Comparison of prognosis in emergency department elderly septic shock patients with initial hypotension versus delayed hypotension

Abstract

Background and importance – Hypotension and advanced-age are significant risk factors for increased sepsis-related mortality. However, the relationship between the timing of hypotension in the emergency department (ED) and the prognosis of elderly patients with septic shock is little understood. Objective – To determine the effect of hypotension on arrival at the ED with the prognosis of elderly patients with septic shock. Design, settings, and participants – A retrospective analysis of a multicenter registry that was prospectively collected from 12 EDs. Patients aged older than 65 years who were diagnosed with septic shock requiring vasopressor support from October 2015 to December 2022 were included. Hypotension was defined as a systolic blood pressure less than 90 mmHg or a mean arterial pressure less than 65 mmHg. Based on the timing of the first hypotension episode, patients were divided into two groups: the initial hypotension group (hypotension on arrival at the ED) and the delayed hypotension group (developed hypotension while staying in the ED). Outcome measures and analysis – The primary outcome was 28-day mortality of elderly patients with septic shock, and the secondary outcomes were ICU admission, mechanical ventilation within 24 h, and renal replacement therapy (RRT) within 24 h. A multivariable Cox proportional hazards model was used to analyze the association between initial hypotension and the outcomes. A Kaplan–Meier curve was constructed to investigate the survival probabilities of the patients. Main results – This study included 1444 patients [868 (60.1%) with initial hypotension and 576 (39.9%) with delayed hypotension]. Initial hypotension was significantly associated with 28-day mortality [hazard ratio: 1.20, 95% confidence interval (CI): 1.00–1.45, P = 0.049]. However, initial hypotension was not associated with ICU admission (hazard ratio: 1.13, 95% CI: 0.96–1.33, P = 0.154), mechanical ventilation within 24 h (hazard ratio: 0.85, 95% CI: 0.69–1.06, P = 0.147), or RRT within 24 h (hazard ratio: 1.05, 95% CI: 0.76–1.46, P = 0.775). Conclusion – This study highlights the prognostic value of initial hypotension in elderly patients with septic shock, showing its association with a high risk of 28-day mortality.