J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 8, Number 8, August 2016, pages 575-581

Predictors of Acute Hemodynamic Decompensation in Early Sepsis: An Observational Study

Figure 1. Retrospective cohort study design. H: hours; IH: initially hypotensive; INT: initially normotensive; OSH: outside hospital; SBP: systolic blood pressure; MAP: mean arterial pressure.

**Table 1.** Demographics
	IH	INT	P^‡
BMI: body mass index. *Value expressed as mean (SD). ^†Value expressed as N (%). ^‡Significance assessed by Student’s t-test or Pearson’s Chi-square test as applicable.
Number of subjects	52	62
Age, years*	79 (12)	75 (11)	0.124
Gender, male^†	52 (100)	61 (98)	0.362
Race^†			0.013
Caucasian	27 (52)	46 (74)
African American and other	25 (48)	16 (26)
Outpatient setting^†			0.619
Home	36 (69)	44 (71)
Nursing Home	16 (31)	17 (27)
Undomiciled	0 (0)	1 (2)
Days of illness prior to presentation*	3 (3)	3 (3)	0.207
BMI, kg/m²*	24 (5)	27 (6)	0.010

Table 1. Demographics

INT

P^‡

BMI: body mass index. *Value expressed as mean (SD). ^†Value expressed as N (%). ^‡Significance assessed by Student’s t-test or Pearson’s Chi-square test as applicable.

Number of subjects

Age, years*

79 (12)

75 (11)

0.124

Gender, male^†

52 (100)

61 (98)

0.362

Race^†

0.013

Caucasian

27 (52)

46 (74)

African American and other

25 (48)

16 (26)

Outpatient setting^†

0.619

Home

36 (69)

44 (71)

Nursing Home

16 (31)

17 (27)

Undomiciled

0 (0)

1 (2)

Days of illness prior to presentation*

3 (3)

0.207

BMI, kg/m²*

24 (5)

27 (6)

0.010

**Table 2.** Past Medical History
	IH	INT	P^†
DM: diabetes mellitus; ESRD: end-stage renal disease; ACE/ARB: angiotensin converting enzyme inhibitor/angiotensin receptor blocker. Heart disease: coronary artery disease, congestive heart failure, and arrhythmia; neurologic disease: dementia, Parkinson’s disease, seizure, cerebral vascular aneurysm, and multiple sclerosis. *Value expressed as N (%). ^†Significance assessed by Pearson’s Chi-square test.
Comorbid conditions*
Cancer	18 (35)	21 (34)	0.933
DM	16 (31)	24 (39)	0.376
ESRD	11 (21)	6 (10)	0.087
Heart disease	22 (42)	31 (50)	0.412
Neurologic disease	11 (21)	15 (24)	0.700
Home medications*
ACE/ARB	22 (42)	27 (44)	0.834
α-blocker	12 (23)	25 (40)	0.050
Aspirin	20 (39)	28 (45)	0.525
β-blocker	26 (50)	25 (40)	0.301
Ca²⁺ channel blocker	12 (23)	13 (21)	0.786
Chronic Steroid	3 (6)	11 (18)	0.045
Diuretics	20 (39)	20 (32)	0.489
Statin	18 (35)	28 (45)	0.253

Table 2. Past Medical History

INT

P^†

DM: diabetes mellitus; ESRD: end-stage renal disease; ACE/ARB: angiotensin converting enzyme inhibitor/angiotensin receptor blocker. Heart disease: coronary artery disease, congestive heart failure, and arrhythmia; neurologic disease: dementia, Parkinson’s disease, seizure, cerebral vascular aneurysm, and multiple sclerosis. *Value expressed as N (%). ^†Significance assessed by Pearson’s Chi-square test.

Comorbid conditions*

Cancer

18 (35)

21 (34)

0.933

16 (31)

24 (39)

0.376

ESRD

11 (21)

6 (10)

0.087

Heart disease

22 (42)

31 (50)

0.412

Neurologic disease

11 (21)

15 (24)

0.700

Home medications*

ACE/ARB

22 (42)

27 (44)

0.834

α-blocker

12 (23)

25 (40)

0.050

Aspirin

20 (39)

28 (45)

0.525

β-blocker

26 (50)

25 (40)

0.301

Ca²⁺ channel blocker

12 (23)

13 (21)

0.786

Chronic Steroid

3 (6)

11 (18)

0.045

Diuretics

20 (39)

20 (32)

0.489

Statin

18 (35)

28 (45)

