariate analysis, ARF (adjusted odds ratio, 7.7; 95% CI, 1.09-54.64) and mechanical ventilation (adjusted odds ratio, 277.6; 95% CI, 12.83-6004.94) were significantly associated with mortality.

Conclusions

Presence of ARF and need for mechanical ventilation are associated with high mortality in patients with liver cirrhosis admitted to the ICU. Acute Physiology and Chronic Health Evaluation II and SOFA are good prognostic models in predicting 30-day mortality and do not differ in performance.     

The impact of body mass index on the physiology of patients with polytrauma

Purpose

Obesity is a growing problem in industrial nations. The aim was to test the hypothesis that overweight patients face early physiologic impairment.

Methods

A total of 651 patients were included in this retrospective study, with an injury severity score greater than 16 and 16 years or older. The sample was subdivided into 3 groups: body mass index (BMI) less than 25 kg/m², BMI of 25 to 30 kg/m², and BMI greater than 30 kg/m². Physiologic scores—Murray, Goris, Marshall and Sequential Organ Failure Assessment scores—were analyzed at admission and at the day of their maximum. Analysis of variance and χ² tests were used, and the significance level was set at P < .05.

Results

All 4 scores showed significant differences at their maxima according to the 3 BMI groups, respectively: Murray score (P < .001), Goris score (P < .05), Marshall score (P < .001), and Sequential Organ Failure Assessment score (P <.05). The injury severity score values of the 3 groups at admission were 27.6 ± 12.0, 29.6 ± 13.2, and 25.3 ± 9.2, respectively (P < .05). The overall mortality rates in the 3 groups were 15.1%, 21.0%, and 20%, respectively (P < .001).

Conclusions

Anticipating BMI-specific critical trauma problems will become mandatory for effective polytrauma treatment in industrialized nations given their increasing prevalence of obesity.     

Usefulness of presepsin (sCD14 subtype) measurements as a new marker for the diagnosis and prediction of disease severity of sepsis in the Korean population

Purpose

Presepsin has recently emerged as a new useful sepsis marker, and our study is focused on the usefulness of presepsin as earlier detection and monitoring biomarker for sepsis comparing with other conventional biomarkers.

Materials and methods

We compared the mean values of presepsin, procalcitonin, interleukin 6, and high-sensitivity C-reactive protein levels between infection group and noninfection group of study subjects and assessed whether the values decreased during treatment. Furthemore, we evaluated the diagnostic accuracy of presepsin in sepsis and compared the mean level of presepsin to the Acute Physiology and Chronic Health Evaluation III score and mortality rate on the 30th day.

Results

Mean presepsin levels were significantly different between infection group and noninfection group (1403.47 pg/mL vs 239.00 pg/mL). During treatment, mean levels of presepsin decreased significantly, and in the receiver operating characteristic curve analysis, the area under curve value of presepsin was significantly higher than that of other biomarkers. The presepsin levels did not correlate significantly with Acute Physiology and Chronic Health Evaluation III scores and mortality rates on the 30th day.

Conclusions

Presepsin showed significantly higher values in infection group than in noninfection group. The diagnostic accuracy of presepsin was higher than other conventional biomarkers. For early diagnosis and treatment of bacterial sepsis, presepsin could be a more useful marker than the other markers.     

Consecutive thrombelastography clot strength profiles in patients with severe sepsis and their association with 28-day mortality: A prospective study

Purpose

The aim of this study was to assess associations between consecutive thrombelastography (TEG) profiles and standard coagulation tests and disease severity and mortality in patients with severe sepsis.

Materials and Methods

This was a prospective observational study of adults with severe sepsis admitted to the intensive care unit (ICU). Clinical scores/variables, infection, TEG, biochemistry, therapy, and overall mortality were recorded.

Results

Fifty patients (60% men, median age 62 years, 28-day mortality 24%) were included. At admission, 22%, 48%, and 30% had a hypocoagulable, normocoagulable, and hypercoagulable TEG clot strength (maximum amplitude [MA]), respectively. Hypocoagulable patients had higher Sequential Organ Failure Assessment and disseminated intravascular coagulation scores compared with hypercoagulable patients and higher 28-day mortality compared with normocoagulable patients (all P < .05). Most patients (73%-91%) displayed a TEG MA comparable with the admission profile during the initial 4 ICU days or until death/discharge. Patients progressing to hypocoagulable MA had a high early mortality (80%) and hypocoagulable MA independently predicted 28-day mortality (adjusted odds ratio, 4.29 [95% confidence interval, 1.35-13.65], P = .014). In hypocoagulable and hypercoagulable patients, only fibrinogen (P = .041 and P < .001, respectively) contributed independently to clot strength, whereas both platelets (P < .001) and fibrinogen (P < .001) contributed independently to clot strength in normocoagulable patients.

