Disease progression in hemodynamically stable patients presenting to the emergency department with sepsis

Abstract

Background: Aggressive diagnosis and treatment of patients presenting to the emergency department (ED) with septic shock has been shown to reduce mortality. To enhance the ability to intervene in patients with lesser illness severity, a better understanding of the natural history of the early progression from simple infection to more severe illness is needed.

Objectives: The objectives were to 1) describe the clinical presentation of ED sepsis, including types of infection and causative microorganisms, and 2) determine the incidence, patient characteristics, and mortality associated with early progression to septic shock among ED patients with infection.

Methods: This was a multicenter study of adult ED patients with sepsis but no evidence of shock. Multivariable logistic regression was used to identify patient factors for early progression to shock and its association with 30-day mortality.

Results: Of 472 patients not in shock at ED presentation (systolic blood pressure > 90 mm Hg and lactate < 4 mmol/L), 84 (17.8%) progressed to shock within 72 hours. Independent factors associated with early progression to shock included older age, female sex, hyperthermia, anemia, comorbid lung disease, and vascular access device infection. Early progression to shock (vs. no progression) was associated with higher 30-day mortality (13.1% vs. 3.1%, odds ratio [OR] = 4.72, 95% confidence interval [CI] = 2.01 to 11.1; p < or = 0.001). Among 379 patients with uncomplicated sepsis (i.e., no evidence of shock or any end-organ dysfunction), 86 (22.7%) progressed to severe sepsis or shock within 72 hours of hospital admission.

Conclusions: A significant portion of ED patients with less severe sepsis progress to severe sepsis or shock within 72 hours. Additional diagnostic approaches are needed to risk stratify and more effectively treat ED patients with sepsis.

Trial registration: ClinicalTrials.gov NCT00258869.

Figures

Figure 1

Study cohort. The study cohort at enrollment and subsequent patient outcomes at 72 hours and 30 days.

Figure 2

Kaplan-Meier survival analysis: 30-day survival stratified by early progression (72 hours) to septic shock. The figure plots 30-day survival for patients with confirmed infection who were not in shock at the time of initial ED evaluation stratified by whether they developed septic shock within 72 hours of initial ED evaluation.

Figure 3

Disease progression among patients with uncomplicated sepsis. Of the 472 patients who were not in shock at the time of enrollment, 93 had evidence of end-organ dysfunction. The remaining 379 patients had no evidence of end organ dysfunction and were categorized as having uncomplicated sepsis. Of these 379 patients with uncomplicated sepsis, 86 (22.7%) developed severe sepsis or septic shock within 72 hours.

Figure 4

Cumulative incidence of severe sepsis or septic shock among ED patients with uncomplicated sepsis (i.e., no evidence of shock or end-organ dysfunction). The figure plots 72-hour cumulative incidence of severe sepsis or septic shock among patients who had uncomplicated sepsis (i.e., no evidence of shock or end-organ dysfunction) at the time of initial ED evaluation. The cumulative incidences of severe sepsis or septic shock at 24, 28, and 72 hours were 13.5, 21.4, and 22.7%, respectively.