- Sozio Emanuela
- Original Article
Early detection of severe cases due to sepsis in Emergency Department in in the era of New Diagnostic Criteria: preliminary data from an Italian “real life” study
- 2/2019-giugno
- ISSN 2532-1285
- https://doi.org/10.23832/ITJEM.2019.017

Sozio Emanuela1, Tarabori Serena2, Bertolino Giacomo3, Carfagna Fabio 4, Novelli Francesca2, Di Paco Irene 1, Tascini Carlo5, Santini Massimo6, Ghiadoni Lorenzo2, Bertini Alessio1

-
Emergency Department , North-West District, Tuscany Health Care, Spedali Riuniti Livorno, Leghorn, Italy
-
Emergency Medicine Unit, Nuovo Santa Chiara University Hospital, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
-
Department of Public Health, Clinical and Molecular Medicine, Università degli studi di Cagliari, Italy
-
Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
-
First Division of Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, Naples, Italy
- Emergency Department, Nuovo Santa Chiara University Hospital, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy

Abstract
Keywords
Sepsis-3; Sepsis; Septic shock; qSOFA; MEWS
Abbreviations
Introduction
Early recognition is a key point of the entire management of sepsis because it allows a timely treatment and this improves survival1, 2. Worldwide estimated incidence is 270 cases per 100,000 inhabitants/year and the mortality rate ranges between 20 and 40%3.
Methods
This real-life prospective study enrolled 349 patients admitted to the ED of Pisa Hospital from 1 March 2017 to 31 May 2018 with diagnosis of infection with or without clinical criteria of sepsis or septic shock, according to the new definitions of sepsis and septic shock (Sepsis -3). Cases were identified through the ICD-9-CM codes and the ED discharge diagnosis of sepsis, severe sepsis or septic shock. The definition was different because the new one had not been introduced in (the) daily clinical practice yet.
Results
|
Overall population |
Infections without sepsis or septic shock criteria |
Sepsis or septic shock criteria |
p-value |
(n = 349) |
(n = 54) |
(n = 295) |
||
Age |
80.0 (71.0 – 87.0) |
76.0 (65.0 – 85.0) |
81.0 (72.0 – 87.0) |
p = 0.023 |
Male sex |
211 (60%) |
36 (67%) |
175 (59%) |
p = 0.388 |
Diabetes |
87 (25%) |
17 (31%) |
70 (24%) |
p = 0.298 |
CCI |
2.0 (1.0 – 4.0) |
3.0 (2.0 – 5.0) |
2.0 (1.0 – 4.0) |
p = 0.015 |
qSOFA |
86/316 (27%) |
2/52 (4%) |
84/264 (32%) |
p < 0.001 |
SOFA score |
4.0 (3.0 – 6.0) |
3.0 (1.0 – 4.0) |
4.0 (3.0 – 6.0) |
p < 0.001 |
GCS |
15.0 (13.0 – 15.0) |
15.0 (15.0 – 15.0) |
15.0 (11.0 – 15.0) |
p < 0.001 |
MEWS |
2.0 (1.0 – 4.0) |
1.0 (0.0 – 2.0) |
3.0 (1.0 – 5.0) |
p < 0.001 |
Shock Index |
0.8 (0.7 – 1.1) |
0.7 (0.6 – 0.8) |
0.8 (0.7 – 1.1) |
p = 0.001 |
End-stage renal failure |
