Disease Progression in Hemodynamically Stable Patients Presenting to the Emergency Department With Sepsis

Authors

  • Seth W. Glickman MD,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Charles B. Cairns MD,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Ronny M. Otero MD,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Christopher W. Woods MD, MPH,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Ephraim L. Tsalik MD, PhD,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Raymond J. Langley PhD,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Jennifer C. Van Velkinburgh PhD,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Lawrence P. Park PhD,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Lawrence T. Glickman VMD, DrPH,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Vance G. Fowler Jr MD, MHS,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Stephen F. Kingsmore MMB, ChB, BAO,

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Emanuel P. Rivers MD, MPH

    1. From the Department of Emergency Medicine, University of North Carolina School of Medicine (SWG, CBC, LTG), Chapel Hill, NC; Henry Ford Hospital (RMO, EPR), Detroit, MI; the Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine (CWW, ELT, LPP, VGF), Durham, NC; and the National Center for Genome Resources (RJL, JCV, SFK), Santa Fe, NM.
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  • Presented at the Society for Academic Emergency Medicine, New Orleans, LA, May 2009.

  • This work was supported by NIH grants AI066569 and P20RR016480, NIH contract HHSN266200400064C, and grants from Pfizer Inc. and Roche Diagnostics Inc. (2005–2010).

  • This study is registered at ClinicalTrials.gov (NCT00258869).

Address for correspondence and reprints: Seth W. Glickman, MD; e-mail: seth_glickman@med.unc.edu.

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 ≤ 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.

ACADEMIC EMERGENCY MEDICINE 2010; 17:383–390 © 2010 by the Society for Academic Emergency Medicine

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