Evaluation Of Diagnostic Criteria In The Early Identification And Treatment Of Sepsis

Title: EVALUATION OF DIAGNOSTIC CRITERIA IN THE EARLY IDENTIFICATION AND TREATMENT OF SEPSIS. Christopher A. Zirker, Charles R. Wira III. Department of Emergency Medicine, Yale University, School of Medicine, New Haven, CT. The recently introduced Sepsis-3 guidelines have yet to be applied to the emergency department (ED) setting. To compare these new definitions clinically with those of Sepsis-2, a retrospective analysis was performed using a dual-center ED registry of patients prospectively identified as having sepsis with organ dysfunction as defined by Sepsis-2. Of 446 registry patients meeting Sepsis-2 criteria, 61.0% (n = 272) had an elevated qSOFA score. 28-day in hospital mortality for patients with an elevated qSOFA was 15.8% compared to 10.9% in patients with non-elevation (p = .162). Rates of mechanical ventilation and vasopressor infusion were 38.6% and 36.4% respectively for patients with elevated qSOFA compared to 19.5% and 13.8% for patients without qSOFA elevation (p < .001). Patients with an elevated qSOFA and a serum lactate >2 mmol/L had a mortality rate of 18.1% vs 8.8% (p = .006) in patients with non-elevated qSOFA or normal lactate. Patients with septic shock as defined by Sepsis-3 (n = 50) had a mortality rate of 34.0% compared to 29.1% in patients with septic shock as defined by Sepsis-2 (n = 79; p = .565). 85.0% (n = 379) of patients had a SOFA score of 2 or higher thus meeting the definition of sepsis, with 30.5% (n = 136) of patients having all data available for calculating a complete SOFA score. Mortality rates were 15.6% in patients with a SOFA score of 2 or greater compared to 4.5% in those without (p = .016). While the Sepsis-3 definitions may help identify patients with a greater risk for mechanical ventilation, vasopressor infusion, and death, the percentage of patients meeting Sepsis-2 criteria who do not meet Sepsis-3 may limit the prognostic utility of these new definitions. Addition of serum lactate to the qSOFA may improve prognostic value and should be investigated further in the ED phase of care. Acknowledgements I would like to extend great thanks to Dr. Charles R. Wira, III, for his help during the development of this work. He is a fantastic mentor and friend, and I have appreciated his generosity of time, knowledge, and enthusiasm throughout the period while we have collaborated on this project. I would additionally like to acknowledge the Yale Emergency Medicine Administrative Section and the Yale DEM EMCCM Division for their support with this work. Specifically, I would like to recognize Drs. John Sather, Ani Aydin, Justin Belsky, Andrew Taylor, and Vivek Parwani for their guidance and support. I would like to thank Bethann Mohammed for her preliminary work with this data, as well as Melissa Wolan, Martina Sanders-Spight, Sundeep Bhat, and Kai Swenson who contributed towards the development of the Yale Emergency Medicine Sepsis Registry and performed prior research from which this work is derived. I would also like to thank my grandfather, Bill Anzalone, and my mother, Toni Anzalone, for the extensive support they have provided to me and my family which has enabled me to attend medical school and thus have the opportunity to complete this work. I would like to thank my children, Tristan, Dylan, and Zach for the enthusiasm they generate about even the most simple things in our world, but most importantly their enthusiasm for me. I return it wholeheartedly. Lastly, I would like to thank my wife, Catherine, for her love as well as tremendous patience and support through the long hours and erratic demands of my medical training. While I may never be able to fully understand the magnitude of the hardships and sacrifices you’ve endured in supporting me through this time, it does not dampen the depth of my appreciation. Thanks for being such a wonderful wife, mother, and friend. Table of