Discussion
death, Coma, organ dysfunction, organ failure, sepsis, liver or respiratory dysfunction, septic
SEPSIS, COMA
To our knowledge, we are the first to identify HRV features that can predict progressive organ dysfunction in early sepsis patients admitted to the ED. Using a mobile bed-side monitor, we collected continuous ECG recordings of 168 unique admissions. POD was defined as de novo kidney, liver or respiratory dysfunction, ICU admission or death within 72 h, and occurred during 11 admissions, while 38 had SOD and 119 did not have organ dysfunction at all. We developed an algorithm to derive HRV features from 48 h long continuous ECG recordings, segmented the continuous measurements in clinically relevant time windows of three hours each and used absolute and trend-based methods to compare HRV features extracted from these ECGs. We demonstrated that AVNN, ULF, VLF, LF and Total Power features differ between the three groups at multiple time-points during the first 12 h after ED admission. We can conclude that each of the scoring methods HRV, SepsisSeverity and qSOFA is predictive of progressive organ failure. Furthermore, the predictive accuracy was not different between the three scores, as demonstrated by comparing the AUROCs of the HRV-score, SepsisSeverity and qSOFA (p > 0.05) Integrating the HRV features into a multivariate prediction model, demonstrated the potential of HRV to be explored as a predictor of progressive organ dysfunction. Yet, as compared to currently used risk stratification tools (e.g. qSOFA), HRV features are extracted only from the ECG and can be relatively continuously obtained from the bedside monitor. For instance, the qSOFA takes measures that have to be obtained by a human, as it contains the Glascow Coma Scale that cannot be measured using a monitor. Using HRV features that can be extracted from the ECG in real-time, measuring intervals can be short (in terms of seconds to minutes) and automated monitoring of the trend is possible. This creates the opportunity to perform trend and variability analysis on a more detailed scale and allows to reveal patterns not seen by human observers investigating multiple individual recordings with a relatively long time interval.The identification of clinically relevant outcomes for patients with early sepsis at the ED can be challenging, as hard outcomes as ICU admission and in-hospital mortality have a relatively low incidence among patients with early sepsis at the ED, as demonstrated in our population and in line with other studies [The Sepsis-3 criteria are the current, widely accepted criteria to determine severity of illness in septic patients at the ED and which consist of the qSOFA and SOFA score [Early prediction of clinical deterioration in patients with sepsis is essential to allow timely initiation of adequate treatment, but supportive data is scarce. The relation between HRV features and clinical outcomes had been investigated before, although other studies either focus on patients presenting at the ED with in a smaller, more severely ill population [