An investigation of temperature and fever burdens in patients with sepsis admitted from the emergency department to the hospital.

Aim: We sought to collect granular data on temperature burden to further explore existing conflicting information on the relationship between temperature alterations and outcomes in patients with sepsis requiring hospital admission. Methods: This was a prospective cohort study that enrolled a convenience sample of patients with sepsis or septic shock admitted to the hospital from the emergency department (ED). A "unit of temperature burden (UTB)" was defined as >1°C (1.8°F) above or below 37°C (98.6°F) for 1 min. Fever burden was defined as the number of UTBs >38°C (100.4°F). The primary objective was to calculate the fever burden in patients with sepsis during their ED stay. This was analyzed for patients who present to triage febrile or hypothermic and also for those who developed temperature abnormalities during their ED stay. The secondary objectives were correlating fever and hypothermia burden with in-hospital mortality, Systemic Inflammatory Response Syndrome (SIRS) criteria, and the quick Sequential (Sepsis-Associated) Organ Failure Assessment (qSOFA) score and identification of patients who may benefit from early implementation of targeted temperature management. Results: A total of 256 patients met the inclusion criteria. The mean age of patients was 60.1 ± 18.4 years; 46% were female and 29.6% were black. The median (interquartile range [IQR]) fever burden for the fever in triage cohort (n = 99) was 364.6 (174.3-716.8) UTB and for the no fever in triage cohort (n = 157) was 179.3 (80.9-374.0) UTB (p = 0.005). The two groups had similar in-hospital mortality (6.1 vs 8.3%; p = 0.5). The median fever burden for the fever anytime cohort was 303.8 (IQR 138.8-607.9) UTB and they had lower mortality than the no fever anytime cohort (4.7% vs 11.2%; p = 0.052). Patients with fever at triage had higher mean SIRS criteria than those without (2.8 vs 2.0; p < 0.001) while qSOFA points were similar (p = 0.199). A total of 27 patients had hypothermia during their ED stay and these patients were older with higher mean SIRS criteria. Conclusions: Patients with sepsis and septic shock have a significant temperature burden in the ED. When comparing patients who had fever at any time during their ED stay with those who never had a fever, a trend toward an inverse relationship between fever burden and mortality was found.

Development, implementation, and refinement of a comprehensive postcardiac arrest care training course in Japan.

Aim: In Japan, no training course is dedicated to postcardiac arrest care (PCAC), including venoarterial extracorporeal membrane oxygenation (VA-ECMO); thus, faculty members of the Japanese Circulation Society developed an original, comprehensive PCAC training course. This report reviews the development, implementation, and refinement of this PCAC training course. Methods: We examined the preserved data from the Japanese Circulation Society PCAC training courses between 2014 and 2020. Data related to the learning content and number of the attendees and instructors were collected and summarized. Results: Sixteen courses were held between August 2014 and February 2020, before the coronavirus disease 2019 (COVID-19) pandemic. A total of 677 health care providers participated: 351 doctors, 225 nurses, 62 perfusionists, five emergency medical professionals, and two pharmacists. Thirty-two attendees' data were missing. The core learning contents of all the courses included a standardized postcardiac arrest algorithm, targeted temperature management, VA-ECMO cannulation skills, and postcannulation management. Concerning curriculum evolution, extracorporeal cardiopulmonary resuscitation simulation, postarrest neurological examination and monitoring, and ultrasound-guided Seldinger technique training were added in the 4th, 5th, and 13th courses, respectively. Conclusion: The Japanese Circulation Society PCAC training course has been developed and refined to provide an organized, comprehensive opportunity for health care providers to acquire specific knowledge and skills in PCAC and VA-ECMO.

Ventilator Management and Respiratory Care After Cardiac Arrest: Oxygenation, Ventilation, Infection, and Injury.

Return of spontaneous circulation after cardiac arrest results in a systemic inflammatory state called the post-cardiac arrest syndrome, which is characterized by oxidative stress, coagulopathy, neuronal injury, and organ dysfunction. Perturbations in oxygenation and ventilation may exacerbate secondary injury after cardiac arrest and have been shown to be associated with poor outcome. Further, patients who experience cardiac arrest are at risk for a number of other pulmonary complications. Up to 70% of patients experience early infection after cardiac arrest, and the respiratory tract is the most common source. Vigilance for early-onset pneumonia, as well as aggressive diagnosis and early antimicrobial agent administration are important components of critical care in this population. Patients who experience cardiac arrest are at risk for the development of ARDS. Risk factors include aspiration, pulmonary contusions (from chest compressions), systemic inflammation, and reperfusion injury. Early evidence suggests that they may benefit from ventilation with low tidal volumes. Meticulous attention to mechanical ventilation, early assessment and optimization of respiratory gas exchange, and therapies targeted at potential pulmonary complications may improve outcomes after cardiac arrest.

Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).

PURPOSE: To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. METHODS: We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. RESULTS: Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. CONCLUSIONS: Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.

The association between hemoglobin concentration and neurologic outcome after cardiac arrest.

PURPOSE: The purpose of the study is to determine the association between hemoglobin concentration (Hgb) and neurologic outcome in postarrest patients. METHODS: We conducted a retrospective cohort study using the Penn Alliance for Therapeutic Hypothermia (PATH) cardiac arrest registry. Inclusion criteria were resuscitated cardiac arrest (inhospital or out of hospital) and an Hgb value recorded within 24 hours of return of spontaneous circulation. The primary outcome was favorable neurologic status at hospital discharge. Survival to hospital discharge was a secondary outcome. RESULTS: There were 598 eligible patients from 21 hospitals. Patients with favorable neurologic outcome had significantly higher median Hgb in the first 2 hours (12.7 vs 10.5 g/dL; P<.001) and 6 hours (12.6 vs 10.6 g/dL; P<.001) postarrest. Controlling for age, pulseless rhythm, etiology, location of arrest, receipt of targeted temperature management, hematologic or metastatic malignancy, or preexisting renal insufficiency, there was a significant relationship between Hgb and neurologic outcome within the first 6 hours after arrest (odds ratio, 1.23; 95% confidence interval, 1.09-1.38) and survival to hospital discharge (odds ratio, 1.20; 95% confidence interval, 1.08-1.34). CONCLUSION: Higher Hgb after cardiac arrest is associated with favorable neurologic outcome, particularly within the first 6 hours. It is unclear if this effect is due to impaired oxygen delivery or if Hgb is a marker for more severe illness.

Inflammatory markers following resuscitation from out-of-hospital cardiac arrest-A prospective multicenter observational study.

AIM: The post-cardiac arrest syndrome is a complex set of pathophysiological processes including a systemic inflammatory response. The goal of the current investigation was to test the hypothesis that early inflammatory markers are independently associated with in-hospital mortality and poor neurological outcome in patients initially resuscitated from out-of-hospital cardiac arrest. METHODS: This was a preplanned analysis of data collected from a prospective observational multicenter study in adult out-of-hospital cardiac arrest patients. Blood was drawn at baseline, 12 and 24h after return of spontaneous circulation and plasma levels of interleukin (IL)-1ß, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-8, IL-10 and tumor necrosis factor (TNF)-α were measured. The primary outcome measure was survival to hospital discharge. We utilized a mixed linear model to compare the levels of cytokines in survivors and non-survivors over time. We used multivariable logistic regression to assess the association between IL-6 levels and mortality. RESULTS: A total of 102 patients were analyzed. Non-survivors and patients with poor functional outcome had statistical significant higher IL-1Ra, IL-6, IL-8, and IL-10 levels (all p<0.001) at all time points (0, 12 and 24h) compared to survivors. Baseline IL-6 levels were a good predictor of mortality (AUC=0.83 [95%CI: 0.75-0.92]). Baseline IL-6 levels were strongly associated with mortality in multivariable analysis (OR: 2.58 [95%CI: 1.93-3.45], p<0.001) but were not associated with neurological outcome in multivariable analysis (OR: 1.33 [95%CI: 0.62-2.86], p=0.47). CONCLUSION: Early inflammatory markers, especially IL-6, are higher in patients with a poor outcome after OHCA. IL-6 remained associated with mortality, but not functional outcome, in multivariable analysis adjusting for patient and event characteristics.

Risk factors for mortality despite early protocolized resuscitation for severe sepsis and septic shock in the emergency department.

PURPOSE: 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.

Post-Acute Care Use and Hospital Readmission after Sepsis.

