title: Risk factors for mortality despite early protocolized resuscitation for severe sepsis and septic shock in the emergency department.
abstract: OBJECTIVE
  The purpose was to identify risk factors associated with in-hospital mortality among emergency department (ED) patients with severe sepsis and septic shock managed with early protocolized resuscitation.
  
  
  METHODS
  This was a retrospective, observational cohort study in an academic, tertiary care ED. We enrolled 411 adult patients with severe sepsis and lactate ≥4.0 mmol/L (n = 203) or septic shock (n = 208) who received protocolized resuscitation from 2005 to 2009. Emergency department variables, microbial cultures, and in-hospital outcomes were obtained from the medical record. Multivariable regression was used to identify factors independently associated with in-hospital mortality.
  
  
  RESULTS
  Mean age was 59.5 ± 16.3 years; 57% were male. Mean lactate was 4.8 mmol/L (3.5-6.7), 54% had positive cultures, and 27% received vasopressors in the ED. One hundred and five (26%) patients died in-hospital. Age, active cancer, do-not-resuscitate status on ED arrival, lack of fever, hypoglycemia, and intubation were independently associated with increased in-hospital mortality. Lactate clearance and diabetes were associated with a decreased risk of in-hospital death.
  
  
  CONCLUSIONS
  We identified a number of factors that were associated with in-hospital mortality among ED patients with severe sepsis or septic shock despite treatment with early protocolized resuscitation. These findings provide insights into aspects of early sepsis care that can be targets for future intervention.
authors.affiliation: Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104. Electronic address: byron.drumheller@gmail.com.
authors.forename: Byron C
authors.initials: BC
authors.lastname: Drumheller
authors.affiliation: Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104. Electronic address: anishagarwal3@gmail.com.
authors.forename: Anish
authors.initials: A
authors.lastname: Agarwal
authors.affiliation: Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104. Electronic address: mark.mikkelsen@uphs.upenn.edu.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Mikkelsen
authors.affiliation: Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104. Electronic address: cham_sante@yahoo.com.
authors.forename: S Cham
authors.initials: SC
authors.lastname: Sante
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104. Electronic address: webera@mail.med.upenn.edu.
authors.forename: Anita L
authors.initials: AL
authors.lastname: Weber
authors.affiliation: Department of Emergency Medicine, Washington Hospital Center, Georgetown University School of Medicine, 110 Irving St NW, Washington DC, 20010. Electronic address: munish.goyal@medstar.net.
authors.forename: Munish
authors.initials: M
authors.lastname: Goyal
authors.affiliation: Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 111 S 11th St, Philadelphia PA, 19107. Electronic address: david.gaieski@jefferson.edu.
authors.forename: David F
authors.initials: DF
authors.lastname: Gaieski
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001778:Blood Coagulation Disorders / Q000097:blood / Q000453:epidemiology; D001786:Blood Glucose; D001806:Blood Urea Nitrogen; D002985:Clinical Protocols; D015331:Cohort Studies; D015897:Comorbidity; D061345:Early Medical Intervention; D004636:Emergency Service, Hospital; D005260:Female; D005334:Fever / Q000453:epidemiology*; D017052:Hospital Mortality; D006801:Humans; D007003:Hypoglycemia / Q000453:epidemiology*; D019934:International Normalized Ratio; D019344:Lactic Acid / Q000097:blood; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009369:Neoplasms / Q000453:epidemiology*; D012151:Resuscitation; D016414:Resuscitation Orders; D012189:Retrospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000097:blood / Q000401:mortality / Q000628:therapy; D012772:Shock, Septic / Q000097:blood / Q000401:mortality* / Q000628:therapy; D062606:Tertiary Care Centers; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
chemical_list: D001786:Blood Glucose; D014662:Vasoconstrictor Agents; D019344:Lactic Acid
keywords: Early goal-directed therapy; Emergency services; Mortality; Risk factors; Sepsis; Septic shock