title: Predictors of Acute Hemodynamic Decompensation in Early Sepsis: An Observational Study.
abstract: BACKGROUND
  The study of sepsis is hindered by its heterogeneous time course and evolution. A subgroup of patients with severe sepsis develops shock soon after the initiation of treatment while others present hypotensive. We sought to determine the incidence of hypotension after the initiation of treatment for sepsis, and characterize their clinical features and course.
  
  
  METHODS
  A retrospective review of electronic medical record of all septic patients (n = 542) that met the definition of septic shock within 24 hours of admission (2011 - 2012) at an urban Veteran Affairs Hospital was performed. Subjects either had 1) initial normotension (INT) with hypotension developing within 24 hours or 2) initial hypotension (IH). Logistic regression was used to model associated factors of INT/IH.
  
  
  RESULTS
  INT occurred in 62 patients (11%) with average initial blood pressure of 120/71 mm Hg and developed hypotension to 79/48 mm Hg. IH was identified in 52 patients (10%) with average presenting blood pressure of 81/46 mm Hg. INT showed evidence of increased sympathetic tone with significantly higher heart rate, blood pressure and temperature. INT patients were younger, more frequently on alpha-blockers, and more likely septic from pneumonia compared to IH patients. INT and IH patients had similar timing of antibiotic initiation, amount of 24-hour fluid resuscitation, vasopressor use, organ dysfunction and mortality at 28 days. Using alpha-blockers, being Caucasian, and having higher temperatures were independent predictors of INT.
  
  
  CONCLUSIONS
  INT is a distinctive presentation of septic shock characterized by rapid deterioration during early treatment. By further studying this subgroup, mediators of septic shock may be identified that clarify pathophysiology and provide timely targeted treatment.
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University School of Medicine, New York, NY, USA; Pulmonary and Critical Care Sections of Veterans Administration, New York Harbor Healthcare System, New York, NY, USA; Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Young Im
authors.initials: YI
authors.lastname: Lee
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University School of Medicine, New York, NY, USA; Pulmonary and Critical Care Sections of Veterans Administration, New York Harbor Healthcare System, New York, NY, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Smith
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University School of Medicine, New York, NY, USA.
authors.forename: Yevgeniya
authors.initials: Y
authors.lastname: Gartshteyn
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University School of Medicine, New York, NY, USA.
authors.forename: Sophia
authors.initials: S
authors.lastname: Kwon
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University School of Medicine, New York, NY, USA.
authors.forename: Erin J
authors.initials: EJ
authors.lastname: Caraher
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University School of Medicine, New York, NY, USA; Pulmonary and Critical Care Sections of Veterans Administration, New York Harbor Healthcare System, New York, NY, USA.
authors.forename: Anna
authors.initials: A
authors.lastname: Nolan
keywords: Adrenergic effects; Fluid therapy; Rehydration solutions; Sepsis; Septic shock; Vascular hypotension