RATIONALE: The epidemiology of post-acute care use and hospital readmission after sepsis remains largely unknown. OBJECTIVES: To examine the rate of post-acute care use and hospital readmission after sepsis and to examine risk factors and outcomes for hospital readmissions after sepsis. METHODS: In an observational cohort study conducted in an academic health care system (2010-2012), we compared post-acute care use at discharge and hospital readmission after 3,620 sepsis hospitalizations with 108,958 nonsepsis hospitalizations. We used three validated, claims-based approaches to identify sepsis and severe sepsis. MEASUREMENTS AND MAIN RESULTS: Post-acute care use at discharge was more likely after sepsis, driven by skilled care facility placement (35.4% after sepsis vs. 15.8%; P < 0.001), with the highest rate observed after severe sepsis. Readmission rates at 7, 30, and 90 days were higher postsepsis (P < 0.001). Compared with nonsepsis hospitalizations (15.6% readmitted within 30 d), the increased readmission risk was present regardless of sepsis severity (27.3% after sepsis and 26.0-26.2% after severe sepsis). After controlling for presepsis characteristics, the readmission risk was found to be 1.51 times greater (95% CI, 1.38-1.66) than nonsepsis hospitalizations. Readmissions after sepsis were more likely to result in death or transition to hospice care (6.1% vs. 13.3% after sepsis; P < 0.001). Independent risk factors associated with 30-day readmissions after sepsis hospitalizations included age, malignancy diagnosis, hospitalizations in the year prior to the index hospitalization, nonelective index admission type, one or more procedures during the index hospitalization, and low hemoglobin and high red cell distribution width at discharge. CONCLUSIONS: Post-acute care use and hospital readmissions were common after sepsis. The increased readmission risk after sepsis was observed regardless of sepsis severity and was associated with adverse readmission outcomes.

Epidemiology and outcomes in patients with severe sepsis admitted to the hospital wards.

PURPOSE: The purpose of this study was to detail the trajectory and outcomes of patients with severe sepsis admitted from the emergency department to a non-intensive care unit (ICU) setting and identify risk factors associated with adverse outcomes. MATERIAL AND METHODS: This was a single-center retrospective cohort study conducted at a tertiary, academic hospital in the United States between 2005 and 2009. The primary outcome was a composite outcome of ICU transfer within 48 hours of admission and/or 28-day mortality. RESULTS: Of 1853 patients admitted with severe sepsis, 841 (45%) were admitted to a non-ICU setting, the rate increased over time (P < .001), and 12.5% of these patients were transferred to the ICU within 48 hours and/or died within 28 days. In multivariable models, age (P < .001), an oncology diagnosis (P < .001), and illness severity as measured by Acute Physiologic and Chronic Health Evaluation II (P = .04) and high (≥4 mmol/L) initial serum lactate levels (P = .005) were associated with the primary outcome. CONCLUSIONS: Patients presenting to the emergency department with severe sepsis were frequently admitted to a non-ICU setting, and the rate increased over time. Of 8 patients admitted to the hospital ward, one was transferred to the ICU within 48 hours and/or died within 28 days of admission. Factors present at admission were identified that were associated with adverse outcomes.

Hospital-based acute care use in survivors of septic shock.

OBJECTIVES: Septic shock is associated with increased long-term morbidity and mortality. However, little is known about the use of hospital-based acute care in survivors after hospital discharge. The objectives of the study were to examine the frequency, timing, causes, and risk factors associated with emergency department visits and hospital readmissions within 30 days of discharge. DESIGN: Retrospective cohort study. SETTING: Tertiary, academic hospital in the United States. PATIENTS: Patients admitted with septic shock (serum lactate≥4 mmol/L or refractory hypotension) and discharged alive to a nonhospice setting between 2007 and 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The coprimary outcomes were all-cause hospital readmission and emergency department visits (treat-and-release encounters) within 30 days to any of the three health system hospitals. Of 269 at-risk survivors, 63 (23.4%; 95% CI, 18.2-28.5) were readmitted within 30 days of discharge and another 12 (4.5%; 95% CI, 2.3-7.7) returned to the emergency department for a treat-and-release visit. Readmissions occurred within 15 days of discharge in 75% of cases and were more likely in oncology patients (p=0.001) and patients with a longer hospital length of stay (p=0.04). Readmissions were frequently due to another life-threatening condition and resulted in death or discharge to hospice in 16% of cases. The reasons for readmission were deemed potentially related to the index septic shock hospitalization in 78% (49 of 63) of cases. The most common cause was infection related, accounting for 46% of all 30-day readmissions, followed by cardiovascular or thromboembolic events (18%). CONCLUSIONS: The use of hospital-based acute care appeared to be common in septic shock survivors. Encounters often led to readmission within 15 days of discharge, were frequently due to another acute condition, and appeared to result in substantial morbidity and mortality. Given the potential public health implications of these findings, validation studies are needed.