Conclusions

The ICU admission TEG MA remained constant for several days in patients with severe sepsis and hypocoagulable MA independently predicted 28-day mortality.     

Prognostic factors of mortality in patients with community-acquired bloodstream infection with severe sepsis and septic shock

Purpose

The purpose of the study was to determine the independent risk factors on mortality in patients with community-acquired severe sepsis and septic shock.

Methods

A single-site prospective cohort study was carried out in a medical-surgical intensive care unit in an academic tertiary care center. One hundred twelve patients with community-acquired bloodstream infection with severe sepsis and septic shock were identified. Clinical, microbiologic, and laboratory parameters were compared between hospital survivors and hospital deaths.

Results

One-hundred twelve patients were included. The global mortality rate was 41.9%, 44.5% in septic shock and 34.4% in severe sepsis. One or more comorbidities were present in 66% of patients. The most commonly identified bloodstream pathogens were Escherichia coli (25%) and Staphylococcus aureus (21.4%). The proportion of patients receiving inadequate antimicrobial treatment was 8.9%. By univariate analysis, age, Acute Physiology and Chronic Health Evaluation II score, at least 3 organ dysfunctions, and albumin, but neither microbiologic characteristics nor site of infection, differed significantly between survivors and nonsurvivors. Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.13; 95% confidence interval, 1.06-1.21) and albumin (odds ratio, 0.34; 95% confidence interval, 0.15-0.76) were independent risk factors associated with global mortality in logistic regression analysis.

Conclusion

In addition to the severity of illness, hypoalbuminemia was identified as the most important prognostic factor in community-acquired bloodstream infection with severe sepsis and septic shock.     

Procollagen type III aminoterminal propeptide as biomarker of host response in severe sepsis

Purpose

The purpose of this study is to test the hypothesis that procollagen type III aminoterminal propeptide (PIIINP) is early elevated in septic episodes and can indicate the acute organ dysfunction/failure characterizing severe sepsis.

Materials and Methods

This prospective study included 107 consecutive septic patients (44 with sepsis, 13 with severe sepsis, and 50 with septic shock) and 45 controls. After blood sampling (within 48 hours after onset of septic episodes), serum was assayed. Patients were followed up, and their disease severity was daily evaluated.

Results

Procollagen type III aminoterminal propeptide (median [range]) increased in patients with sepsis (9.4 [2.2-42.4] ng/mL) compared with controls (3.6 [1.9-4.9] ng/mL; P < .001), exhibiting further significant increase in patients with severe sepsis and septic shock (19.5 [6.0-52.4] and 20.2 [1.8-89.2] ng/mL, respectively; P < .01-.001 vs sepsis). Among biomarkers of host response severity, PIIINP was the sole that was independently associated with severe sepsis/septic shock (P = .01). The area under the receiver operating characteristic curve for PIIINP to predict which patients with sepsis would eventually develop severe sepsis/septic shock was 0.87; the cutoff of 12 ng/mL had sensitivity 82% and specificity 89%.

Conclusions

Increased serum PIIINP can signify severe sepsis/septic shock and predict which patients with sepsis will eventually develop severe sepsis/septic shock, thus representing a biomarker of risk stratification of patients with sepsis.     

Relationship between the timing of administration of IgM and IgA enriched immunoglobulins in patients with severe sepsis and septic shock and the outcome: a retrospective analysis

Purpose

Because the use of IgM and IgA enriched polyclonal intravenous immunoglobulins (eIg) is a standard of care in critically ill patients admitted to our intensive care unit (ICU) with the diagnosis of severe sepsis or septic shock, we investigated if the delay from the onset of severe sepsis and septic shock and their administration could influence the outcome.

Materials and Methods

The medical records of all patients with severe sepsis or septic shock admitted to our ICU from July 2004 through October 2009 and treated with eIg (Pentaglobin®; Biotest, Dreieich, Germany) were retrospectively examined.

