• Mark E Mikkelsen, David F Gaieski, Barry D Fuchs, Scarlett L Bellamy, Jason D Christie, Nuala J Meyer, Chirag V Shah, Sarah Lyon, and Andrea N Miltiades.
• 1Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania 2Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania 3Pulmonary and Allergy Associates, Morristown Medical Center 4Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania 5Department of Anesthesiology, Columbia University Medical Center 6Department of Emergency Medicine, Medstar Washington Hospital Center, Georgetown University School of Medicine.
• Shock. 2013 Oct 1.

BackgroundAcute respiratory distress syndrome (ARDS) is a serious complication of sepsis and sepsis-associated ARDS is associated with significant morbidity and mortality. To date, no study has directly examined the epidemiology of ARDS in severe sepsis from the earliest presentation to the health care system, the Emergency Department (ED).MethodsSingle-center retrospective, observational cohort study of 778 adults with severe sepsis presenting to the ED. The primary outcome was the development of ARDS requiring mechanical ventilation during the first 5 hospital days. ARDS was defined using the Berlin definition. We used multivariable logistic regression to identify risk factors associated independently with ARDS development.ResultsThe incidence of ARDS was 6.2% (48 of 778 patients) in the entire cohort. ARDS development varied across the continuum of care: 0.9% of patients fulfilled criteria for ARDS in the ED, 1.4% admitted to the ward developed ARDS, and 8.9% admitted to the ICU developed ARDS. ARDS developed a median of 1 day after admission and was associated with a four-fold higher risk of in-hospital mortality (14% vs. 60%, p<0.001). Independent risk factors associated with increased risk of ARDS development included: intermediate (2-3.9 mmol/L) (p=0.04) and high (≥ 4) serum lactate levels (p=0.008), lung injury prediction score (LIPS) (p<0.001) and microbiologically-proven infection (p=0.01).ConclusionsIn patients presenting to the ED with severe sepsis, the rate of sepsis-associated ARDS development varied across the continuum of care. ARDS developed rapidly and was associated with significant mortality. Elevated serum lactate levels in the ED and a recently validated clinical prediction score were independently associated with the development of ARDS in severe sepsis.

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