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Epidemiology of severe sepsis in the emergency department and difficulties in the initial assistance
Rezende, Ederlon;Silva Junior, Jo?o Manoel;Isola, Alexandre Marine;Campos, Edvaldo Vieira;Amendola, Cristina Prata;Almeida, Samantha Longhi;
Clinics , 2008, DOI: 10.1590/S1807-59322008000400008
Abstract: background: the aim of this study was to determine the occurrence rate, demographics, clinical characteristics, and outcomes of patients with severe sepsis admitted to the emergency department. methods: a prospective study evaluating all patients admitted to the emergency department unit in a public hospital of tertiary complexity in a six-month period was conducted. during this period, the emergency team was trained to diagnose sepsis. patients who met the diagnostic criteria for severe sepsis were followed until their discharge from the hospital. results: a total of 5,332 patients were admitted to the emergency department, and 342 met the criteria for severe sepsis/septic shock. the median (interquartile range) age of patients was 74 (65-84) years, and 52.1% were male. the median apache ii and sofa scores at diagnosis were 19 (15-25) and 5 (3-7), respectively. the median number of dysfunctional organ systems per patient was 2 (1-3). the median hospital length of stay was 10 (4.7-17) days, and the hospital mortality rate was 64%. only 31% of the patients were diagnosed by the emergency department team as septic. about 33.5% of the 342 severe sepsis patients admitted to the emergency department were referred to an icu, with a median time delay of 24 (12-48) hours. training improved diagnosis and decreased the time delay for septic patients in arriving at the icu. conclusions: the occurrence rate of severe sepsis in the emergency department was 6.4%, and the rate of sepsis diagnosed by the emergency department team as well as the number of patients transferred to the icu was very low. educational campaigns are important to improve diagnosis and, hence, treatment of severe sepsis.
The outcome of patients presenting to the emergency department with severe sepsis or septic shock
Emanuel Rivers
Critical Care , 2006, DOI: 10.1186/cc4973
Abstract: A recent retrospective, observational study by Ho and coworkers [1] measured the incidence and outcome of septic patients presenting at an Australian emergency department (ED) with criteria for early goal-directed therapy (EGDT) and found significantly fewer EGDT candidates than previous studies [2]. A number of initiatives aiming to reduce worldwide mortality associated with sepsis, such as the Surviving Sepsis Campaign, have previously noted the importance of the tenets of early hemodynamic optimization to try and overcome this devastating disease. In patients with severe sepsis or septic shock, clinicians must be aware that a considerable proportion of those with significant lactic acidosis can have near normal serum bicarbonate or normal calculated anion gap values, which may lead to underestimated disease severity [3-5]. In the EGDT study [2], of the patients enrolled with a lactate level greater than 4 mmol/l, more than 30% had a bicarbonate level greater than 22 and an anion gap of less than or equal to 15 mEq/l. Other studies have shown that even if an anion gap is present, the mortality rate is significantly higher for lactic acidosis (56%) than for strong ion gap acidosis (39%) and hyperchloremic acidosis (29%) [6]. Despite mentioning lactate as a criterion in the study, Ho and coworkers did not report data regarding the levels or number of measurements found. Thus, it is possible that they underestimated the prevalence of high-risk patients in need of early hemodynamic optimization. This may explain why they strikingly found only 50 patients over 3.5 years (14.2 per year) meeting criteria for severe sepsis and septic shock in a large teaching hospital emergency department (ED) that sees 40,000 patients each year with a 30% admission rate.The lactate level of 4 mmol/l, as used in the EGDT study, was internally and externally validated. In their study of 1218 patients, Aduen and colleagues [3] found that lactate concentrations above 4 mmol/l were 98.2% spec
Prevalence and record of alcoholism among emergency department patients
Boniatti, Márcio Manozzo;Diogo, Luciano Passamani;Almeida, Caroline Lorenzoni;Cardoso, Michelle de Oliveira;
Clinics , 2009, DOI: 10.1590/S1807-59322009000100006
Abstract: objectives: the purpose of this study was to investigate the prevalence of alcoholism among inpatients, to identify social and demographic factors associated with this prevalence and to determine its rate of recognition by the medical team. methods: the study population consisted of all patients admitted to the emergency room at hospital s?o lucas, porto alegre, brazil, between july and september of 2005. the data were collected in two steps: an interview with the patient and a review of the medical records to investigate the cases of alcoholism recorded by the medical team. the questionnaire consisted of questions concerning social and demographic data, smoking habits and alcohol use disorders identification test. results: we interviewed 248 patients. twenty-eight (11.3%) were identified as alcoholics. compared to the patients with a negative alcohol use disorders identification test value (less than 8), those with a positive alcohol use disorders identification test were more likely to be male, illiterate and smokers. the medical records of 217 (87.5%) patients were reviewed. only 5 (20.0%) of the 25 patients with a positive alcohol use disorders identification test whose medical records were reviewed were identified as alcoholics by the medical team. the diagnosis made by the medical team, compared to alcohol use disorders identification test, shows only a 20% sensitivity, 93% specificity and positive and negative predictive values of 29% and 90%, respectively. conclusion: alcoholism has been underrecognized in patients who are hospitalized, and, as such, this opportunity for possible early intervention is often lost. key social and demographic factors could provide physicians with risk factors and, when used together with a standardized diagnostic instrument, could significantly improve the rate of identification of alcoholic patients.
