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115 Impact of Timely Antibiotic Administration on Outcomes in Patients With Severe Sepsis and Septic Shock in the Emergency Department
Research Forum Abstracts
115
Impact of Timely Antibiotic Administration on Outcomes in Patients With Severe Sepsis and Septic Shock in the Emergency Department
Joo YM, Chae MK, Hwang SY, Jin SC, Cha WC, Shin TG, Sim MS, Jo IJ, Song KJ, Jeong YK/Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Study Objectives: We aimed to investigate the effect of timely antibiotic administration on outcomes in patients with severe sepsis and septic shock in the emergency department (ED). Methods: We analyzed the sepsis registry for adult patients who initially presented to an ED of a tertiary hospital and met the criteria for severe sepsis or septic shock between August 2008 and March 2012. Timely antibiotic use was defined as when a broad spectrum antibiotic was administered within three hours from the time of ED arrival. Multivariable logistic and linear regression analyses were performed to assess the associations between timely antibiotics and outcomes including hospital mortality and change in Sequential Organ Failure Assessment (SOFA) score (delta SOFA ¼ SOFA at ED recognition - SOFA after 48 hours), and hospital length of stay (LOS). Results: A total of 591 patients were included. In-hospital mortality was 16.9% for patients receiving timely antibiotics (N ¼ 377) and 22.9% for patients receiving delayed antibiotics (N¼214) (P¼.04). Adjusted odds ratio of in-hospital survival was 0.55 (95% confidence interval [CI], 0.34 to 0.89; P¼.02) in patients receiving timely antibiotics. They also had significantly higher delta SOFA (2 versus 1, P<.01) and shorter hospital LOS among survivors (11 days versus 15 days, P<.01). Multivariable linear regression analyses, adjusting age, severity, achievements of early resuscitation goals, showed that timely antibiotic administration was significantly associated with increased delta SOFA and decreased hospital LOS. Conclusions: In conclusion, early antibiotic use within three hours from the time of ED arrival was significantly associated with improved outcomes including inhospital survival, reversal of organ failure, and shorter hospital LOS in patients with severe sepsis and septic shock.
EMF-116
Platelet Mitochondrial Function in Early Severe Sepsis
Puskarich M, Jones AE/University of Mississippi Medical Center, Jackson, MS
Study Objectives: The prognostic value of lactate in sepsis is well established, but evolving literature suggests that lactate elevation does not result solely from tissue hypoperfusion, but can also arise following sepsis-induced changes in aerobic metabolism, sometimes referred to as cytopathic hypoxia. Recent advances allow for the measurement of mitochondrial function in peripherally available cells such as platelets, and the degree of mitochondrial dysfunction from multiple cell lines is associated with mortality in sepsis. However, it remains unclear if these changes are present on emergency department (ED) presentation, and if the degree of dysfunction is associated with metabolic changes. We sought to determine the association between platelet mitochondrial function as measured by high resolution respirometry and 1) lactate and pyruvate levels and 2) severity of illness as measured by the Sequential Organ Failure Assessment (SOFA) score. Methods: Prospective observational cohort of ED patients presenting to a single, urban, tertiary care ED from November 2013 to present. Abbreviated inclusion criteria were age >17, 2 or more SIRS criteria, hypotension despite fluid resuscitation, and confirmed or suspected infection; exclusion criteria include established do not resuscitate order, transfer with resuscitation in progress, and inability to obtain informed consent. Blood was drawn and immediately processed to yield a platelet rich plasma which was placed in an O2k Oxygraph (Oroboros Instruments, Austria). Routine respiration rate was determined by measuring the rate of oxygen consumption in a chamber with a fixed volume of oxygen. Leak and oxidative phosphorylation (oxphos) rates were determined following serial additions of oligomycin and FCCP. Residual nonmitrochondrial oxygen consumption following the addition of rotenone and antimycin A was subtracted from these values, and all values were normalized
S42 Annals of Emergency Medicine
to cell count. SOFA score, lactate and pyruvate were measured at enrollment. L/P ratio was calculated as the quotient of lactate/pyruvate. Descriptive statistics and simple linear regression were used to determine the association between mitochondrial measurements and lactate and pyruvate measurements, as well as SOFA score. All tests were two-sided and P values of <.05 were considered significant. Results: Eight patients were enrolled to date. Median SOFA score was 7 (IQR 3.5, 9.5). Initial median lactate and pyruvate levels were 1.6 mmol/L (IQR 0.7, 3.2) and 0.09 mmol/L (IQR 0.04, 0.10); while median L/P ratio was 23 (IQR 16, 39). There were significant associations between routine and leak respiration and lactate value (P¼.006 and .01), and a trend towards a linear association between routine, leak, and oxphos rates and SOFA score (P¼.1, .36, and .12). Similar trends were not observed with pyruvate or L/P ratios. Conclusion: In the first study of platelet mitochondrial function in ED patients with sepsis to date, there is a suggestion of associations between several measures of mitochondrial function and both severity of illness and lactate levels, supportive of the hypothesis that elevated lactate may be partially due to changes in mitochondrial function. If validated in an ongoing study of a larger cohort of patients, these data suggest that novel therapeutics targeting mitochondrial function deserve further clinical investigation.