11 (3%) |
3 (6%) |
8 (3%) |
p = 0.396 |
Chronic Liver diseases |
19 (5%) |
5 (9%) |
14 (5%) |
p = 0.309 |
COPD |
44 (13%) |
13 (24%) |
31 (11%) |
p = 0.011 |
Tumors |
68 (19%) |
18 (33%) |
50 (17%) |
p = 0.009 |
Immunodepression / immunosuppresion |
35 (10%) |
8 (15%) |
27 (9%) |
p = 0.304 |
Previous surgery |
32 (9%) |
6 (11%) |
26 (9%) |
p = 0.778 |
Previous trauma exposure |
22 (6%) |
3 (6%) |
19 (6%) |
p = 1.000 |
Previous antimicrobial treatments |
126/343 (37%) |
22/53 (42%) |
104/290 (36%) |
p = 0.529 |
Corticosteroid treatments |
62 (18%) |
12 (22%) |
50 (17%) |
p = 0.460 |
Prostheses |
57 (16%) |
13 (24%) |
44 (15%) |
p = 0.141 |
CVC |
38 (11%) |
5 (9%) |
33 (11%) |
p = 0.857 |
Bladder Catheter |
57 (16.3%) |
5 (9.3%) |
52 (17.8%) |
p = 0.120 |
SIRS criteria |
233 (67%) |
30 (56%) |
203 (69%) |
p = 0.081 |
Hospitalization |
331 (95%) |
52 (96%) |
279 (95%) |
p = 0.849 |
ICU |
30 (9%) |
2 (4%) |
28 (9%) |
p = 0.258 |
Overall mortality |
76 (22%) |
4 (7%) |
72 (24%) |
p = 0.009 |
In-emergency department mortality |
14 (4%) |
0 (0%) |
14 (5%) |
p = 0.126 |
In-Hospital mortality |
62/331 (19%) |
4/52 (8%) |
58/279 (21%) |
p = 0.042 |
Discharge a home |
4 (1%) |
2 (4%) |
2 (1%) |
p = 0.130 |
Length of hospital stay (days) |
7.0 (4.0 – 10.0) |
6.5 (5.0 – 12.0) |
7.0 (4.0 – 10.0) |
p = 0.213 |
MAP |
132.7 (113.3 – 156.7) |
139.7 (122.7 – 162.0) |
128.3 (111.7 – 156.7) |
p = 0.041 |
Hypotension |
101/313 (32%) |
7/50 (14%) |
94/263 (36%) |
p = 0.004 |
Body Temperature (°C) |
37.6 (36.7 – 38.5) |
37.6 (36.5 – 38.1) |
37.6 (36.7 – 38.5) |
p = 0.285 |
WBC ᴧ103 |
13.9 (9.4 – 20.8) |
13.9 (10.0 – 20.1) |
13.8 (9.3 – 21.1) |
p = 0.865 |
Platelets ᴧ106 |
190.0 (126.0 – 276.0) |
217.0 (170.0 – 289.0) |
184.0 (123.0 – 273.0) |
p = 0.058 |
Plasmatic creatinine value (mg/dl) |
1.4 (0.9 – 2.2) |
1.2 (0.9 – 2.1) |
1.4 (1.0 – 2.3) |
p = 0.130 |
Lactate value (mmol/l) |
1.8 (1.1 – 3.3) |
1.0 (0.8 – 1.2) |
2.1 (1.2 – 3.6) |
p < 0.001 |
PCT value (pg/ml) |
2.3 (0.6 – 11.2) |
1.0 (0.4 – 4.4) |
2.7 (0.7 – 12.4) |
p = 0.010 |
Bilirubin value (mg/dl) |
0.6 (0.4 – 1.1) |
0.5 (0.3 – 0.7) |
0.7 (0.4 – 1.2) |
p = 0.006 |
Blood cultures |
128/314 (41%) |
22/52 (42%) |
106/262 (40%) |
p = 0.925 |
Intravenous fluids |
303 (87%) |
46 (85%) |
257 (87%) |
p = 0.867 |
Antibiotic therapy BEFORE sampling blood cultures |
89/126 (71%) |
17/23 (74%) |
72/103 (70%) |
p = 0.898 |
Empiric antibiotic therapy |
249/343 (73%) |
38/53 (72%) |
211/290 (73%) |
p = 1.000 |
Qualitative variables |
Survivors (n=273) |
Overall mortality (n=76) |
*p value chi square or fisherF’s test |
||
n. |
% |
n. |
% |
||
Male Sex |
169 |
61.9% |
42 |
55.3% |
0.295 |
End-stage renal failure |
9 |
3.3% |
2 |
2.6% |
1.000 |
Cardiovascular diseases |
125 |
45.8% |
42 |
55.3% |
