Severe sepsis and septic shock in patients transported by prehospital services versus walk in patients to the emergency department

BackgroundSepsis is a leading cause of death in the hospital for which aggressive treatment is recommended to improve patient outcomes. It is possible that sepsis patients brought in by emergency medical services (EMS) have a unique advantage in the emergency department (ED) which could improve sepsis bundle compliance.ObjectiveTo evaluate patient care processes and outcome differences between severe sepsis and septic shock patients in the emergency department who were brought in by EMS compared to non-EMS patients.MethodsWe performed a retrospective chart review of all severe sepsis and septic shock patients who declared in the ED during January 2012 thru December 2014. We compared differences in patient characteristics, patient care processes, sepsis bundle compliance metrics, and outcomes between both groups.ResultsOf the 1066 patients included in the study, 387 (36.6%) were brought in by EMS and 679 (63.7%) patients arrived via non-EMS transport. In the multivariate regression model, time of triage to sepsis declaration (coeff = −0.406; 95% CI = −0.809, −0.003; p = 0.048) and time of triage to physician (coeff = −0.543; 95% CI = −0.864, −0.221; p = 0.001) was significantly shorter for EMS patients. We found no statistical difference in adjusted individual sepsis compliance metrics, overall bundle compliance, or mortality between both groups.ConclusionEMS transported patients have quicker sepsis declaration times and are seen sooner by ED providers. However, we found no statistical difference in bundle compliance or patient outcomes between walk in patients and EMS transported patients.     

Attitudes Toward Influenza Vaccination Administration in the Emergency Department Among Patients: A Cross-Sectional Survey

IntroductionInfluenza is a serious, vaccine-preventable illness. The current vaccination rates in Canada are below target rates, highlighting the potential need for more convenient ways to receive vaccinations. Wait times to be seen in Canadian emergency departments are escalating, and using the time spent waiting to offer and administer an influenza vaccine could potentially improve ease of access to immunization for some Canadians.MethodsThe aim of this cross-sectional study was to gauge public interest and identify perceived barriers and facilitators to influenza vaccine availability in a Canadian emergency and trauma center. Anonymous questionnaires were completed by a convenience sample of adult patients classified as low acuity (n = 151) as 1 arm of a 2-arm study.ResultsOf the unvaccinated patients, 34.6% expressed willingness to be vaccinated in the emergency department. The patients who had received a vaccine in the previous year were significantly more willing to accept the vaccine in the emergency department (χ² [1] = 23.78, P < 0.001). The 3 top factors associated with having received vaccination in the previous year include trust in vaccine information (χ² [2] = 27.34, P < 0.001), immunity preferences (χ² [2] = 32.25, P < 0.001), and beliefs about efficacy (χ² [2] = 44.90, P < 0.001).DiscussionPatients classified as low acuity were supportive of ED influenza vaccination. In addition, some of the unvaccinated participants had unmet education needs (ie, regarding trustworthy sources of vaccine information, immunity, and vaccine efficacy) that would require addressing before they would likely consider receiving influenza vaccination in future during their ED visit.     

Plasma syndecan-1 is associated with fluid requirements and clinical outcomes in emergency department patients with sepsis

BackgroundDegradation of the endothelial glycocalyx is recognized as a major part of the pathophysiology of sepsis. Previous clinical studies, mostly conducted in intensive care settings, showed associations between glycocalyx shedding and clinical outcomes. We aimed to explore the association of plasma syndecan-1, a marker of glycocalyx degradation, with the subsequent fluid requirements and clinical outcomes of emergency department patients with sepsis.MethodsThis was a post hoc analysis of a randomized trial of fluid resuscitation in the emergency department. The study was conducted in the emergency department of an urban 1500-bed tertiary care center. The data of 95 adults who were diagnosed with sepsis-induced hypoperfusion and had undergone baseline syndecan-1 measurement were included. The syndecan-1 levels at baseline (T0) and hour 6 (T6) were studied to characterize their association with clinical outcomes, including subsequent fluid administration, organ failure outcomes and mortality.ResultsThe median syndecan-1 levels at T0 and T6 were 207 (IQR 135–438) and 207 (IQR 128–490) ng/ml, respectively. Syndecan-1 levels at T0 were correlated with baseline sequential organ failure assessment (SOFA) score (ρ = 0.35, p < 0.001). Syndecan-1 levels at both T0 and T6 were correlated with subsequent fluid administration over 24 and 72 h and associated with the diagnosis of septic shock, the maximum dose of vasopressors and the need for renal replacement therapy (p < 0.05). Higher syndecan-1 levels at T6 were associated with higher 90-day mortality (p = 0.03).ConclusionsIn the emergency department, syndecan-1 levels were associated with fluid requirements, sepsis severity, organ dysfunction, and mortality.     