Shock Index and Early Recognition of Sepsis in the Emergency Department: Pilot Study  [cached]
Tony Berger,Jeffrey Green,Timothy Horeczko,Yolanda Hagar
Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health , 2013,
Abstract: Introduction: Screening for severe sepsis in adult emergency department (ED) patients mayinvolve potential delays while waiting for laboratory testing, leading to postponed identification orover-utilization of resources. The systemic inflammatory response syndrome (SIRS) criteria are inaccurateat predicting clinical outcomes in sepsis. Shock index (SI), defined as heart rate / systolicblood pressure, has previously been shown to identify high risk septic patients. Our objective was tocompare the ability of SI, individual vital signs, and the systemic inflammatory response syndrome(SIRS) criteria to predict the primary outcome of hyperlactatemia (serum lactate ≥ 4.0 mmol/L) as asurrogate for disease severity, and the secondary outcome of 28-day mortality.Methods: We performed a retrospective analysis of a cohort of adult ED patients at an academiccommunity trauma center with 95,000 annual visits, from February 1st, 2007 to May 28th, 2008.Adult patients presenting to the ED with a suspected infection were screened for severe sepsisusing a standardized institutional electronic order set, which included triage vital signs, basic laboratorytests and an initial serum lactate level. Test characteristics were calculated for two outcomes:hyperlactatemia (marker for morbidity) and 28-day mortality. We considered the following covariatesin our analysis: heart rate >90 beats/min; mean arterial pressure < 65 mmHg; respiratory rate > 20breaths/min; ≥ 2 SIRS with vital signs only; ≥2 SIRS including white blood cell count; SI ≥ 0.7; andSI ≥ 1.0. We report sensitivities, specificities, and positive and negative predictive values for theprimary and secondary outcomes.Results: 2524 patients (89.4%) had complete records and were included in the analysis. 290(11.5%) patients presented with hyperlactatemia and 361 (14%) patients died within 28 days.Subjects with an abnormal SI of 0.7 or greater (15.8%) were three times more likely to present withhyperlactatemia than those with a normal SI (4.9%). The negative predictive value (NPV) of a SI ≥0.7 was 95%, identical to the NPV of SIRS.Conclusion: In this cohort, SI ≥ 0.7 performed as well as SIRS in NPV and was the most sensitivescreening test for hyperlactatemia and 28-day mortality. SI ≥ 1.0 was the most specific predictorof both outcomes. Future research should focus on multi-site validation, with implications for earlyidentification of at-risk patients and resource utilization.
National estimates of emergency department visits for pediatric severe sepsis in the United States  [PDF]
Sara Singhal,Mathias W. Allen,John-Ryan McAnnally,Kenneth S. Smith
PeerJ , 2013, DOI: 10.7717/peerj.79
Abstract: Objective. We sought to determine the characteristics of children presenting to United States (US) Emergency Departments (ED) with severe sepsis. Study design. Cross-sectional analysis using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Using triage vital signs and ED diagnoses (defined by the International Classification of Diseases, Ninth Revision codes), we identified children <18 years old presenting with both infection (triage fever or ICD-9 infection) and organ dysfunction (triage hypotension or ICD-9 organ dysfunction). Results. Of 28.2 million pediatric patients presenting to US EDs each year, severe sepsis was present in 95,055 (0.34%; 95% CI: 0.29–0.39%). Fever and respiratory infection were the most common indicators of an infection. Hypotension and respiratory failure were the most common indicators of organ dysfunction. Most severe sepsis occurred in children ages 31 days–1 year old (32.1%). Most visits for pediatric severe sepsis occurred during winter months (37.4%), and only 11.1% of patients arrived at the ED by ambulance. Over half of severe sepsis cases were self-pay or insured by Medicaid. A large portion (44.1%) of pediatric severe sepsis ED visits occurred in the South census region. ED length of stay was over 3 h, and 16.5% were admitted to the hospital. Conclusion. Nearly 100,000 children annually present to US EDs with severe sepsis. The findings of this study highlight the unique characteristics of children treated in the ED for severe sepsis.