Results

A total of 129 adult patients with severe sepsis or septic shock were considered eligible. Thirty-two percent of patients died during the ICU stay. Survivors were given eIg significantly earlier than nonsurvivors (23 vs 63 hours, P < .05). The delay in the administration of eIg and the Simplified Acute Physiology Score II were the only variables that entered stepwise a propensity score-adjusted logistic model. The delay in the administration of eIg was a significant predictor of the odds of dying during the ICU stay (odds ratio for 1 hour of delay, 1.007; P < .01; 99% confidence interval from 1.001 to 1.010) and proved to be independent from the Simplified Acute Physiology Score II and other variables.

Conclusions

The efficacy of eIg, being maximal in early phases of severe sepsis and/or septic shock, is probably time dependent.     

Timing and appropriateness of initial antibiotic therapy in newly presenting septic patients

Objective

To determine the effectiveness of antibiotic regimens and time to antibiotics in septic patients admitted to an intensive care unit from the emergency department.

Methods

A retrospective case-control study of patients with sepsis syndromes admitted from the emergency department between August 2010 and July 2011 was conducted. Standard demographic information, time frames for written antibiotic orders and administration, and information regarding site of culture, organisms identified, sensitivities, and antibiotic effectiveness were documented.

Results

Four hundred medical records were reviewed; 184 patients met the study inclusion criteria and were included in the final analysis. Simplified Acute Physiology Scores II and Sequential Organ Failure Assessment scores were 49 and 6, respectively, and overall in-hospital mortality was 20.7%. Patients with positive blood cultures had higher Simplified Acute Physiology Scores II scores (56.0 vs 46.0, P = .0125). Serum lactate levels were also significantly higher in the in-hospital mortality group (3.2 vs 2.1, P = .0068). Computerized physician order entry dramatically decreased the median times to the last appropriate antibiotic administration (3.183 hours vs 6.992 hours, P < .0001) but did not alter mortality (20.6% vs 20.8%). Appropriateness of empiric antibiotic regimens was similar between patients surviving and those who died during their hospital stay (63.5% vs 68.8%, P = .58).

Conclusions

Median times to the first antibiotic administration and last needed appropriate antibiotic administration were less than 3 and 5 hours, respectively; these times were similar between patients who survived and those who died during their hospital stay. Patients with a serum lactate level higher than 2.5 mmol/L were associated with a 2.5-times increased risk of mortality.     

Troponin-I as a prognosticator of mortality in severe sepsis patients

Purpose

The purpose of this retrospective study was to evaluate cardiac troponin-I (cTnI) as a 28-day mortality prognosticator and predictor for a drotrecogin alfa (activated) (DrotAA) survival benefit in recombinant human activated Protein C Worldwide Evaluation in Severe Sepsis patients.

Methods

Cardiac troponin-I was measured using the Access AccuTnI Troponin I assay (Beckman Coulter, Fullerton, CA). There were 598 patients (305 DrotAA, 293 placebo) with baseline cTnI data (cTnI negative [<0.06 ng/mL], n = 147; cTnI positive [≥0.06 ng/mL], n = 451).

Results

Cardiac troponin-I–positive patients were older (mean age, 61 vs 56 years; P = .002), were sicker (mean Acute Physiology and Chronic Health Evaluation II, 26.1 vs 22.3; P < .001), had lower baseline protein C levels (mean level, 49% vs 56%; P = .017), and had higher 28-day mortality (32% vs 14%, P < .0001) than cTnI-negative patients. Elevated cTnI was an independent prognosticator of mortality (odds ratio, 2.020; 95% confidence interval, 1.153-3.541) after adjusting for other significant variables. Breslow-Day interaction test between cTnI levels and treatment was not significant (P = .65).

Conclusion

This is the largest severe sepsis study reporting an association between elevated cTnI and higher mortality. Cardiac troponin-I elevation was not predictive of a survival benefit with DrotAA treatment.     

Full Outline of UnResponsiveness score and Glasgow Coma Scale in medical patients with altered sensorium: Interrater reliability and relation to outcome

Purpose

Full Outline of UnResponsiveness, or FOUR score (FS), is a recently described scoring system for evaluation of altered sensorium. This study examined interrater reliability for FS and Glasgow Coma Scale (GCS) among medical patients with altered mental status and compared outcome predictability of GCS, FS, and Sequential Organ Failure Assessment score.