Emergency department sepsis screening tool decreases time to antibiotics in patients with sepsis

Recent literature has highlighted the importance of early identification and treatment of sepsis; however, limited data exists to help recognize sepsis in the emergency department (ED) through use of a screening tool. The purpose of this study was to evaluate the impact of a sepsis screening tool implemented in an academic medical center ED on compliance with the 3-hour sepsis bundle.This was a retrospective cohort study that included a total of 115 patients, of which 58 were in the pre-tool group and 57 were in the post-tool group. There was no difference in 3-hour bundle compliance between groups (36.2% vs. 47.4%, P?=?0.26). There was no difference in the following bundle components: lactate (79.3% vs. 80.7%, P?=?0.85), blood cultures (86.2% vs. 96.5%, P?=?0.09), blood cultures before administering antibiotics (91.4% vs. 100%, P?=?0.57) and adequate fluids administration (44.7% vs. 41.9%, P?=?0.820). A significantly higher number of patients received antibiotics within 3?h in the post-tool group (58.6% vs. 89.5%, P?<?0.001). Statistically significant secondary outcomes included average time to antibiotics (P?=?0.04), administering antibiotics within an hour (P?>?0.001), and ICU length of stay (P?=?0.03). There was no difference in 30-day mortality, however mortality was numerically lower in the post-tool group (36.2% vs. 26.3%, P?=?0.25).Although implementation of an ED sepsis screening tool did not increase 3-hour bundle compliance, it did increase the proportion of patients receiving timely antimicrobial therapy and demonstrated a trend towards decreased mortality.     

Association of ischemia modified albumin with mortality in qSOFA positive sepsis patients by sepsis-3 in the emergency department

BackgroundThe early detection and treatment of sepsis and septic shock patients in emergency departments are critical. Ischemia modified albumin (IMA) is a biomarker produced by ischemia and oxygen free radicals which are related to the pathogenesis of sepsis-induced organ dysfunction. This study aimed to investigate whether IMA was associated with short-term mortality in quick sequential organ failure assessment (qSOFA)-positive sepsis or septic shock patients screened by the sepsis management program.MethodFrom September 2019 to April 2020, patients who arrived at the emergency departments with qSOFA-positive sepsis or septic shock were included in this retrospective observational study.ResultsAmong 124 patients analyzed, IMA was higher in the non-surviving group than in the surviving group (92.6 ± 8.1 vs. 86.8 ± 6.2 U/mL, p < 0.001). The area under the receiver operating characteristics curve was 0.703 (95% CI: 0.572–0.833, p < 0.001). The optimal IMA cutoff was 90.45 (sensitivity 60.9%, specificity 79.2%). IMA values were independently associated with 28-day mortality in the multivariate Cox proportional hazard model (adjusted hazard ratio (aHR) = 1.16, 95% CI: 1.06–1.27, p < 0.01).ConclusionsIn this study, we showed that IMA in the emergency departments was associated with 28-day mortality in qSOFA-positive sepsis and septic shock patients. Further studies are needed to evaluate the clinical value of IMA as a useful biomarker in large populations and multicenter institutions.     

