Location of presentation of septic shock has an impact on clinical outcome

Introduction

Patients with septic shock have a mortality rate of 50–60% and require timely and directed interventions. The aim of this study was to use the Cooper Surviving Sepsis Campaign database [1] to compare characteristics, treatments and outcomes of septic shock (SS) patients diagnosed in the emergency department (ED) with patients developing SS in medical wards (MW) and the ICU.

Methods

The studied population included patients admitted to Cooper Hospital during March 2006–August 2007. Seventy SS patients were diagnosed in the ED, 27 SS patients were diagnosed in the MW and 12 SS patients were diagnosed in the ICU. APACHE II scores, the infection source, time from SS presentation to transfer to the ICU, achieving central venous pressure (CVP) and ScvO₂ targets, need for mechanical ventilation (MV) and inhospital mortality were reviewed.

Results

ICU SS patients had APACHE II scores of 30.9 ± 5.6, compared with 23.2 ± 6.1 for the MW patients and 21.8 ± 7.7 for the ED patients (P < 0.01). Pneumonia was the primary infection for the ICU group and urinary tract infection for the ED and MW groups. ICU patients had a higher percentage of MV (100%) use during the first 24 hours after shock onset, compared with 70% for the MW patients and 45% for the ED patients (P = 0.01). ICU mortality was 83%, compared with 59% for the MW patients and 25% for ED patients (P = 0.01). There was a median 9.8 hours from SS presentation to transfer to the ICU in ED patients, compared with 3.1 hours in the MW patients (P < 0.01). In the ED group the median was 7.9 hours for achieving CVP ≥ 8 mmHg and 8.2 hours for vena cava oxygen saturation (ScVO₂) ≥ 70%; in the MW group it was 6.3 hours for CVP ≥ 8 mmHg and 10.8 hours for ScVO₂ ≥ 70%; and in the ICU group it was 1.8 hours for CVP ≥ 8 mmHg (P < 0.05 vs ED and MW) and 7.8 hours for ScVO₂ ≥ 70%.

Conclusion

The APACHE II score, use of MV in the first 24 hours and mortality were higher in ICU-diagnosed SS patients. The data suggest that patients who develop SS in the ICU are at higher risk of death compared with those presenting with SS to the ED and or developing SS in the MW.