0.253

**Table 3.** Clinical Parameters at Presentation
	IH	INT	P*
HR: heart rate; RR: respiration rate; BP: blood pressure; MAP: mean arterial pressure; CBC: complete blood count; WBC: white blood count; Hct: hematocrit; AST: aspartate transaminase; ALT: alanine transaminase. All available values reported in mean (SD). *Calculated by Student’s t-test.
HR, per minute	81 (22)	97 (25)	0.001
RR, per minute	20 (4)	20 (5)	0.275
BP, mm Hg
Systolic	81 (10)	120 (16)	< 0.001
Diastolic	46 (9)	71 (14)	< 0.001
MAP	57 (7)	88 (12)	< 0.001
Temperature, °F	98.8 (2)	100.4 (2)	< 0.001
APACHE II lab values within 24 h
CBC
WBC, × 10³/µL	17 (10)	14 (8)	0.054
Hct, %	33 (6)	34 (7)	0.470
Platelet, × 10³/µL	230 (140)	211 (92)	0.383
Chemistries
Sodium, mEq/L	141 (7)	139 (5)	0.057
Potassium, mEq/L	5.7 (6)	4.7 (0.9)	178
CO₂, mmol/L	22 (7)	25 (6)	0.037
Creatinine, mg/dL	3.9 (3)	2.2 (1)	< 0.001
Liver function test
AST, U/L	117 (320)	93 (190)	0.616
ALT, U/L	107 (321)	63 (127)	0.327
Bilirubin, mg/dL	1.6 (4.2)	1.0 (0.8)	0.215
Lactate, mmol/L	3 (3)	3 (2)	0.476

Table 3. Clinical Parameters at Presentation

INT

HR: heart rate; RR: respiration rate; BP: blood pressure; MAP: mean arterial pressure; CBC: complete blood count; WBC: white blood count; Hct: hematocrit; AST: aspartate transaminase; ALT: alanine transaminase. All available values reported in mean (SD). *Calculated by Student’s t-test.

HR, per minute

81 (22)

97 (25)

0.001

RR, per minute

20 (4)

20 (5)

0.275

BP, mm Hg

Systolic

81 (10)

120 (16)

< 0.001

Diastolic

46 (9)

71 (14)

< 0.001

MAP

57 (7)

88 (12)

< 0.001

Temperature, °F

98.8 (2)

100.4 (2)

< 0.001

APACHE II lab values within 24 h

CBC

WBC, × 10³/µL

17 (10)

14 (8)

0.054

Hct, %

33 (6)

34 (7)

0.470

Platelet, × 10³/µL

230 (140)

211 (92)

0.383

Chemistries

Sodium, mEq/L

141 (7)

139 (5)

0.057

Potassium, mEq/L

5.7 (6)

4.7 (0.9)

178

CO₂, mmol/L

22 (7)

25 (6)

0.037

Creatinine, mg/dL

3.9 (3)

2.2 (1)

< 0.001

Liver function test

AST, U/L

117 (320)

93 (190)

0.616

ALT, U/L

107 (321)

63 (127)

0.327

Bilirubin, mg/dL

1.6 (4.2)

1.0 (0.8)

0.215

Lactate, mmol/L

3 (3)

3 (2)

0.476

**Table 4.** Sepsis Source and Treatment
	IH	INT	P^‡
GI: gastrointestinal; H: hours; min: minutes. *Value expressed as mean (SD). ^†Value expressed as N (%). ^‡Significance assessed by Student’s t-test or Chi-square test as applicable.
Source of infection^†
Cellulitis	3 (6)	9 (15)	0.130
GI	12 (23)	9 (15)	0.240
Line infection	3 (6)	1 (2)	0.230
Pneumonia	5 (10)	15 (24)	0.042
Urinary tract	25 (48)	22 (36)	0.174
Unclear source	6 (12)	7 (11)	0.967
Positive culture^†
Blood	12 (23)	16 (26)	0.736
Urine	19 (37)	17 (27)	0.297
Others	14 (27)	4 (7)	0.003
Gram stain^†
Gram positive	18 (35)	9 (15)	0.012
Gram negative	23 (44)	21 (34)	0.258
Time to hypotension, H:min*	-	3:18	-
Time to antibiotics, H:min*	2:21 (1:48)	2:52 (2:47)	0.268
Amount of fluid in 24 h, L*	3.9 (2)	4.3 (2)	0.217
Required vasopressor^†	12 (23)	13 (21)	0.786
Mortality^†
28 days	14 (27)	15 (24)	0.739
1 year	28 (54)	31 (50)	0.682

Table 4. Sepsis Source and Treatment

INT

P^‡

GI: gastrointestinal; H: hours; min: minutes. *Value expressed as mean (SD). ^†Value expressed as N (%). ^‡Significance assessed by Student’s t-test or Chi-square test as applicable.