The role of the serum lactate level at the first admission to the emergency department in predicting mortality

IntroductionLactate is an easily measurable laboratory parameter that is considered a potentially useful prognostic marker for determining risk in emergency department patients. The aim of this study was to investigate the role of serum lactate in the patients who were admitted to the emergency department at the time of admission.MethodsPatients who were admitted to the emergency department for various reasons between June 2017 and January 2018 were included in the study. Demographic data, laboratory findings, mortality and hospitalization rates of the patients were analyzed. The primary endpoint was determined as the role of serum lactate in predicting mortality, and the secondary endpoint in predicting hospitalization.ResultsOf the 1382 patients, 47.4% (n = 655) were female and 52.6% (n = 727) were male. The mean age of the patients was 60.99 ± 20.04 (18–100) years. In 59.6% (n = 824) of the patients, the most common hypertension (36%) was an additional disease. Mortality was found in 43 (3.1%) patients. It was observed that 20.5% (n = 284) of the patients were hospitalized. The ages of patients with hospitalization and mortality were found to be statistically significant higher than those without hospitalization and without mortality (p = 0.001; p < 0.01). There was no statistically significant difference between the serum lactate measurements of the patients according to hospitalization (p > 0.05). The serum lactate levels of the patients with mortality were found to be statistically significant higher than those without mortality (p = 0.001; p < 0.01). The cut off point for serum lactate level in predicting mortality was found to be ≥3.6 mmol/L. The mortality rate was found to be statistically significant higher in patients with serum lactate level 3,6 mmol/L and above (p = 0,001; p < 0,01).ConclusionIn conclusion, we believe in the light of the findings of our study that the serum lactate level is effective and reliable in the prediction of mortality in patients who present to emergency department for any reason. However, prospective studies with broader patient groups are required in this subject.     

Exhaled end-tidal carbon dioxide as a predictor of lactate and pediatric sepsis

ObjectiveThe objective of this study was to investigate the relationship between exhaled end-tidal carbon dioxide (ETCO₂) and serum lactate via nasal capnography and to assess the ability of ETCO₂ to predict disease severity in children with suspected sepsis in a pediatric emergency department.MethodsThis prospective study included patients (≥ 30 days to ≤21 years of age) who presented with suspected sepsis to a tertiary pediatric emergency department. Pearson correlation coefficient was generated to measure the linear relationship between ETCO₂ and lactate. Receiver operating characteristic curves (ROC) were generated to assess the performance of ETCO₂ to predict a lactate ≥2 mmol/L and severe disease. Severe disease was defined as severe sepsis and septic shock.ResultsFrom November 1, 2018 to March 31, 2020, 105 emergency department patients underwent evaluation for suspected sepsis. Sixty-nine patients met the inclusion criteria for the study. There was an inverse relationship between ETCO₂ and lactate with a correlation coefficient of −0.34 (p = .005). Severe disease had lower ETCO₂ (32 ± 6 mmHg, p < .001) and higher lactate (3.3 ± 1.7 mmol/L, p < .001). The area under the curve (AUC) for ETCO₂ to predict severe disease was 0.75 (95% CI 0.63, 0.86). An ETCO₂ cut off point of 30 mmHg correlated with a sensitivity of 93% and specificity of 32%.ConclusionsWe observed a significant inverse relationship between ETCO2 and lactate in children presenting with suspected sepsis. A lower ETCO2 was predictive of severe disease.     

The adverse effect of emergency department crowding on compliance with the resuscitation bundle in the management of severe sepsis and septic shock

Introduction

The aim of this study is to evaluate the effects of emergency department (ED) crowding on the implementation of tasks in the early resuscitation bundle during acute care of patients with severe sepsis and septic shock, as recommended by the Surviving Sepsis Campaign guidelines.

Methods

We analyzed the sepsis registry from August 2008 to March 2012 for patients presenting to an ED of a tertiary urban hospital and meeting the criteria for severe sepsis or septic shock. The ED occupancy rate, which was defined as the total number of patients in the ED divided by the total number of ED beds, was used for measuring the degree of ED crowding. It was categorized into three groups (low; intermediate; high crowding). The primary endpoint was the overall compliance with the entire resuscitation bundle.

Results

A total of 770 patients were enrolled. Of the eligible patients, 276 patients were assigned to the low crowding group, 250 patients to the intermediate crowding group, and 244 patients to the high crowding group (ED occupancy rate: ≤ 115; 116–149; ≥ 150%). There was significant difference in compliance rates among the three groups (31.9% in the low crowding group, 24.4% in the intermediate crowding group, and 16.4% in the high crowding group, P < 0.001). In a multivariate model, the high crowding group had a significant association with lower compliance (adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.26 to 0.76; P = 0.003). When the ED occupancy rate was included as a continuous variable in the model, it had also a negative correlation with the overall compliance (OR of 10% increase of the ED occupancy rate, 0.90; 95% CI, 0.84 to 0.96, P = 0.002).

