Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA.
Crit Care Med. 2018 Oct;46(10):1592-1599. doi: 10.1097/CCM.0000000000003260.
Presenting symptoms in patients with sepsis may influence rapidity of diagnosis, time-to-antibiotics, and outcome. We tested the hypothesis that vague presenting symptoms are associated with delayed antibiotics and increased mortality. We further characterized individual presenting symptoms and their association with mortality.
Retrospective cohort study.
Emergency department of large, urban, academic U.S. hospital.
All adult patients with septic shock treated in the emergency department between April 2014 and March 2016.
None.
Of 654 septic shock cases, 245 (37%) presented with vague symptoms. Time-to-antibiotics from first hypotension or elevated lactate was significantly longer for those with vague symptoms versus those with explicit symptoms of infection (1.6 vs 0.8 hr; p < 0.01), and in-hospital mortality was also substantially higher (34% vs 16%; p < 0.01). Patients with vague symptoms were older and sicker as evidenced by triage hypotension, Sequential Organ Failure Assessment score, initial serum lactate, and need for intubation. In multivariate analysis, vague symptoms were independently associated with mortality (adjusted odds ratio, 2.12; 95% CI, 1.32-3.40; p < 0.01), whereas time-to-antibiotics was not associated with mortality (adjusted odds ratio, 1.01; 95% CI, 0.94-1.08; p = 0.78). Of individual symptoms, only the absence of fever, chills, or rigors (odds ratio, 2.70; 95% CI, 1.63-4.47; p < 0.01) and presence of shortness of breath (odds ratio, 1.97; 95% CI, 1.23-3.15; p < 0.01) were independently associated with mortality.
More than one third of patients with septic shock presented to the emergency department with vague symptoms that were not specific to infection. These patients had delayed antibiotic administration and higher risk of mortality even after controlling for demographics, illness acuity, and time-to-antibiotics in multivariate analysis. These findings suggest that the nature of presenting symptoms is an important component of sepsis clinical phenotyping and may be an important confounder in sepsis epidemiologic studies.
脓毒症患者的首发症状可能会影响诊断的速度、抗生素的使用时间和结局。本研究旨在验证首发症状不明确与抗生素使用延迟和死亡率升高相关的假设。我们进一步对单个首发症状及其与死亡率的相关性进行了特征描述。
回顾性队列研究。
美国大型城市学术型医院的急诊科。
2014 年 4 月至 2016 年 3 月期间在急诊科接受治疗的所有脓毒性休克成年患者。
无。
在 654 例脓毒性休克患者中，245 例（37%）表现出不明确的症状。与明确感染症状的患者相比，首发低血压或高乳酸血症后抗生素使用时间明显延长（1.6 小时比 0.8 小时；p < 0.01），住院死亡率也明显升高（34%比 16%；p < 0.01）。首发症状不明确的患者年龄更大、病情更重，其表现为分诊低血压、序贯器官衰竭评估评分、初始血清乳酸水平以及需要插管。多变量分析显示，首发症状不明确与死亡率独立相关（调整后的优势比，2.12；95%可信区间，1.32-3.40；p < 0.01），而抗生素使用时间与死亡率无关（调整后的优势比，1.01；95%可信区间，0.94-1.08；p = 0.78）。在单个症状中，仅发热、寒战或肌痛缺失（优势比，2.70；95%可信区间，1.63-4.47；p < 0.01）和呼吸急促（优势比，1.97；95%可信区间，1.23-3.15；p < 0.01）与死亡率独立相关。
超过三分之一的脓毒性休克患者在急诊科就诊时的首发症状不明确，不具有感染特异性。即使在多变量分析中考虑了人口统计学、疾病严重程度和抗生素使用时间，这些患者的抗生素使用也会延迟，且死亡风险更高。这些发现表明，首发症状的性质是脓毒症临床表型的一个重要组成部分，并且可能是脓毒症流行病学研究中的一个重要混杂因素。
