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The Septic Cliff: Development of Hypotension While in the Emergency Department FREE TO VIEW

Shant Shirvanian, MD; Jeffrey Fried, MD; Jonathan Grotts, MA
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Santa Barbara Cottage Hospital, Santa Barbara, CA

Chest. 2013;144(4_MeetingAbstracts):423A. doi:10.1378/chest.1703388
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SESSION TITLE: Sepsis and Shock Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: To identify the frequency and predictors of patients admitted to the ICU with severe sepsis or septic shock, who were initially normotensive at emergency department (ED) triage and subsequently developed hypotension in the ED.

METHODS: Patients and most clinical data were from the IRB approved Santa Barbara Cottage Hospital Sepsis Registry, a prospectively collected database of all patients admitted to our adult intensive care units (ICU) with severe sepsis and septic shock. The study population was admitted from the ED to the ICU from January 1, 2011 - December 31, 2011. Vital signs, medications in the ED, microbiology and additional laboratory values were retrospectively collected.

RESULTS: Out of 224 patients, 57 were hypotensive (mean arterial pressure (MAP) < 65mmHg) at initial ED triage and were excluded. Of 167 patients with an initial MAP ≥ 65mmHg, 107 (64.1%) subsequently developed hypotension (Group H). The remaining 60 patients remained normotensive (Group N). The average time from initial vital signs to hypotension for Group H was 152.8 minutes. Group H had a lower initial MAP (83.5mmHg vs 96.2mmHg, p <0.001) and a lower absolute neutrophil count (8.9 vs 11.3, p=0.048). Comparing the two groups, there were no significant differences in initial heart rate, temperature, timing of antibiotic or sedative medication administration, procalcitonin, creatinine, total white blood cell (WBC) count, immature WBC counts, lactate, site of infection, cultured organism, organism gram stain characteristics, or in-hospital mortality.

CONCLUSIONS: Approximately two thirds of patients admitted to ICU with severe sepsis or septic shock have a normal blood pressure at ED triage which drops significantly while still being evaluated in the ED. We could identify no clinically useful predictors of this phenomenon which we term the “sepsis cliff.”

CLINICAL IMPLICATIONS: These patients might benefit from more frequent blood pressure measurements while in the ED. This might result in the earlier detection of hypotension which may lead to more expeditious and appropriate treatment.

DISCLOSURE: The following authors have nothing to disclose: Shant Shirvanian, Jeffrey Fried, Jonathan Grotts

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