Conclusions

ED crowding was significantly associated with lower compliance with the entire resuscitation bundle and decreased likelihood of the timely implementation of the bundle elements.     

Clinical and Demographic Parameters of Patients Treated Using a Sepsis Protocol

PurposeThe purpose of this study was to investigate potential differences by sex in the demographic and clinical characteristics of patients treated utilizing a sepsis electronic bundle order set. Risk factors for in-hospital mortality were also assessed.MethodsData on patients in whom the sepsis order set was initiated in the emergency department over a 16-month period were entered into the hospital database. Data were analyzed for differences by sex in demographic and clinical factors, treatment modalities, and in-hospital mortality. The Bonferroni correction was applied to account for multiple comparisons; α was set at 0.006 for sex differences.FindingsA total of 2204 patients were included. Male and female cohorts were similar with regard to a variety of demographic and clinical factors, including age, Emergency Severity Index (ESI) levels 1 and 2, time to disposition, appropriateness of antibiotics, and total fluids given by weight. The ESI is an assessment score ranging from 1 to 5 (1 is emergent). There were modest differences in the source of infection (genitourinary was 4% more common in women; P = 0.03) and mode of arrival (men were 4% more likely to arrive by ambulance; P = 0.03). These differences did not achieve our predefined α of 0.006 when the Bonferroni correction was applied. Factors associated with in-hospital mortality were advanced age, arrival by ambulance, and an ESI level of 1 or 2 (all, P < 0.01).ImplicationsWomen were more likely to have a genitourinary cause of sepsis and less likely to arrive by ambulance. Risk factors of in-hospital mortality were older age, arrival by ambulance, and an ESI level of 1 or 2, but not sex.     

Effectiveness of polymyxin B-immobilized hemoperfusion against sepsis and septic shock: A systematic review and meta-analysis

PurposeTo evaluate the efficacy and safety of Polymyxin B-immobilized hemoperfusion (PMX-HP) against sepsis or septic shock.MethodsWe searched databases (PubMed, EMBASE and Cochrane Library) to identify eligible randomized controlled trials (RCTs). The primary outcomes we included in this review were mortality at the longest follow-up available and serious adverse events associated with treatments. We used the Cochrane risk of bias assessment tool to evaluate risk of bias. Trial Sequential Analysis (TSA) was performed to assess the conclusion reached in our research.ResultsThirteen studies including 1163 patients were identified. Use of PMX-HP could reduce overall mortality [relative risk (RR) 0.68, 95% confidence interval (CI) 0.51–0.91, P = 0.01]. An interesting finding was that the mortality of patients in Acute Physiology and Chronic Health Evaluation (APACHE II) scores <25 group (RR 0.64, 95% CI 0.52–0.78, P < 0.0001) and sepsis group (RR 0.48, 95% CI 0.32–0.72, P = 0.0003) significantly decreased after PMX-HP treatment. The result also showed that PMX-HP could reduce endotoxin levels [Standardized mean difference (SMD) -1.53, 95% CI -2.92– -0.13, P = 0.03] and improve mean arterial pressure (SMD 1.07, 95% CI 0.14–2.01, P = 0.02). Serious adverse events between the PMX-HP group and standard therapy group were not significantly different (RR 2.16, 95% CI 0.97–4.80, I² = 0%, P = 0.06). However, TSA did not provide conclusive evidence and more high quality RCTs were required.ConclusionUsing PMX-HP to treat patients with less severe sepsis can reduce overall mortality and is safe. Treatment efficacy may benefit from the reduction of endotoxin level and the improvement of hemodynamics. More high quality RCTs are required to further evaluate the clinical role of PMX-HP against severe sepsis or septic shock.     

End-tidal carbon dioxide is associated with mortality and lactate in patients with suspected sepsis

Objective

Exhaled end-tidal carbon dioxide (Etco₂) concentration is associated with lactate levels in febrile patients. We assessed the association of Etco₂ with mortality and lactate levels in patients with suspected sepsis.