Source of infection^†

Cellulitis

3 (6)

9 (15)

0.130

12 (23)

9 (15)

0.240

Line infection

3 (6)

1 (2)

0.230

Pneumonia

5 (10)

15 (24)

0.042

Urinary tract

25 (48)

22 (36)

0.174

Unclear source

6 (12)

7 (11)

0.967

Positive culture^†

Blood

12 (23)

16 (26)

0.736

Urine

19 (37)

17 (27)

0.297

Others

14 (27)

4 (7)

0.003

Gram stain^†

Gram positive

18 (35)

9 (15)

0.012

Gram negative

23 (44)

21 (34)

0.258

Time to hypotension, H:min*

3:18

Time to antibiotics, H:min*

2:21 (1:48)

2:52 (2:47)

0.268

Amount of fluid in 24 h, L*

3.9 (2)

4.3 (2)

0.217

Required vasopressor^†

12 (23)

13 (21)

0.786

Mortality^†

28 days

14 (27)

15 (24)

0.739

1 year

28 (54)

31 (50)

0.682

**Table 5.** Indices of Severity of Illness
	IH	INT	P^‡
*Value expressed as mean (SD). ^†Value expressed as N (%). ^‡Significance assessed by Student’s t-test or Chi-square test as applicable.
Charlson comorbidity index*	7 (2)	7 (2)	0.795
APACHE II*	20 (5)	18 (5)	0.070
Organ dysfunction^†
Respiratory	7 (14)	8 (13)	0.930
Kidney	35 (67)	38 (61)	0.505
Liver	11 (22)	19 (31)	0.277
Length of stay, days*
ICU	15 (13)	17 (26)	0.149
Hospital	8 (6)	8 (6)	0.960

Table 5. Indices of Severity of Illness

INT

P^‡

*Value expressed as mean (SD). ^†Value expressed as N (%). ^‡Significance assessed by Student’s t-test or Chi-square test as applicable.

Charlson comorbidity index*

7 (2)

0.795

APACHE II*

20 (5)

18 (5)

0.070

Organ dysfunction^†

Respiratory

7 (14)

8 (13)

0.930

Kidney

35 (67)

38 (61)

0.505

Liver

11 (22)

19 (31)

0.277

Length of stay, days*

ICU

15 (13)

17 (26)

0.149

Hospital

8 (6)

0.960

**Table 6.** Logistic Regression Model Predictive of INT
Covariates	Crude*	P	Adjusted*	P
AUC: area under the curve. *Values expressed as odds ratio (95% CI). Hosmer-Lemeshow of adjusted final model: Chi-square 9.67, df = 8, P = 0.289.
α-Blocker	2.25 (0.991 - 5.118)	0.053	3.02 (1.09 - 8.36)	0.033
Caucasian	2.66 (1.21 - 5.85)	0.015	3.23 (1.23 - 8.50)	0.018
Temperature	1.37 (1.15 - 1.64)	0.001	1.36 (1.11 - 1.67)	0.003
Age	0.98 (0.94 - 1.01)	0.124	0.97 (0.93 - 1.01)	0.188
BMI	1.09 (1.02 - 1.17)	0.014	1.08 (0.99 - 1.17)	0.071
Pneumonia	2.74 (0.92 - 8.22)	0.072	2.70 (0.80 - 9.15)	0.110
AUC			0.815 (0.736 - 0.894)

Table 6. Logistic Regression Model Predictive of INT

Covariates

Crude*

Adjusted*

AUC: area under the curve. *Values expressed as odds ratio (95% CI). Hosmer-Lemeshow of adjusted final model: Chi-square 9.67, df = 8, P = 0.289.

α-Blocker

2.25 (0.991 - 5.118)

0.053

3.02 (1.09 - 8.36)

0.033

Caucasian

2.66 (1.21 - 5.85)

0.015

3.23 (1.23 - 8.50)

0.018

Temperature

1.37 (1.15 - 1.64)

0.001

1.36 (1.11 - 1.67)

0.003

Age

0.98 (0.94 - 1.01)

0.124

0.97 (0.93 - 1.01)

0.188

BMI

1.09 (1.02 - 1.17)

0.014

1.08 (0.99 - 1.17)

0.071

Pneumonia

2.74 (0.92 - 8.22)

0.072

2.70 (0.80 - 9.15)

0.110

AUC

0.815 (0.736 - 0.894)