Morr Marius, Lukasz Alexander, Rübig Eva, Pavenstädt Hermann, Kümpers Philipp
Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Strasse 33, 48149, Münster, Germany.
BMC Emerg Med. 2017 Mar 23;17(1):11. doi: 10.1186/s12873-017-0122-9.
Appropriate and timely recognition of sepsis is a prerequisite for starting goal-directed therapy bundles. We analyzed the appropriateness of sepsis recognition and documentation with regard to adequacy of therapy and outcome in an internal medicine emergency department (ED).
This study included 487 consecutive patients ≥18 years of age who presented to a university hospital ED during a 4-week period. Clinical, laboratory, and follow-up data were acquired independently from documentation by ED physicians. The study team independently rated quality of sepsis classification (American College of Chest Physicians/Society of Critical Care Medicine definitions), diagnostic workup, and guideline-adherent therapy in the ED.
Of 487 included patients, 110 presented because of infection. Of those, 54 patients matched sepsis criteria, including 20 with organ damage and thus severe sepsis, as rated by the study team. Sepsis was not recognized in 32 of these 54 cases (59%). Multivariate binary logistic regression analysis revealed that higher systolic blood pressure (p <0.05), the ability to stand (p <0.01) and a low number of documented vital signs in the ED discharge letter (p < 0.05) were independent predictors of missed sepsis. Surprisingly, adequate detection of the septic focus (81 vs. 93%, p = 0.17), appropriate fluid administration (86 vs. 87%, p = 0.39), and guideline-adherent antibiotic regimen (95 vs. 100%, p = 0.42) did not differ between cases of recognized and unrecognized sepsis, respectively. Non-recognition affected neither death-censored length of hospital stay (median 7.63 d vs. 7.13 d, p = 0.42) nor a combined endpoint of death or ICU admission to (9 vs. 12%, p = 0.55).
Non-recognition of sepsis in ED patients with serious infections who formally meet organizational sepsis definitions seems to have no deleterious impact on initial therapy adequacy.
及时准确地识别脓毒症是启动目标导向治疗方案的前提条件。我们分析了在内科急诊科中，脓毒症识别及记录的恰当性与治疗充分性和预后的关系。
本研究纳入了连续4周内就诊于某大学医院急诊科的487例年龄≥18岁的患者。临床、实验室及随访数据均独立于急诊科医生的记录获取。研究团队独立评估急诊科中脓毒症分类（美国胸科医师学会/危重病医学会定义）、诊断检查及遵循指南治疗的质量。
在纳入的487例患者中，110例因感染就诊。其中，研究团队评估有54例符合脓毒症标准，包括20例伴有器官损害即严重脓毒症。这54例患者中有32例（59%）未被识别出脓毒症。多因素二元逻辑回归分析显示，较高的收缩压（p<0.05）、能够站立（p<0.01）以及急诊科出院小结中记录的生命体征数量较少（p<0.05）是脓毒症漏诊的独立预测因素。令人惊讶的是，脓毒症确诊组与未确诊组在感染灶的充分检出率（81%对93%，p=0.17）、适当的液体输注率（86%对87%，p=0.39）以及遵循指南的抗生素治疗方案比例（95%对100%，p=0.42）方面并无差异。未识别脓毒症对校正死亡后的住院时间（中位数7.63天对7.13天，p=0.42）以及死亡或入住重症监护病房的复合终点（9%对12%，p=0.55）均无影响。
对于正式符合机构脓毒症定义的严重感染急诊科患者，未识别脓毒症似乎对初始治疗充分性没有有害影响。