Methods

This was a prospective observational study. We enrolled 201 adult patients presenting with suspected infection and 2 or more systemic inflammatory response syndrome criteria. Lactate and Etco₂ were measured and analyzed with patient outcomes.

Results

The area under the receiver operator characteristics curve (AUC) was 0.75 (confidence interval [CI], 0.65-0.86) for lactate and mortality and 0.73 (CI, 0.61-0.84) for Etco₂ and mortality. When analyzed across the different categories of sepsis, the AUCs for lactate and mortality were 0.61 (CI, 0.36-0.87) for sepsis, 0.69 (CI, 0.48-0.89) for severe sepsis, and 0.74 (CI, 0.55-0.93) for septic shock. The AUCs for Etco₂ and mortality were 0.60 (CI, 0.37-0.83) for sepsis, 0.67 (CI, 0.46-0.88) for severe sepsis, and 0.78 (CI, 0.59-0.96) for septic shock. There was a significant inverse relationship between Etco₂ and lactate in all categories, with correlation coefficients of − 0.421 (P < .001) in the sepsis group, − 0.597 (P < .001) in the severe sepsis group, and − 0.482 (P = .011), respectively. Adjusted odds ratios were calculated, demonstrating 3 significant predictors of mortality: use of vasopressors 16.4 (95% CI, 1.80-149.2), mechanical ventilation 16.4 (95% CI, 3.13-85.9), and abnormal Etco₂ levels 6.48 (95% CI, 1.06-39.54).

Conclusions

We observed a significant association between Etco₂ concentration and in-hospital mortality in emergency department patients with suspected sepsis across a range of disease severity.     

Evaluation of the Effect of Intravenous Immunoglobulin Dosing on Mortality in Patients with Sepsis: A Network Meta-analysis

PurposeIntravenous immunoglobulin (IVIG) has been proposed as an adjunctive therapy for sepsis. Related systematic reviews and meta-analyses of IVIG in sepsis indicate that IVIG can reduce the mortality of sepsis in adults. However, the effective dose of IVIG has not been clearly determined to date. We aimed to conduct an updated meta-analysis and use a network meta-analysis to elucidate the efficacy of IVIG dosing regimens in sepsis treatment.MethodsWe searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE for articles published on or before February 14, 2019. We performed a direct meta-analysis to update a previous meta-analysis of the effects of IVIG therapy on mortality in adult patients with septic shock and a network meta-analysis to evaluate the efficacy of IVIG dosing regimens in sepsis treatment.FindingsCompared with the control treatment, the IVIG treatment reduced the all-cause mortality of patients with sepsis (odds ratio = 0.61; 95% CI, 0.41–0.92; P = 0.018), but significant heterogeneity was found across the studies (I² = 45.0%; P = 0.04). Regarding the IVIG dosage regimens, the highest total dose range (1.5–2 g/kg) was the optimal dose of administration (surface under the cumulative ranking curve = 84.7%).ImplicationsOn the basis of the available data, IVIG treatment is likely to reduce the all-cause mortality of patients with sepsis, and the highest total dose range (1.5–2 g/kg) is likely the optimal dose of administration.     

Timeline of sepsis bundle component completion and its association with septic shock outcomes

PurposeTo assess the impact of the timeline of sepsis bundle completion with clinical outcomes in septic shock.Materials and methodsWe retrospectively studied adult (≥18 years) patients with septic shock from January 1, 2006, through May 31, 2018, who were admitted to the intensive care unit in Mayo Clinic, Rochester. We divided patients into three groups based on the SSC compliant 1) <1h, 2) 1.1 to 3 h, 3) >3 h after the time of septic shock diagnosis.ResultsWe enrolled 1052 septic shock patients, among 8% were in group 1, 26% in group 2, and the remaining in group 3. Those who completed all bundle components within 3 h had the lowest 28-day mortality (17.5% vs. 31.4%, p < .001) and higher survival at 90 days (HR = 0.67; 95% CI 0.55–0.80; p < .001). Sepsis bundle completion in <1 h had no significant advantage in 28-day mortality (21.5% vs.15.9%, p = .4) or 90-day survival compared with group 2 (HR = 1.08; 95% CI 0.77–1.53; p = .6).ConclusionsWe showed an association between the completion of SSC bundle components within three hours with lower mortality or earlier shock reversal. This relationship was not evident when compared to bundle completion in 1 h vs. within 3 h.     

