Outcomes and Factors Associated with Occult Septic Shock in Emergency Department Patients with Soft Tissue Infection

Laura Marie Tiffany; Quincy K Tran; Maie Abdel-Wahab; Austin Widjaja; Aya Aligabi; Fernando Albelo; Samantha Asunción; Dominique Gelmann; Daniel J Haase; Sharon Henry; Evan Leibner; Lucas Sjeklocha

doi:10.4103/jets.jets_38_22

Outcomes and Factors Associated with Occult Septic Shock in Emergency Department Patients with Soft Tissue Infection

J Emerg Trauma Shock. 2022 Jul-Sep;15(3):128-134. doi: 10.4103/jets.jets_38_22. Epub 2022 Sep 28.

Authors

Laura Marie Tiffany¹, Quincy K Tran^{2

3}, Maie Abdel-Wahab⁴, Austin Widjaja⁴, Aya Aligabi⁴, Fernando Albelo⁵, Samantha Asunción⁵, Dominique Gelmann⁵, Daniel J Haase^{2

3}, Sharon Henry⁶, Evan Leibner^{7

8}, Lucas Sjeklocha^{2

3

7}

Affiliations

¹ The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
² Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
³ Program in Trauma, The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
⁴ Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
⁵ University of Maryland School of Medicine, Baltimore, MD, USA.
⁶ Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
⁷ University of Maryland Medical Center, Baltimore, MD, USA.
⁸ Department of Emergency Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York City, NY.

Abstract

Introduction: Patients who develop occult septic shock (OSS) are associated with worse outcomes than those with early septic shock (ESS). Patients with skin and soft tissue infection (SSTI) may have underlying organ dysfunction due to OSS, yet the prevalence and the outcomes of patients with SSTI and early versus occult shock have not been described. This study compared the clinical characteristics of SSTI patients and the prevalence of having no septic shock (NSS), ESS, or OSS.

Methods: We retrospectively analyzed charts of adult patients who were transferred from any emergency department to our academic center between January 1, 2014, and December 31, 2016. Outcomes of interest were the development of OSS and acute kidney injury (AKI). We performed logistic regressions to measure the association between clinical factors with the outcomes and created probability plots to show the relationship between key clinical variables and outcomes of OSS or AKI.

Results: Among 269 patients, 218 (81%) patients had NSS, 16 (6%) patients had ESS, and 35 (13%) patients had OSS. Patients with OSS had higher mean serum lactate concentrations than patients with NSS (3.5 vs. 2.1 mmol/L, P < 0.01). Higher sequential organ failure assessment (SOFA) score was associated with higher likelihood of developing OSS (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.23-1.62, P < 0.001). NSS was associated with very low odds of developing AKI (OR 0.16, 95% CI 0.08-0.33, P < 0.001).

Conclusions: 13% of the patients with SSTI developed OSS. Patients with OSS had elevated serum lactate concentration and higher SOFA score than those with NSS. Increased SOFA score is a predictor for the development of OSS.

Keywords: Acute kidney injury; early septic shock; necrotizing soft tissue infection; occult septic shock.