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Unauthorized reproduction of this article is prohibited. 7 EARLY- VERSUS LATE-ONSET SHOCK IN EUROPEAN INTENSIVE CARE UNITS Yasser Sakr,* Jean-Louis Vincent, † Tobias Schuerholz, ‡ Daniela Filipescu, § Alain Romain, k Hans Hjelmqvist, ¶ and Konrad Reinhart;* on behalf of the SOAP investigators* *Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Jena, Germany; † Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium; ‡ Department of Anaesthesia, Medizinische Hochschule, Hannover, Germany; § Department of Anesthesiology & Cardiac Intensive Care, Institute of Cardiovascular Diseases, Bucharest, Romania; k Department of Intensive Care, St Pierre University Hospital, Brussels, Belgium; and ¶ Intensive Care Unit, Karolinska University Hospital, Stockholm, Sweden Received 11 Sep 2006; first review completed 19 Oct 2006; accepted in final form 26 Apr 2007 ABSTRACT—We investigated the possible differences in epidemiology, clinical course, management, and outcome between early and late occurrence of shock using data from the Sepsis Occurrence in Acutely Ill Patients Study, a large European multicenter study, which prospectively collected data from all adult intensive care unit (ICU) patients admitted to a participating center within a 2-week period in 2002. Shock was defined as hemodynamic compromise necessitating the administration of vasopressor agents. Early and late shock were defined as onset of shock within the first 2 days in the ICU or later, respectively. Of 3,147 patients, 1,058 (33.6%) had shock at any time, of whom 462 (43.7%) had septic shock. Patients with late shock had a higher incidence of respiratory (87.4 vs. 69.7%, P G 0.001) and hepatic (15.5 vs. 8.7%, P G 0.05) failure, and more often received dopamine (44.7% vs. 34.5%, P G 0.05) and albumin (31.1% vs. 20.3%, P G 0.001) than patients who developed shock early. Intensive care unit and hospital mortality rates were greater in patients who developed shock late, rather than early (52.4% vs. 36.8% and 55.3% vs. 43%, respectively, P G 0.02). In a multivariable analysis, late shock was associated with an independent risk of higher ICU mortality in shock patients (odds ratio, 2.6; 95% confidence interval, 1.6Y4.3, P G 0.001). These observations have important implications in establishing individual prognosis as well as in the design and interpretation of clinical trials. KEYWORDS—Mortality, organ failure, septic shock INTRODUCTION Despite advances in supportive therapy, mortality rates in intensive care unit (ICU) patients with acute circulatory failure (shock) range from 30% to 72% (1). Septic shock is a common cause of cardiovascular failure with the highest degree of morbidity and mortality (2Y4). Improving survival seems to be related to early recognition and appropriate therapy (5, 6). The time of onset of shock may be very important in determining outcome. In a cohort of patients who had positive bacterial cultures and septic shock, Lundberg et al. (7) reported lower mortality rates in patients who developed shock in the ICU than those who acquired septic shock on a general ward despite the fact that the former were younger and had lower Acute Physiology and Chronic Health Evalua- tion II scores than the latter. These authors (7) proposed that the observed differences in mortality may have been due to earlier therapeutic interventions being administered in patients on the ICU. However, Roman-Marchant et al. (8) showed that, although septic shock in ICU patients was more severe when of early onset, as reflected by more severe organ dysfunction, greater lactic acidosis, and higher vasopressor requirement, the outcome was better, as reflected by a shorter duration of the shock episode, shorter ICU stay, and slightly lower mortality rates, than septic shock of late onset. These observations (7, 8) reflect the possible variability in character- istics and outcome of septic shock according to the location and the time of onset of shock; however, both studies are limited by being single-center experiences and by the relatively small numbers of patients included. Characterizing this variability in a large cohort of ICU patients may be important in identifying high-risk patients, allocating medical recourses, and guiding future therapeutic trials. The aim of our study was, therefore, to investigate possible differences in epidemiology, clinical course, management, and outcome between patients with early- and late-onset shock due to any cause and due to sepsis among ICU patients included in a large European multicenter study. METHODS Study design This study is a subanalysis of the Sepsis Occurrence in Acutely Ill Patients (SOAP) study (9), a prospective, multicenter, observational study that was initiated by a working group of the European Society of Intensive Care Medicine to evaluate the epidemiology of sepsis in European countries. We included all adult patients (915 years) admitted to the participating centers (see the BAppendix[ for a list of participating countries and centers) between May 1 and May 15, 2002. Patients were followed-up until death, hospital discharge, or for 60 days. Those who stayed in the ICU for routine postoperative observation for less than 24 h were excluded. Institutional review board approval was either waived or expedited in participating institutions, and informed consent was not required because this epidemio- logic observational study did not require any deviation from routine medical practice. 636 SHOCK, Vol. 28, No. 6, pp. 636Y643, 2007 Address reprint requests to Prof. Jean-Louis Vincent, Department of Intensive Care, Erasme University Hospital, Route de Lennik 808, B-1070 Brussels, Belgium. E-mail: jlvincen@ulb.ac.be. DOI: 10.1097/shk.0b013e3180cab855 Copyright Ó 2007 by the Shock Society