The index of oxygenation to respiratory rate as a prognostic factor for mortality in Sepsis

ObjectivesAn index combining respiratory rate and oxygenation (ROX) has been introduced, and the ROX index is defined as the ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate. In sepsis, hypoxemia and tachypnea are commonly observed. We performed this study to investigate the association between the ROX index and 28-day mortality in patients with sepsis or septic shock.MethodsThis retrospective study included 2862 patients. The patients were divided into three groups according to the ROX index: Group I (ROX index >20), Group II (ROX index >10 and ≤ 20), and Group III (ROX index ≤10).ResultsThe median ROX index was significantly lower in the nonsurvivors than in the survivors (12.8 and 18.2, respectively) (p < 0.001). The 28-day mortality rates in Groups I, II and III were 14.5%, 21.3% and 34.4%, respectively (p < 0.001). In the multivariable Cox regression analysis, Group III had an approximately 40% higher risk of death than Group I during the 28-day period (hazard ratio = 1.41, 95% confidence interval 1.13–1.76). The area under the curve of the ROX index was significantly higher than that of the quick Sequential Organ Failure Assessment score (p < 0.001).ConclusionsThe ROX index was lower in nonsurvivors than in survivors, and a ROX index less than or equal to 10 was an independent prognostic factor for 28-day mortality in patients with sepsis or septic shock. Therefore, the ROX index could be used as a prognostic marker in sepsis.     

Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality

OBJECTIVE: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock. DESIGN: Two-year prospective observational cohort. SETTING: Academic tertiary care facility. PATIENTS: Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock. INTERVENTIONS: Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance. MEASUREMENTS AND MAIN RESULTS: Patients had a mean age of 63.8 +/- 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 +/- 10.6, emergency department length of stay 8.5 +/- 4.4 hrs, hospital length of stay 11.3 +/- 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17-0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01). CONCLUSIONS: Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.     

Triage of patients with fever: The Manchester triage system's predictive validity for sepsis or septic shock and seven-day mortality

ObjectiveUp to 15% of patients arrive in the emergency department suffering from fever. Triage is their first contact and is responsible for the stratification of patients according to the severity of the condition for which they are presenting at the emergency department. The aim of this study is to assess the predictive validity of the Manchester Triage System in patients with fever for sepsis or septic shock and seven-day mortality.MethodsThe sensitivity, specificity and negative predictive value of the Manchester Triage System was assessed by priority code allocation towards seven-day mortality and the diagnosis of sepsis or septic shock.ResultsA total of 3831 patients were evaluated in the emergency department for fever between 1 January 2017 and 30 June 2019. Of these, 1.9% were diagnosed with sepsis or septic shock. Using the Manchester Triage System to predict diagnosis of sepsis or septic shock provided a sensitivity of 88.7%, a specificity of 50.1% and a negative predictive value of 99.5%. For seven-day mortality, sensitivity was 44.4%, specificity was 92.3% and the negative predictive value was 99.3%.ConclusionThe Manchester Triage System has demonstrated high sensitivity and negative predictive value in patients with fever diagnosed with sepsis or septic shock. For patients with sepsis or septic shock one-third of cases with an incorrectly assigned priority code were caused by incorrect application of the Manchester Triage System.     

Early lactate clearance in septic patients with elevated lactate levels admitted from the emergency department to intensive care: Time to aim higher?

Purpose

Septic patients with hyperlactatemia have increased mortality rates, irrespective of hemodynamic and oxygen-derived variables. The aims of the study are the following: (1) to ascertain whether lactate clearance (LC) (percentage change in lactate over unit time) predicts mortality in septic patients admitted to intensive care directly from the emergency department and (2) to calculate the optimal “cut-off” value for mortality prediction.

Methods

Three-year retrospective observational study of consecutive patients with severe sepsis and septic shock admitted to intensive care from the emergency department of a tertiary UK hospital. We calculated 6-hour LC, performed receiver operating characteristic analyses to calculate optimal cut-off values for initial lactate and LC, dichotomized patients according to the LC cut-off, and calculated hazard ratios using a Cox proportional hazards model.

