Date of Award

9-20-2010

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

First Advisor

Charles R. Wira III

Second Advisor

Lori Post

Third Advisor

Steven Bernstein, Federico Vaca

Abstract

Cumulative Organ Dysfunction in the ED as a Predictor of Mortality in Patients with Severe Sepsis Martina Trinese Sanders-Spight, (Sponsored by: Charles R. Wira III), Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT HYPOTHESIS AND SPECIFIC AIMS OF STUDY: The primary aim of this study is to evaluate the hypothesis that increasing cumulative organ dysfunction in patients presenting to the Emergency Department (ED) with severe sepsis or septic shock correlates with 28-day and total in-hospital mortality, mechanical ventilation requirement and vasopressor use within 72 hours of presentation. This investigation also aims to elucidate differences in patients with high cumulative organ dysfunction scores (≥5) and low cumulative organ dysfunction scores (<5), as well as externally validate the Mortality in Emergency Department Sepsis (MEDS) score. METHODS: This study is a retrospective chart review of patients at Yale ¨C New Haven Hospital who presented to the ED with severe sepsis or septic shock. Included patients were at least 18 years of age, met at least two of four criteria for Systemic Inflammatory Response Syndrome (SIRS), had a documented suspicion of clinical infection, as well as manifested acute organ injury. Patients were stratified according to the number of cumulative organ failures. The principle outcome measure in this study was in-hospital mortality. Secondary outcomes include vasopressor use within 72 hours and mechanical ventilation rates, as well as MEDS scores. RESULTS: Of the 521 patients who met criteria for enrollment in our study, 83.5% (n=435) were classified as severe sepsis patients and 16.5% (n=86) as septic shock patients. The overall in-hospital mortality rate in this study was 15.2% (n=79). Septic shock patients experienced higher mortality (33.7%, n=29) than patients diagnosed with severe sepsis (11.5%, n=50). The five or more organ injury group had more males (59.5%) than females (40.5%), likely due to a higher number of baseline co-morbidities among males in that group, more liver disease and congestive heart failure and had fewer residents presenting from extended care facilities. Organ failure groups had mortality rates as follows: one or two organ failures, 8.7%; three or four, 13.8%; five or six, 19.5%; and seven or more, 55.9% (p<0.05 when comparing the one or two organ dysfunction group to the highest two groups (five or six and seven or more organ dysfunctions). Fifty-four patients (48.6%) in the higher cumulative organ failures group were mechanically ventilated compared to 99 (24.1%) in the fewer cumulative organ failures group (p<0.0001). Nearly 56% (n=56) in the higher dysfunctional group versus 17% (n=70) in the lower dysfunctional group received vasopressor support within 72 hours (p<0.0001). Patients with fewer than five organ failures had a mean MEDS score of 10.7 ± 4.5, as compared to the other group with mean MEDS score of 12.5 ± 4.9 (p=0.0002). When the experimental groups are further stratified, the MEDS scores neither trended with cumulative organ failure, nor with the three study end-points, including mortality, vasopressor and mechanical ventilation rates. CONCLUSION: This study demonstrated that the Emergency Department assessment of cumulative organ dysfunction is a promising measurement of disease severity in patients who present with severe sepsis and septic shock because it correlates with in-hospital mortality, early vasopressor and mechanical ventilation rates. The MEDS scoring system was not externally validated by this study.

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