title: 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.
  
  
  OBJECTIVE
  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.
authors.affiliation: Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA. seth_glickman@med.unc.edu
authors.forename: Seth W
authors.initials: SW
authors.lastname: Glickman
authors.forename: Charles B
authors.initials: CB
authors.lastname: Cairns
authors.forename: Ronny M
authors.initials: RM
authors.lastname: Otero
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Woods
authors.forename: Ephraim L
authors.initials: EL
authors.lastname: Tsalik
authors.forename: Raymond J
authors.initials: RJ
authors.lastname: Langley
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: van Velkinburgh
authors.forename: Lawrence P
authors.initials: LP
authors.lastname: Park
authors.forename: Lawrence T
authors.initials: LT
authors.lastname: Glickman
authors.forename: Vance G
authors.initials: VG
authors.lastname: Fowler
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Kingsmore
authors.forename: Emanuel P
authors.initials: EP
authors.lastname: Rivers
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000704:Analysis of Variance; D002423:Cause of Death; D015331:Cohort Studies; D003131:Combined Modality Therapy; D016001:Confidence Intervals; D018450:Disease Progression; D042241:Early Diagnosis; D004636:Emergency Service, Hospital; D004638:Emergency Treatment / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D020380:Needs Assessment; D016017:Odds Ratio; D012189:Retrospective Studies; D018570:Risk Assessment; D018805:Sepsis / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D012720:Severity of Illness Index; D012737:Sex Factors; D012772:Shock, Septic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D016019:Survival Analysis; D013997:Time Factors