Age-related differences in biomarkers of acute inflammation during hospitalization for sepsis.

The authors aimed to evaluate age-related differences in inflammation biomarkers during the first 72 h of hospitalization for sepsis. This was a secondary analysis of a prospective observational cohort of adult patients (n = 855) from 10 urban academic emergency departments with confirmed infection and two or more systemic inflammatory response syndrome criteria. Six inflammation-related biomarkers were analyzed-chemokine (CC-motif) ligand-23, C-reactive protein, interleukin-1 receptor antagonist, neutrophil gelatinase-associated lipocalin (NGAL), peptidoglycan recognition protein, and tumor necrosis factor receptor-1a (TNFR-1a)-measured at presentation and 3, 6, 12, 24, 48, or 72 h later. The median age was 56 (interquartile range, 43 - 72) years, and sepsis severity was 38% sepsis, 16% severe sepsis without shock, and 46% septic shock; the overall 30-day mortality was 12%. Older age was associated with higher sepsis severity: 41% of subjects aged 18 to 34 years had severe sepsis or septic shock compared with 71% for those aged 65 years or older (P < 0.001). In longitudinal models adjusting for demographics, comorbidities, and infection source, older age was associated with higher baseline values for chemokine (CC-motif) ligand-23, interleukin-1 receptor antagonist, NGAL, and TNFR-1a (all P < 0.05). However, older adults had higher mean values during the entire 72-h period only for NGAL and TNFR-1a and higher final 72-h values only for TNFR-1a. Adjustment or stratification by sepsis severity did not change the age-inflammation associations. Although older adults had higher levels of inflammation at presentation and an increased incidence of severe sepsis and septic shock, these age-related differences in inflammation largely resolved during the first 72 h of hospitalization.

A review of emergency cardiopulmonary bypass for severe poisoning by cardiotoxic drugs.

Cardiovascular collapse remains a leading cause of death in severe acute drug intoxication. Commonly prescribed medications such as antidysrhythmics, calcium channel antagonists, and beta adrenergic receptor antagonists can cause refractory cardiovascular collapse in massive overdose. Emergency cardiopulmonary bypass (ECPB), a modality originating in cardiac surgery, is a rescue technique that has been successfully implemented in the treatment of refractory cardiogenic shock and cardiac arrest unresponsive to traditional medical interventions. More recently a growing number of animal studies, case reports, and case series have documented its use in refractory hemodynamic collapse in poisoned patients. This article will review current ECPB techniques and explore its growing role in the treatment of severely hemodynamically compromised poisoned patients.

Initial clinical predictors of significant coronary lesions after resuscitation from cardiac arrest.

Urgent coronary angiography following cardiac arrest is an important consideration as part of a therapeutic hypothermia/postresuscitation care bundle. Few data exist to guide the selection of patients who should receive postarrest angiography. This investigation sought to evaluate patient-level variables on initial postarrest presentation and their association with significant coronary lesions on subsequent angiography. Clinical and angiographic data were collected on consecutive postarrest patients from July 2007 to April 2012 who underwent coronary angiography during hospitalization. Univariate and multivariable analyses were performed to determine the relationship between patient characteristics, clinical data, and the outcome measure, defined as the presence of at least one coronary lesion with >75% stenosis. Of 527 cardiac arrest patients, 267 achieved return of spontaneous circulation; 106 of these initial survivors received coronary angiography. This cohort had a mean age of 58.1±13.5 years and a survival to discharge of 73/106 (69%), with therapeutic hypothermia utilized in 79/106 (75%) patients. Significant coronary lesions were found on angiography in 68/106 (64%) patients. Multivariable adjusted analysis demonstrated that significant lesions were associated with a prior known history of coronary disease and/or prior myocardial infarction (odds ratio [OR] 6.2, 95% confidence interval [CI] 1.6-24.4, p=0.009), and with initial rhythm of ventricular fibrillation/ventricular tachycardia (OR 2.9, 95% CI 1.1-7.7, p=0.033), but not with hypertension, tobacco use, age, or initial troponin measurements. Prior known history of coronary disease and a shockable arrest rhythm were associated with significant coronary lesions on subsequent angiography. Normal initial troponin values and younger age did not exclude clinically relevant lesions postarrest.