Use of Early Goal-Directed Therapy in the Emergency Department before and after the Sepsis Trilogy  [PDF]
Loren K. Reed, Benton R. Hunter, Tyler M. Stepsis
Open Journal of Emergency Medicine (OJEM) , 2016, DOI: 10.4236/ojem.2016.42005
Abstract: The management of sepsis evolved recently with the publication of three large trials (referred to as the sepsis trilogy) investigating the efficacy of early goal-directed therapy (EGDT). Our goal was to determine if the publication of these trials has influenced the use of EGDT when caring for patients with severe sepsis and septic shock in the emergency department (ED). In February 2014, we surveyed a sample of board-certified emergency medicine physicians regarding their use of EGDT in the ED. A follow-up survey was sent after the publication of the sepsis trilogy. Data was analyzed using 95% confidence intervals to determine if there was a change in the use of EGDT following the publication of the above trials. Subgroup analyses were also performed with regard to academic affiliation and emergency department volume. Surveys were sent to 308 and 350 physicians in the pre-and post-publication periods, respectively. Overall, ED use of EGDT did not change with publication of the sepsis trilogy, 48.7% (CI 39.3% - 58.2%) before and 50.5% (CI 40.6% - 60.3%) after. Subgroup analysis revealed that academic-affiliated EDs significantly decreased EGDT use following the sepsis trilogy while nonacademic departments significantly increased EGDT use. Use of EGDT was significantly greater in community departments versus academic departments following the publication of the sepsis trilogy. There was no change overall in the use of EGDT protocols when caring for patients with severe sepsis and septic shock, but subgroup analyses revealed that academic departments decreased their use of EGDT while community departments increased use of EGDT. This may be due to varying rates of uptake of the medical literature between academic and community healthcare systems.
Successful Introduction of an Emergency Department Electronic Heal th Record  [cached]
Douglas A. Propp
Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health , 2012,
Abstract: Our emergency department had always relied on a paper-based infrastructure. Our goal was to convert to a paperless, efficient, easily accessible, technologically advanced system to support optimal care. We outline our sequential successful transformation, and describe the resistance, costs, incentives and benefits of the change. Critical factors contributing to the significant change included physician leadership, training and the rate of the endorsed change. We outline various tactics, tools, challenges and unintended benefits and problems.
The Mortality in Emergency Department Sepsis Score as a Predictor of 1-Month Mortality among Adult Patients with Sepsis: Weighing the Evidence  [PDF]
Bayushi Eka Putra,Ling Tiah
ISRN Emergency Medicine , 2013, DOI: 10.1155/2013/896802
Abstract: Objective. To evaluate the performance of Mortality in Emergency Department Sepsis (MEDS) score in comparison to biomarkers as a predictor of mortality in adult emergency department (ED) patients with sepsis. Methods. A literature search was performed using PubMed, ScienceDirect, SpringerLink, and Ovid databases. Studies were appraised by using the C2010 Consensus Process for Levels of Evidence for prognostic studies. The respective values for area under the curve (AUC) were obtained from the selected articles. Results. Four relevant articles met the selection process. Three studies defined the 1-month mortality as death occurring within 28 days of ED presentation, while the remaining one subcategorised the outcome measure as (5-day) early and (6- to 30-day) late mortality. In all four studies, the MEDS score performed better than the respective comparators (C-reactive protein, lactate, procalcitonin, and interleukin-6) in predicting mortality with an AUC ranging from 0.78 to 0.89 across the studies. Conclusion. The MEDS score has a better prognostic value than the respective comparators in predicting 1-month mortality in adult ED patients with suspected sepsis. 1. Case You have just attended to a 70-year-old male patient who presented to the emergency department (ED) with fever for 2 days associated with dysuria. He has a history of hypertension with previous ischaemic stroke and currently stays at a nursing home. On examination, he is lethargic but of normal mental status. His vital signs are as follows: temperature 38.8°C, heart rate 96 beats/min, blood pressure 110/70?mmHg, and respiratory rate 22 breaths/min. Urinalysis suggests a urinary tract infection. The white cell count is 16,000 per mm3 with 10% bands while the platelet count is 140,000 per mm3. Blood and urine cultures are sent and the appropriate antibiotics administered. Blood specimens for serum lactate and procalcitonin are also sent as part of the routine septic work-up in your ED, but the results are not available yet. Concerned about the risk of mortality and the applicability of early goal-directed therapy (EGDT) in this case, you wonder if there are any validated clinical prediction tools that can risk stratify ED patients with sepsis in a more timely manner. 2. Background Sepsis and its spectrum of clinical entities remain one of the common critical illnesses encountered in the emergency department (ED) with an estimated mortality rate of 20–30% in population-based studies [1, 2]. Timely identification with early institution of appropriate therapy for sepsis is essential for