Patients and Methods

Adult patients with altered mental status due to medical causes were rated by neurology consultants and internal medicine residents on FS and GCS. Interobserver reliability for GCS and FS was assessed using κ score. Relation with outcomes was explored using univariate and multivariate analyses.

Main Results

Of the 100 patients (age, 62 ± 17 years), 60 had neurologic conditions; 26, metabolic encephalopathy; 9, infections; and 7, others. Thirty-nine patients died at 3 months. κ Scores ranged from 0.71 to 0.85 for GCS and from 0.71 to 0.95 for FS. On multivariate analysis, GCS was predictive of outcome at 3 months; FS was predictive of mortality. Area under the receiver operating characteristic curves suggested equivalent performance of both scoring systems.

Conclusions

Interrater reliability and outcome predictability for FS were comparable with those for GCS. This study supports the use of FS for evaluation of altered mental status in the medical wards.     

Discriminative value of inflammatory biomarkers for suspected sepsis

Background

Circulating biomarkers can facilitate sepsis diagnosis, enabling early management and improved outcomes. Procalcitonin (PCT) has been suggested to have superior diagnostic utility compared to other biomarkers.

Study Objectives

To define the discriminative value of PCT, interleukin-6 (IL-6), and C-reactive protein (CRP) for suspected sepsis.

Methods

PCT, CRP, and IL-6 were correlated with infection likelihood, sepsis severity, and septicemia. Multivariable models were constructed for length-of-stay and discharge to a higher level of care.

Results

Of 336 enrolled subjects, 60% had definite infection, 13% possible infection, and 27% no infection. Of those with infection, 202 presented with sepsis, 28 with severe sepsis, and 17 with septic shock. Overall, 21% of subjects were septicemic. PCT, IL6, and CRP levels were higher in septicemia (median PCT 2.3 vs. 0.2 ng/mL; IL-6 178 vs. 72 pg/mL; CRP 106 vs. 62 mg/dL; p < 0.001). Biomarker concentrations increased with likelihood of infection and sepsis severity. Using receiver operating characteristic analysis, PCT best predicted septicemia (0.78 vs. IL-6 0.70 and CRP 0.67), but CRP better identified clinical infection (0.75 vs. PCT 0.71 and IL-6 0.69). A PCT cutoff of 0.5 ng/mL had 72.6% sensitivity and 69.5% specificity for bacteremia, as well as 40.7% sensitivity and 87.2% specificity for diagnosing infection. A combined clinical-biomarker model revealed that CRP was marginally associated with length of stay (p = 0.015), but no biomarker independently predicted discharge to a higher level of care.

Conclusions

In adult emergency department patients with suspected sepsis, PCT, IL-6, and CRP highly correlate with several infection parameters, but are inadequately discriminating to be used independently as diagnostic tools.     

ED bedside point-of-care lactate in patients with suspected sepsis is associated with reduced time to iv fluids and mortality

Objective

Early recognition and treatment of sepsis improves outcomes. We determined the effects of bedside point-of-care (POC) lactate measurement on test turnaround time, time to administration of IV fluids and antibiotics, mortality, and ICU admissions in adult ED patients with suspected sepsis. We hypothesized that bedside lactate POC testing would reduce time to IV fluids and antibiotics.

Methods

We compared 80 ED patients with suspected sepsis and a lactate level of 2 mmol/L or greater before and 80 similar patients after introduction of POC lactate measurements. Groups were compared with Χ² and Mann Whitney U tests. A sample size of 80 patients in each group had 85% power to detect a 30-minute difference in time to IV fluids or antibiotics.

Results

Study groups were similar in age, gender, baseline lactate levels, sepsis severity, and Sequential Organ Failure Assessment (SOFA) scores. Introduction of POC lactate was associated with significant reductions in test turnaround time (34 [26-55] vs. 122 [82-149] minutes; P < 0.001), time to IV fluids (55 [34-83] vs. 71 [42-110] minutes; P = 0.03), mortality (6% vs. 19%; P = 0.02), and ICU admissions (33% vs. 51%, P = 0.02), but not time to IV antibiotics (89 [54-156] vs. 88 [60-177] minutes; P = 0.35).

Conclusions

Implementation of bedside POC lactate measurement in adult ED patients with suspected sepsis reduces time to test results and time to administration of IV fluids but not antibiotics. A significant reduction in mortality and ICU admissions was also demonstrated, which is likely due, at least in part, to POC testing.