A 52-year-old man with malaise and a petechial rash.

BACKGROUND: Capnocytophaga canimorsus is a Gram-negative, fusiform, rod-shaped organism that is part of the normal oral flora of dogs, cats, and other animals. A significant number of Emergency Department (ED) patients are surgically or functionally asplenic and may be at marked risk for overwhelming post-splenectomy infection (OPSI). OPSI has a mortality rate estimated to be up to 70%. The risk of sepsis is estimated to be 30-60 times greater after splenectomy, and C. canimorsus is one of the organisms that can cause catastrophic OPSI. OBJECTIVES: To describe a case of C. canimorsus septic shock in a post-splenectomy patient and review the epidemiology of OPSI, the role of the spleen in protecting the body from infection, and the potential role of early goal-directed therapy in the resuscitation of patients with OPSI. CASE REPORT: A 52 year-old man with a past medical history significant for idiopathic thrombocytopenic purpura (status post-splenectomy), and non-Hodgkin lymphoma (treated for cure), was brought to the ED with the chief complaints of light-headedness, malaise, and a rapidly spreading rash. He was found to be hypotensive, tachycardic, and tachypneic, and had a marked lactic acidosis. He was aggressively resuscitated with large volume fluid resuscitation and treated empirically with broad-spectrum antibiotics for septic shock of unclear etiology. His clinical course was complicated by acute lung injury and renal failure. Blood cultures grew C. canimorsus; he was extubated on hospital day 7 and discharged home several days later in good condition. CONCLUSIONS: Patients status-post-splenectomy are at greatly increased risk for infection from encapsulated organisms and other organisms, including C. canimorsus, which is part of the normal oral flora of dogs, cats, and other animals. It can be spread to humans by bites, scratches, or less invasive forms of animal-human contact. C. canimorsus infection can lead to OPSI. Early recognition and aggressive clinical management, including early goal-directed therapy and rapid administration of antibiotics, may minimize the morbidity and mortality of this condition and other etiologies of severe sepsis and septic shock.

The diagnostic accuracy of plasma neutrophil gelatinase-associated lipocalin in the prediction of acute kidney injury in emergency department patients with suspected sepsis.

STUDY OBJECTIVE: We assess the diagnostic accuracy of plasma neutrophil gelatinase-associated lipocalin (NGAL) to predict acute kidney injury in emergency department (ED) patients with suspected sepsis. METHODS: We conducted a secondary analysis of a prospective observational study of a convenience sample of patients from 10 academic medical center EDs. Inclusion criteria were adult patients aged 18 years or older, with suspected infection or a serum lactate level greater than 2.5 mmol/L; 2 or more systemic inflammatory response syndrome criteria; and a subsequent serum creatinine level obtained within 12 to 72 hours of enrollment. Exclusion criteria were pregnancy, do-not-resuscitate status, cardiac arrest, or dialysis dependency. NGAL was measured in plasma collected at ED presentation. Acute kidney injury was defined as an increase in serum creatinine measurement of greater than 0.5 mg/dL during 72 hours. RESULTS: There were 661 patient enrolled, with 24 cases (3.6%) of acute kidney injury that developed within 72 hours after ED presentation. Median plasma NGAL levels were 134 ng/mL (interquartile range 57 to 277 ng/mL) in patients without acute kidney injury and 456 ng/mL (interquartile range 296 to 727 ng/mL) in patients with acute kidney injury. Plasma NGAL concentrations of greater than 150 ng/mL were 96% sensitive (95% confidence interval [CI] 79% to 100%) and 51% (95% CI 47% to 55%) specific for acute kidney injury. In comparison, to achieve equivalent sensitivity with initial serum creatinine level at ED presentation required a cutoff of 0.7 mg/dL and resulted in specificity of 17% (95% CI 14% to 20%). CONCLUSION: In this preliminary investigation, increased plasma NGAL concentrations measured on presentation to the ED in patients with suspected sepsis were associated with the development of acute kidney injury. Our findings support NGAL as a promising new biomarker for acute kidney injury; however, further research is warranted.