The association of near-infrared spectroscopy-derived tissue oxygenation measurements with sepsis syndromes, organ dysfunction and mortality in emergency department patients with sepsis
Nathan I Shapiro, Ryan Arnold, Robert Sherwin, Jennifer O'Connor, Gabriel Najarro, Sam Singh, David Lundy, Teresa Nelson, Stephen W Trzeciak, Alan E Jones, the Emergency Medicine Shock Research Network (EMShockNet)
Critical Care , 2011, DOI: 10.1186/cc10463
Abstract: This prospective, observational study comprised a convenience sample of three cohorts of adult patients (age > 17 years) at three urban university emergency departments: (1) a septic shock cohort (systolic blood pressure < 90 after fluid challenge; the "SHOCK" cohort, n = 58), (2) a sepsis without shock cohort (the "SEPSIS" cohort, n = 60) and emergency department patients without infection (n = 50). We measured the StO2 initial, StO2 occlusion and StO2 recovery slopes for all patients. Outcomes were sepsis syndrome severity, organ dysfunction (SOFA score at 24 hours) and in-hospital mortality.Among the 168 patients enrolled, mean initial StO2 was lower in the SHOCK cohort than in the SEPSIS cohort (76% vs 81%), with an impaired occlusion slope (-10.2 and 5.2%/minute vs -13.1 and 4.4%/minute) and an impaired recovery slope (2.4 and 1.6%/second vs 3.9 and 1.7%/second) (P < 0.001 for all). The recovery slope was well-correlated with SOFA score at 24 hours (-0.35; P < 0.001), with a promising area under the curve (AUC) for mortality of 0.81. The occlusion slope correlation with SOFA score at 24 hours was 0.21 (P < 0.02), with a fair mortality AUC of 0.70. The initial StO2 was significantly but less strongly correlated with SOFA score at 24 hours (-0.18; P < 0.04), with a poor mortality AUC of 0.56.NIRS measurements for the StO2 initial, StO2 occlusion and StO2 recovery slope were abnormal in patients with septic shock compared to sepsis patients. The recovery slope was most strongly associated with organ dysfunction and mortality. Further validation is warranted.NCT01062685Severe sepsis currently accounts for > 500,000 emergency department (ED) visits [1] and over 750,000 cases annually in the United States [2]. While the etiologies and presentations of sepsis remain extremely heterogeneous, the disease pathophysiology comprises a dysregulated host response, activation of the inflammatory and coagulation cascades, tissue hypoxia, cellular dysfunction, organ dysfunction
Cytokine Profiles in Sepsis Have Limited Relevance for Stratifying Patients in the Emergency Department: A Prospective Observational Study  [PDF]
Virginie Lvovschi, Laurent Arnaud, Christophe Parizot, Yonathan Freund, Ga?lle Juillien, Pascale Ghillani-Dalbin, Mohammed Bouberima, Martin Larsen, Bruno Riou, Guy Gorochov, Pierre Hausfater
PLOS ONE , 2011, DOI: 10.1371/journal.pone.0028870
Abstract: Introduction Morbidity, mortality and social cost of sepsis are high. Previous studies have suggested that individual cytokines levels could be used as sepsis markers. Therefore, we assessed whether the multiplex technology could identify useful cytokine profiles in Emergency Department (ED) patients. Methods ED patients were included in a single tertiary-care center prospective study. Eligible patients were >18 years and met at least one of the following criteria: fever, suspected systemic infection, ≥2 systemic inflammatory response syndrome (SIRS) criteria, hypotension or shock. Multiplex cytokine measurements were performed on serum samples collected at inclusion. Associations between cytokine levels and sepsis were assessed using univariate and multivariate logistic regressions, principal component analysis (PCA) and agglomerative hierarchical clustering (AHC). Results Among the 126 patients (71 men, 55 women; median age: 54 years [19–96 years]) included, 102 had SIRS (81%), 55 (44%) had severe sepsis and 10 (8%) had septic shock. Univariate analysis revealed weak associations between cytokine levels and sepsis. Multivariate analysis revealed independent association between sIL-2R (p = 0.01) and severe sepsis, as well as between sIL-2R (p = 0.04), IL-1β (p = 0.046), IL-8 (p = 0.02) and septic shock. However, neither PCA nor AHC distinguished profiles characteristic of sepsis. Conclusions Previous non-multiparametric studies might have reached inappropriate conclusions. Indeed, well-defined clinical conditions do not translate into particular cytokine profiles. Additional and larger trials are now required to validate the limited interest of expensive multiplex cytokine profiling for staging septic patients.
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