117
The Impact of Hurricane Sandy on Mental HealthRelated Emergency Departments Visits
Frankel KC, Allegra CM, Eskin B, Allegra JR/Morristown Medical Center, Morristown, NJ; Rutgers University School of Social Work, New Brunswick, NJ; Morristown Medical Center, Morristown, NJ
Study Objective: Hurricane Sandy caused extensive damage in the New York Metropolitan area. Recent studies have shown that natural disasters lead to greater need for mental health services. Our objective was to examine the effect of Sandy on the number of mental health-related visits to 17 emergency departments (EDs) in the New York Metropolitan area. Methods: Design: Retrospective cohort of ED visits. Setting: 17 New York Metropolitan area EDs with 28,000 to 84,000 annual visits. Subjects: Consecutive ED patients. Protocol: We arbitrarily a priori chose to compare mental health related visits on the storm day and on the next five days (“storm days”) to the average of the same days of the week for the four preceding weeks (“pre-storm days”). We classified mental health visits into categories using ICD9 codes. We combined ICD9 codes for anxiety and drug abuse categories and placed all the other mental health related visits in the “other mental health” category. We calculated 95% confidence intervals (95% CI) for ED visits for these categories on storm days and pre-storm days. Results: The database had 15,273 ED visits on the storm days and an average of 14,190 visits on the pre-storm days. The only statistically significant change was a 28% (95% CI: 18%, 37%) decrease in “other mental health” visits (see Table). The five most common diagnoses comprising 66% of the visits in the “other mental health” category, in descending order of the number of visits, were depressive disorder, bipolar disorder, episodic mood disorder, psychosis and schizophrenia. Of these, depressive disorder was the greatest single contributor to the 28% decrease between storm and pre-storm days. Conclusions: Contrary to other studies of natural disasters we found no change in ED visits for anxiety and drug abuse. However, other mental healthrelated visits decreased after Sandy, particularly those for depressive disorder. Why patients with depression in particular had a decreased tendency to visit EDs after Sandy is unclear. Nonetheless, our overall findings suggest that additional mental health resources may not be needed during similar future storms.
Table. ED Visits on Pre-Storm and Storm Days
ED Visits Anxiety Drug Abuse Other Mental Health
Pre-Storm Days
Storm days
Change (Storm vs. Pre-storm)
95% Confidence Interval
214 295 299
228 304 215
7% 3% -28%
-7%, 22% -8%, 15% -18%, -37%
Volume 64, no. 4s : October 2014
115
Impact of Timely Antibiotic Administration on Outcomes in Patients With Severe Sepsis and Septic Shock in the Emergency Department
Joo YM, Chae MK, Hwang SY, Jin SC, Cha WC, Shin TG, Sim MS, Jo IJ, Song KJ, Jeong YK/Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
Study Objectives: We aimed to investigate the effect of timely antibiotic administration on outcomes in patients with severe sepsis and septic shock in the emergency department (ED). Methods: We analyzed the sepsis registry for adult patients who initially presented to an ED of a tertiary hospital and met the criteria for severe sepsis or septic shock between August 2008 and March 2012. Timely antibiotic use was defined as when a broad spectrum antibiotic was administered within three hours from the time of ED arrival. Multivariable logistic and linear regression analyses were performed to assess the associations between timely antibiotics and outcomes including hospital mortality and change in Sequential Organ Failure Assessment (SOFA) score (delta SOFA ¼ SOFA at ED recognition - SOFA after 48 hours), and hospital length of stay (LOS). Results: A total of 591 patients were included. In-hospital mortality was 16.9% for patients receiving timely antibiotics (N ¼ 377) and 22.9% for patients receiving delayed antibiotics (N¼214) (P¼.04). Adjusted odds ratio of in-hospital survival was 0.55 (95% confidence interval [CI], 0.34 to 0.89; P¼.02) in patients receiving timely antibiotics. They also had significantly higher delta SOFA (2 versus 1, P<.01) and shorter hospital LOS among survivors (11 days versus 15 days, P<.01). Multivariable linear regression analyses, adjusting age, severity, achievements of early resuscitation goals, showed that timely antibiotic administration was significantly associated with increased delta SOFA and decreased hospital LOS. Conclusions: In conclusion, early antibiotic use within three hours from the time of ED arrival was significantly associated with improved outcomes including inhospital survival, reversal of organ failure, and shorter hospital LOS in patients with severe sepsis and septic shock.