A prospective, multicenter derivation of a biomarker panel to assess risk of organ dysfunction, shock, and death in emergency department patients with suspected sepsis.

OBJECTIVE: To define a biomarker panel to predict organ dysfunction, shock, and in-hospital mortality in emergency department (ED) patients with suspected sepsis. DESIGN: Prospective observational study. SETTING: EDs of ten academic medical centers. PATIENTS: There were 971 patients enrolled. INCLUSION CRITERIA: 1) ED patients age > 18; 2) suspected infection or a serum lactate level > 2.5 mmol/L; and 3) two or more systemic inflammatory response syndrome criteria. EXCLUSION CRITERIA: pregnancy, do-not-resuscitate status, or cardiac arrest. MEASUREMENTS AND MAIN RESULTS: Nine biomarkers were assayed from blood draws obtained on ED presentation. Multivariable logistic regression was used to identify an optimal combination of biomarkers to create a panel. The derived formula for weighting biomarker values was used to calculate a "sepsis score," which was the predicted probability of the primary outcome of severe sepsis (sepsis plus organ dysfunction) within 72 hrs. We also assessed the ability of the sepsis score to predict secondary outcome measures of septic shock within 72 hrs and in-hospital mortality. The overall rates of each outcome were severe sepsis, 52%; septic shock, 39%; and in-hospital mortality 7%. Among the nine biomarkers tested, the optimal 3-marker panel was neutrophil gelatinase-associated lipocalin, protein C, and interleukin-1 receptor antagonist. The area under the curve for the accuracy of the sepsis score derived from these three biomarkers was 0.80 for severe sepsis, 0.77 for septic shock, and 0.79 for death. When included in multivariate models with clinical variables, the sepsis score remained highly significant (p < 0.001) for all the three outcomes. CONCLUSIONS: A biomarker panel of neutrophil gelatinase-associated lipocalin, interleukin-1ra, and Protein C was predictive of severe sepsis, septic shock, and death in ED patients with suspected sepsis. Further study is warranted to prospectively validate the clinical utility of these biomarkers and the sepsis score in risk-stratifying patients with suspected sepsis.

Discordance between serum creatinine and creatinine clearance for identification of ED patients with abdominal pain at risk for contrast-induced nephropathy.

STUDY OBJECTIVE: Despite creatinine clearance (CrCl) being a better estimate of renal function, serum creatinine (Cr) is more commonly used to screen for renal insufficiency in patients scheduled for an enhanced abdominal computed tomography (CT) in an attempt to reduce the likelihood of contrast-induced nephropathy (CIN). Our objective was to determine the incidence of renal insufficiency (a CrCl <60 mL/min) among patients who have serum Cr below 1.5 mg/dL (the most commonly accepted Cr cutoff for the administration of intravenous contrast). This study was conducted in a population of emergency department patients with acute abdominal pain being considered for CT scan. METHODS: We performed post hoc analysis of a prospective cross-sectional study that enrolled nongravid adults with acute nontraumatic abdominal pain. Patients on dialysis were excluded. The data that we collected included demographics, history, duration/description of pain, patient reported weight, laboratory data, imaging studies, and final diagnosis. Creatinine clearance values (< or >60 mL/min) were compared to Cr values of 1.0, 1.2, 1.5, and 1.8 mg/dL to determine the percentage of patients at risk for nephropathy after contrast injection at each Cr cutoff. Descriptive statistics were used with 95% confidence intervals (CIs). RESULTS: Seven hundred sixty-five patients were enrolled; 59% (451/765) had an abdominal CT scan. Of 108 patients with CrCl less than 60 mL/min, 59 patients had a Cr less than 1.8 mg/dL (55%; 95% CI, 45%-64%); 43 had a Cr less than 1.5 mg/dL, the most commonly accepted Cr cutoff for contrast administration (40%; 95% CI, 31%-50%); 21 patients had a Cr less than 1.2 mg/dL (19%; 95% CI, 12%-28%); and 10 had a Cr less than 1.0 mg/dL (9%; 95% CI, 5%-16%). CONCLUSION: The most commonly used Cr cutoff (1.5 mg/dL) for contrast administration fails to identify 40% of the patients at risk for CIN. Future studies should address whether using CrCl rather than serum Cr decreases the incidence of contrast-induced nephropathy.