Results

One hundred six patients were identified; 78, after exclusions. Lactate clearance was independently associated with 30-day mortality (P < .04); optimal cut-off, 36%. Mortality rates were 61.1% and 10.7% for patients with 6-hour LC 36% or less and greater than 36%, respectively. Hazard ratio for death with LC 36% or less was 7.33 (95% confidence interval, 2.17-24.73; P < .001).

Conclusions

Six-hour LC was independently associated with mortality, and the optimal cut-off value was 36%, significantly higher than previously reported. We would support further research investigating this higher LC as a distinct resuscitation end point in patients with severe sepsis and septic shock.     

Is lactic acidosis predictive of outcomes in pediatric diabetic ketoacidosis?

ObjectivesThe objective of this study was to investigate the significance and prevalence of lactic acidosis in pediatric diabetic ketoacidosis (DKA) presenting to the emergency department.MethodsA retrospective cohort study of children (age ≤ 21 years) presenting to a tertiary care emergency department in DKA from December 1, 2015 to December 1, 2018. Patients needed to have DKA requiring admission to the pediatric intensive care unit and have had a lactate level collected while in the emergency department to be included.Results92 patients resulting in 113 encounters had DKA and a lactate level collected in the emergency department. The mean lactate level was 3.5 mmol/L (±SD 2.1). 72 (63.7%) encounters had lactic acidosis (p < 0.001). There was no significant association between the presence of lactic acidosis and pediatric intensive care unit length of stay (p = 0.321), hospital length of stay (p = 0.426), morbidity (p = 0.552) and mortality (p = 1.000). Initial glucose levels were significantly higher in the patients presenting with lactic acidosis (p = 0.001).ConclusionsLactic acidosis is a common finding in pediatric DKA patients presenting to the emergency department. Serum lactate alone should not be used as an outcome predictor in pediatric DKA.     

Serum caspase 3 levels are associated with early mortality in severe septic patients

ObjectiveHigher caspase 3 activity has been found in lymphocytes of septic patients than of healthy controls. However, an association between serum caspase 3 levels at moment of severe sepsis diagnosis and mortality in septic patients has not been previously demonstrated, and this was the main objective of the present study.MethodsThis is an observational study of 216 patients with severe sepsis in 6 Spanish intensive care units. We collected serum samples at moment of severe sepsis diagnosis to determine levels of caspase 3 and caspase-cleaved cytokeratin (CCCK) 18. End point was 30-day mortality.ResultsWe found higher serum caspase 3 levels (P < .001) and caspase-cleaved cytokeratin 18 (P = .001) in nonsurvivors (n = 76) than in survivors (n = 140). Multiple binary logistic regression analysis showed that serum caspase 3 levels greater than 0.25 ng/mL were associated with 30-day mortality (odds ratio, 6.51; 95% confidence interval, 3.32-12.77; P < .001). Receiver operating characteristic analysis showed that the area under the curve to predict 30-day mortality for serum caspase 3 levels was 0.73 (95% confidence interval, 0.67-0.79; P < .001).ConclusionsThe major novel findings of our study were that there is an association between serum caspase 3 levels at moment of severe sepsis diagnosis and mortality in septic patients and that serum caspase 3 levels could be used as prognostic biomarker, and further studies are needed to corroborate these findings.     

Sepsis与感染性休克的急诊救治及流程优化

Sepsis及感染性休克是临床常见的综合症,与患者预后密切相关。早期救治对Sepsis及感染性休克至关重要。急诊医师在早期诊断Sepsis、评价危险因素和早期复苏方面均起到至关重要的作用。目前证据表明,“Sepsis的集束化治疗”能够改善此类患者预后,2018年4月“拯救Sepsis运动”再次更新了相关推荐意见,提出了“1 h集束化治疗目标”,这对急诊医师提出了更高的要求。本文拟从救治流程、具体处理及可能的政策指导方面讨论Sepsis及感染性休克的急诊优化治疗,以期提高指南依从性和治疗质量,由此改善此类患者的预后。