ABSTRACT
This thesis analyzes the management of patients with sepsis and septic shock arrived at the AOUP Emergency Department and then admitted to Emergency Medicine ward: the study places particular emphasis on variables that may have affected the time of initiation of therapy .
Finally, it is studied whether these differences or other factors have somehow influenced the prognosis in the Department.
The management of patients with sepsis and septic shock in the Emergency Department was respected as defined by the guidelines of the SSC.
As regards the timing, not all patients taken into consideration have received the first dose of antibiotics within 3h but this is mainly due to the fact that most of them did not show such critical parameters (ie, a qSOFA≥2) to justify an administration of antimicrobials before to receive additional data to support a septic condition. Furthermore, being more than half of the population evaluated with a priority code not red at the triage, the wait before the medical examination has played an important role. In this sense, the introduction of the "Incharge Room" in the ED has led to a significant increase in the speed of patient care.
The overcrowding in the ED does not seem to affect the start of treatment: on the contrary, it is in conditions of greater access that was highlighted greater rapidity of begin of fluid administration.
As expected the most critically ill patients (qSOFA score ≥2, lower mean arterial pressure) have received the fluids more quickly.
Considering the role of qSOFA also in the administration of antimicrobials (faster in the presence of a score ≥2), the present thesis has shown that this score, introduced by the new guidelines, was an innovative important tool for the rapid management of the septic patient in the ED.
In patients with numerous comorbidities, however, it remains less easy the early detection of an infectious condition underlying the clinical presentation and then to quickly start the antimicrobial treatment.
The main factors that influence the development of septic shock are related to the patient (low white blood cells), the degree of organ dysfunction (high SOFA score, reduced MAP) and the type of infection (multiple infections and residence in health care home where is probably present a greater risk of colonization by multi-resistant bacteria).
The main factors that affect the death, which occurred in about half of cases within the first day of hospitalization, are also related to the patient (greater number of comorbidities), the
degree of organ dysfunction (high SOFA score, progression to shock ) and the type of infection (respiratory).
Finally, while the most critical patients have a distribution of access throughout the day, it seems that patients that have proved a lower risk of progression to shock and death have been especially concentrated during daylight hours, in the presence of a greater number of accesses in the Emergency Department.
The timing of therapy did not significantly influence the outcome: the trends that emerged in the study seems to have been more important an early hemodynamic resuscitation compared to antimicrobial therapy.
In conclusion, the qSOFA made it possible to identify and treat early septic patients. Unfortunately, in patients with advanced age and a large number of comorbidities this has not led to a significant benefit in terms of prognostic.
The ER doctor does not know in which patients the disease process has progressed beyond the "inflection point" but for this very reason he cannot delay the administration of the antibiotics, in order to save that percentage still retrievable .