EMF-116
Platelet Mitochondrial Function in Early Severe Sepsis
Puskarich M, Jones AE/University of Mississippi Medical Center, Jackson, MS
Study Objectives: The prognostic value of lactate in sepsis is well established, but evolving literature suggests that lactate elevation does not result solely from tissue hypoperfusion, but can also arise following sepsis-induced changes in aerobic metabolism, sometimes referred to as cytopathic hypoxia. Recent advances allow for the measurement of mitochondrial function in peripherally available cells such as platelets, and the degree of mitochondrial dysfunction from multiple cell lines is associated with mortality in sepsis. However, it remains unclear if these changes are present on emergency department (ED) presentation, and if the degree of dysfunction is associated with metabolic changes. We sought to determine the association between platelet mitochondrial function as measured by high resolution respirometry and 1) lactate and pyruvate levels and 2) severity of illness as measured by the Sequential Organ Failure Assessment (SOFA) score. Methods: Prospective observational cohort of ED patients presenting to a single, urban, tertiary care ED from November 2013 to present. Abbreviated inclusion criteria were age >17, 2 or more SIRS criteria, hypotension despite fluid resuscitation, and confirmed or suspected infection; exclusion criteria include established do not resuscitate order, transfer with resuscitation in progress, and inability to obtain informed consent. Blood was drawn and immediately processed to yield a platelet rich plasma which was placed in an O2k Oxygraph (Oroboros Instruments, Austria). Routine respiration rate was determined by measuring the rate of oxygen consumption in a chamber with a fixed volume of oxygen. Leak and oxidative phosphorylation (oxphos) rates were determined following serial additions of oligomycin and FCCP. Residual nonmitrochondrial oxygen consumption following the addition of rotenone and antimycin A was subtracted from these values, and all values were normalized
S42 Annals of Emergency Medicine
to cell count. SOFA score, lactate and pyruvate were measured at enrollment. L/P ratio was calculated as the quotient of lactate/pyruvate. Descriptive statistics and simple linear regression were used to determine the association between mitochondrial measurements and lactate and pyruvate measurements, as well as SOFA score. All tests were two-sided and P values of <.05 were considered significant. Results: Eight patients were enrolled to date. Median SOFA score was 7 (IQR 3.5, 9.5). Initial median lactate and pyruvate levels were 1.6 mmol/L (IQR 0.7, 3.2) and 0.09 mmol/L (IQR 0.04, 0.10); while median L/P ratio was 23 (IQR 16, 39). There were significant associations between routine and leak respiration and lactate value (P¼.006 and .01), and a trend towards a linear association between routine, leak, and oxphos rates and SOFA score (P¼.1, .36, and .12). Similar trends were not observed with pyruvate or L/P ratios. Conclusion: In the first study of platelet mitochondrial function in ED patients with sepsis to date, there is a suggestion of associations between several measures of mitochondrial function and both severity of illness and lactate levels, supportive of the hypothesis that elevated lactate may be partially due to changes in mitochondrial function. If validated in an ongoing study of a larger cohort of patients, these data suggest that novel therapeutics targeting mitochondrial function deserve further clinical investigation.
117
The Impact of Hurricane Sandy on Mental HealthRelated Emergency Departments Visits
Frankel KC, Allegra CM, Eskin B, Allegra JR/Morristown Medical Center, Morristown, NJ; Rutgers University School of Social Work, New Brunswick, NJ; Morristown Medical Center, Morristown, NJ
Study Objective: Hurricane Sandy caused extensive damage in the New York Metropolitan area. Recent studies have shown that natural disasters lead to greater need for mental health services. Our objective was to examine the effect of Sandy on the number of mental health-related visits to 17 emergency departments (EDs) in the New York Metropolitan area. Methods: Design: Retrospective cohort of ED visits. Setting: 17 New York Metropolitan area EDs with 28,000 to 84,000 annual visits. Subjects: Consecutive ED patients. Protocol: We arbitrarily a priori chose to compare mental health related visits on the storm day and on the next five days (“storm days”) to the average of the same days of the week for the four preceding weeks (“pre-storm days”). We classified mental health visits into categories using ICD9 codes. We combined ICD9 codes for anxiety and drug abuse categories and placed all the other mental health related visits in the “other mental health” category. We calculated 95% confidence intervals (95% CI) for ED visits for these categories on storm days and pre-storm days. Results: The database had 15,273 ED visits on the storm days and an average of 14,190 visits on the pre-storm days. The only statistically significant change was a 28% (95% CI: 18%, 37%) decrease in “other mental health” visits (see Table). The five most common diagnoses comprising 66% of the visits in the “other mental health” category, in descending order of the number of visits, were depressive disorder, bipolar disorder, episodic mood disorder, psychosis and schizophrenia. Of these, depressive disorder was the greatest single contributor to the 28% decrease between storm and pre-storm days. Conclusions: Contrary to other studies of natural disasters we found no change in ED visits for anxiety and drug abuse. However, other mental healthrelated visits decreased after Sandy, particularly those for depressive disorder. Why patients with depression in particular had a decreased tendency to visit EDs after Sandy is unclear. Nonetheless, our overall findings suggest that additional mental health resources may not be needed during similar future storms.
Table. ED Visits on Pre-Storm and Storm Days
ED Visits Anxiety Drug Abuse Other Mental Health
Pre-Storm Days
Storm days
Change (Storm vs. Pre-storm)
95% Confidence Interval
214 295 299
228 304 215
7% 3% -28%
-7%, 22% -8%, 15% -18%, -37%
Volume 64, no. 4s : October 2014