0.144 |
COPD |
31 |
11.4% |
13 |
17.1% |
0.182 |
Diabetes |
69 |
25.3% |
18 |
23.7% |
0.777 |
Chronic Liver diseases |
17 |
6.2% |
2 |
2.6% |
0.389 |
Immunodepression/ immunosuppression |
26 |
9.5% |
9 |
11.8% |
0.552 |
Tumors |
59 |
21.6% |
9 |
11.8% |
0.057 |
Previous Corticosteroid treatments |
43 |
15.8% |
19 |
25.0% |
0.062 |
Previous trauma exposure |
18 |
6.6% |
4 |
5.3% |
0.795 |
Previous surgery |
25 |
9.2% |
7 |
9.2% |
0.989 |
CVC |
28 |
10.3% |
10 |
13.2% |
0.473 |
Bladder Catheter |
41 |
15.0% |
16 |
21.1% |
0.208 |
Prostheses |
49 |
17.9% |
8 |
10.5% |
0.122 |
Altered mental status |
61 |
22.3% |
43 |
56.6% |
<0.001 |
Hypotension |
67 |
27.6% |
34 |
48.6% |
0.001 |
PAM <=70 |
4 |
1.6% |
2 |
2.9% |
0.619 |
Hypothermia or Hyperthermia |
97 |
39.0% |
14 |
22.2% |
0.013 |
Lactate > 1.8 mmol/L |
118 |
43.7% |
62 |
83.8% |
<0.001 |
Leukocytosis or leukopenia |
177 |
65.3% |
54 |
73.0% |
0.214 |
PCT ≥ 0.5 pg/ml |
202 |
76.8% |
63 |
88.7% |
0.028 |
Creatinine ≥ 1.2 mg/dl |
153 |
56.5% |
54 |
74.0% |
0.007 |
Bilirubin ≥ 1.2 mg/dl |
34 |
18.6% |
15 |
32.6% |
0.038 |
PLT ≤ ᴧ106 |
97 |
35.8% |
25 |
33.8% |
0.749 |
qSOFA criteria |
48 |
19.3% |
38 |
56.7% |
<0.001 |
SIRS criteria |
176 |
64.5% |
57 |
75.0% |
0.085 |
MEWS ≥ 5 |
49 |
17.9% |
35 |
46.1% |
<0.001 |
Shock index ≥ 0.7 |
162 |
67.8% |
56 |
81.2% |
0.031 |
Quantitative variables |
Survived |
Dead |
*p value Mann-Whitney Test |
||
Median |
25-75 Percentile |
Median |
25-75 Percentile |
||
Age |
79.0 |
[70 – 86] |
84.0 |
[73.5 – 90] |
0.013 |
CCI |
2.0 |
[1 – 4] |
3.0 |
[1 – 4] |
0.366 |
GCS |
15.0 |
[14 – 15] |
10.5 |
[6 – 15] |
<0.001 |
MAP |
136.67 |
[115 – 160] |
120.00 |
[103 – 140] |
0.001 |
Body Temperature (°C) |
37.8 |
[36.8 – 38.5] |
37.0 |
[36.0 – 38] |
0.001 |
Lactate value (mmol/l) |
1.6 |
[1.0 – 2.7] |
3.9 |
[2.0 – 6.6] |
<0.001 |
WBC ᴧ103 |
13.49 |
[9.27 – 19.75] |
15.91 |
[9.43 – 24.92] |
0.072 |
PCT (pg/ml) |
2.0 |
[0.5 – 10.6] |
3.0 |
[1.2 – 16.8] |
0.038 |
Plasmatic creatinine (mg/dl) |
1.3 |
[0.9 – 1.9] |
2.0 |
[1.1 – 3.5] |
<0.001 |
Bilirubin (mg/dl) |
0.59 |
[0.38 – 1.00] |
0.96 |
[0.47 – 1.60] |
0.005 |
Platelets ᴧ106 |
186.0 |
[128.0- 274.0] |
195.5 |
[109 – 292] |
0.942 |
SOFA SCORE |
4.0 |
[3.0 – 5.0] |
6.0 |
[4.0 – 9.0] |
<0.001 |
MEWS |
2.0 |
[1.0 – 4.0] |
4.0 |
[2.5 – 6.0] |
<0.001 |
Shock index |
0.77 |
[0.65 – 0.98] |
0.98 |
[0.77 – 1.29] |
<0.001 |
Variables |
OR |
CI 95% |
p value |
Male sex |
0.760 |
0.455 – 1.271 |
0.296 |
Age |
1.026 |
1.002 – 1.050 |
0.031 |
End-stage renal failure |
0.793 |
0.168 – 3.749 |
0.770 |
Cardiovascular diseases |
1.463 |
0.877 – 2.438 |
0.145 |
COPD |
1.611 |
0.796 – 3.258 |
0.185 |
Diabetes |
0.918 |
0.506 – 1.664 |
0.777 |
Chronic Liver diseases |
0.407 |
0.092 – 1.802 |
0.236 |
