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Predictors of mortality in severe sepsis

To the Editor,

We read with interest the article recently published by McCor- mack and colleagues [1]. The authors evaluated the prognostic role of The Mortality in Emergency Department Sepsis (MEDS) score in ED patients with severe sepsis. They found that patients in the mortality group had older age; higher lactate; lower albumin; and higher international normalized ratio, ED intubation, and intensive care unit admission.

Despite the efficacy of modern treatment, severe sepsis is the leading cause of death due to infection [2]. Sepsis is a complex process with a high degree of variability, and current studies showed that myocardial dysfunction, which is characterized by transient biventricular impairment of intrinsic myocardial con- tractility, is a common complication in patients with sepsis and septic shock. Cardiac troponins and Natriuretic peptides are bio- markers that were previously introduced for diagnosis and risk stratification in patients with acute coronary syndrome and con- gestive heart failure, respectively. However, the elevation of car- diac troponin natriuretic peptide levels in patients with sepsis, severe sepsis, or septic shock has been shown to indicate left ventricular dysfunction and a poor prognosis [3]. Therefore, we would be grateful if the authors have and would provide the data regarding troponin and natriuretic peptide levels on admis- sion and their relationship with the severity of the disease in pa- tients with sepsis.

Mugla University, Faculty of Medicine, Department of Infectious Diseases

and Clinical Microbiology

Volkan Dogan, MD? Ozcan Basaran, MD Murat Biteker, MD

Mugla University, Faculty of Medicine, Department of Cardiology

?Corresponding author. Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah, Haluk Ozsoy Cad., 48000, Mugla

Tel.: +90 252 214 13 26

E-mail: addresses [email protected]

[email protected]

http://dx.doi.org/10.1016/j.ajem.2016.06.092

References

1. McCormack D, Ruderman A, Menges W, Kulkarni M, Murano T, Keller SE. Usefulness of the mortality in severe sepsis in the emergency department score in an urban tertiary care hospital. Am J Emerg Med 2016;34(6):1117-20.
2. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013;369(9):840-51.
3. Klouche K, Pommet S, Amigues L, Bargnoux AS, Dupuy AM, Machado S, et al. plasma brain natriuretic peptide and troponin levels in severe sepsis and septic shock: relationships with systolic myocardial dysfunction and intensive care unit mortality.J Intensive Care Med 2014;29(4):229-37. http://dx.doi.org/10.1177/0885066612471621 [Epub 2013 Jan 1].

   elevated cardiac biomarkers are not associated

   

   with mortality in low-risk cardiac patients with severe sepsis?,??

   To the Editor,

   Previous research has shown that cardiac dysfunction in severe sepsis worsens outcomes and increases mortality [1]. Dogan et al. [2] in their correspondence point out that further evidence is still necessary to prove that elevated cardiac biomarkers, specifically Cardiac troponin I and brain natriuretic (BNP) levels, are associated with higher mortality for patients with severe sepsis. As requested, we conducted an analysis using the same study sample that was used to evaluate the Mortality in Severe Sepsis in the Emergency Department scoring method, which identified several clinical factors associated with higher in-hospital mortality [3]. For statistical analysis, the Student t test was used to determine an association between cardiac biomarkers, ejection fraction (EF%), and in-hospital mortality.

   Of 182 patients who presented to the emergency department with severe sepsis, 127 (70%) had an initial CTnI level (0.20 +- 0.06 ng/mL;

   95% confidence interval [CI], 0.07-0.33), and 44 (24%) had a second

   cTnI level (0.52 +- 0.16 ng/mL; 95% CI, 0.19-0.86). The Upper limit of normal for cTnI at our institution is 0.3 ng/mL indicating that the mean cTnI for the second cTnI was significantly higher than initial cTnI in our patient cohort (P = .03). Only 37 patients (20%) were found to have a reported BNP level (909.62 +- 338.39 pg/mL; 95% CI, 223.32-1595.93), and 45 patients (25%) had an EF% (53.22 +- 3.16;

   95% CI, 46.86-59.59) determined by echocardiogram during the hospital course. Our analysis did not find a significant association between survival and mortality for initial cTnI (0.24 +- 0.09 ng/mL vs 0.12 +- 0.05 ng/mL; P = .39), second cTnI (0.50 +- 0.21 ng/mL vs 0.55 +-

   0.27 ng/mL; P = .87), and BNP (767.16 +- 315.37 pg/mL vs 1294.20 +-

   946.84 pg/mL; P = .49). The EF% did not significantly differ between survival and mortality groups (53.52 vs 52.78; P = .91).

   ? Funding: None.

   ?? Presentations: None.