Immunodepression / immunosuppression |
1.276 |
0.571 – 2.853 |
0.553 |
Tumors |
0.487 |
0.229 – 1.035 |
0.061 |
Previous Corticosteroid treatments |
1.783 |
0.966 – 3.291 |
0.064 |
Previous trauma exposure |
0.787 |
0.258 – 2.399 |
0.674 |
Previous surgery |
1.006 |
0.418 – 2.425 |
0.989 |
CVC |
1.326 |
0.613 – 2.868 |
0.474 |
Bladder catheter |
1.509 |
0.793 – 2.872 |
0.210 |
Prostheses |
0.538 |
0.243 – 1.191 |
0.126 |
Hypotension |
2.481 |
1.436 – 4.286 |
0.001 |
Hypothermia or Hyperthermia |
0.448 |
0.235 – 0.854 |
0.015 |
Leukocytosis or leukopenia |
1.434 |
0.81 – 2.537 |
0.216 |
qSOFA criteria |
5.487 |
3.082 – 9.769 |
<0.001 |
SIRS criteria |
1.653 |
0.930 – 2.939 |
0.087 |
CCI |
0.998 |
0.895 – 1.113 |
0.968 |
SOFA score |
1.467 |
1.316 – 1.636 |
<0.001 |
GCS |
0.804 |
0.753 – 0.858 |
<0.001 |
MAP |
0.986 |
0.977 – 0.995 |
0.002 |
Body Temperature |
0.660 |
0.517 – 0.844 |
0.001 |
Lactate value |
1.364 |
1.224 – 1.519 |
<0.001 |
WBC |
1.036 |
1.011 – 1.062 |
0.005 |
PCT |
1.005 |
0.996 – 1.014 |
0.310 |
Creatinine value |
1.325 |
1.14 – 1.541 |
<0.001 |
Bilirubin value |
1.433 |
1.105 – 1.858 |
0.007 |
Platelets |
1.000 |
0.998 – 1.002 |
0.919 |
MEWS |
1.333 |
1.205 – 1.475 |
<0.001 |
Shock index |
6.582 |
2.793 – 15.514 |
<0.001 |

Discussion and Conclusion
Conclusions
Sepsis is of great clinical importance, being responsible for more than one third of all hospital admissions, and it is associated with a large economic burden on healthcare. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) reviewed and updated sepsis definitions. Sepsis is now defined as a “life-threatening organ dysfunction caused by a dysregulated host response to infection”; organ dysfunction is defined as an increase in SOFA score ≥ 2 but SOFA requires laboratory values which may not be rapidly available. qSOFA was developed to provide an abbreviated version that can easily be performed at the bedside by the non-specialist but the main utility of qSOFA appears to be for the characterization of patients with suspected or known infection, in whom sepsis should be considered, who are at a higher risk of developing a poor outcome, and who may benefit from more frequent observations and targeted interventions.
Although all clinical tools used for early diagnosis of triage in ED were sub-optimal, our preliminary analysis showed that lactates value and the use of clinical tools in ED such as EWS (in our case the MEWS) or more simply the shock index, could be used in the triage phase to identify patients at risk of poor prognosis due to sepsis or septic shock. Using these tools as “red flags”, an immediate management could be carried out, after a “few minutes” evaluation during triage phases.
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