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Gill A, Ackermann K, Hughes C, Lam V, Li L. Does lactate enhance the prognostic accuracy of the quick Sequential Organ Failure Assessment for adult patients with sepsis? A systematic review. BMJ Open 2022; 12:e060455. [PMID: 36270756 PMCID: PMC9594532 DOI: 10.1136/bmjopen-2021-060455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To investigate whether adding lactate to the quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) improves the prediction of mortality in adult hospital patients, compared with qSOFA alone. DESIGN Systematic review in accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies guidelines. DATA SOURCES Embase, Medline, PubMed, SCOPUS, Web of Science, CINAHL and Open Grey databases were searched in November 2020. ELIGIBILITY CRITERIA Original research studies published after 2016 comparing qSOFA in combination with lactate (LqSOFA) with qSOFA alone in adult patients with sepsis in hospital. The language was restricted to English. DATA EXTRACTION AND SYNTHESIS Title and abstract screening, full-text screening, data extraction and quality assessment (using Quality Assessment of Diagnostic Accuracy Studies-2) were conducted independently by two reviewers. Extracted data were collected into tables and diagnostic test accuracy was compared between the two tests. RESULTS We identified 1621 studies, of which 11 met our inclusion criteria. Overall, there was a low risk of bias across all studies. The area under the receiver operating characteristic (AUROC) curve for qSOFA was improved by the addition of lactate in 9 of the 10 studies reporting it. Sensitivity was increased in three of seven studies that reported it. Specificity was increased in four of seven studies that reported it. Of the six studies set exclusively within the emergency department, five published AUROCs, all of which reported an increase following the addition of lactate. Sensitivity and specificity results varied throughout the included studies. Due to insufficient data and heterogeneity of studies, a meta-analysis was not performed. CONCLUSIONS LqSOFA is an effective tool for identifying mortality risk both in adult inpatients with sepsis and those in the emergency department. LqSOFA increases AUROC over qSOFA alone, particularly within the emergency department. However, further original research is required to provide a stronger base of evidence in lactate measurement timing, as well as prospective trials to strengthen evidence and reduce bias. PROSPERO REGISTRATION NUMBER CRD42020207648.
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Affiliation(s)
- Angus Gill
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Khalia Ackermann
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Clifford Hughes
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Vincent Lam
- Macquarie Medical School, Macquarie University, Sydney, New South Wales, Australia
| | - Ling Li
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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SOFA Score in relation to Sepsis: Clinical Implications in Diagnosis, Treatment, and Prognostic Assessment. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7870434. [PMID: 35991153 PMCID: PMC9385349 DOI: 10.1155/2022/7870434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/11/2022] [Accepted: 07/22/2022] [Indexed: 01/31/2023]
Abstract
Purpose To analyze the clinical significance of the sequential organ failure assessment (SOFA) score in the diagnosis, treatment, and prognostic assessment of sepsis. Methods 140 patients with sepsis from January 2020 to January 2021 were selected as the observation group, and 40 healthy people were selected as the control group. The observation group was divided into mild group, severe group, and septic shock group by single blind grouping according to the condition of the disease, and they were also divided into survival group and death group according to the prognosis. Collect the fasting venous blood of the subjects in each group in the morning, compare the levels of total bilirubin (TBIL), blood creatinine (CR), and platelet count (PLT) in each group, and record and compare the patients' respiratory system oxygen partial pressure/inhaled oxygen concentration (po2/fio2), acute physiology and chronic health scoring system II (APACHE II), sequential organ failure assessment (sofa) score, q-SOFA score, and △SOFA score; Pearson analysis was used to analyze the correlation between SOFA score and other indicators; multivariate logistic regression was used to analyze the prognostic risk factors of patients with sepsis; receiver-operating characteristic curve (ROC) was used to analyze the value of SOFA score alone and in combination in the diagnosis, condition, and prognosis of sepsis. Results There were significant differences in Apache II score, SOFA score, q-SOFA score map, po2/fio2, PLT, GCS, TBIL, and serum creatinine (SCR) between the control group and the observation group (P < 0.05). There were significant differences in Apache II score, SOFA score, q-SOFA score, mean arterial pressure (map) po2/fio2, PLT, Glasgow Coma Score (GCS), TBIL, SCR, and △SOFA score among patients in mild, severe, and septic shock groups (P < 0.05). There were significant differences in age, Apache II score, SOFA score, q-SOFA score, map, po2/fio2, PLT, GCS, TBIL, SCR, and △SOFA score between survival group and death group (P < 0.05). SOFA score and q-SOFA score were significantly positively correlated with TBIL and SCR and significantly negatively correlated with po2/fio2 and PLT; △SOFA score was significantly negatively correlated with TBIL and SCR and significantly positively correlated with map, po2/fio2, PLT, and GCS. Apache II score, SOFA score, and q-SOFA score were independent risk factors for sepsis patients, and △SOFA score, po2/fio2, and GCS score were protective factors (P < 0.05). ROC curve analysis showed that the AUC of sepsis combined with SOFA score and q-SOFA score was 0.880; the AUC of sepsis assessed by SOFA score, q-SOFA score, and △SOFA score was 0.929; the AUC of sepsis prognosis assessed by SOFA score, q-SOFA score, and △SOFA score was 0.900. Conclusion SOFA score, q-SOFA score, and △SOFA score were abnormally expressed in patients with sepsis and were risk factors for the severity of the patient's condition and prognosis. The SOFA score, q-SOFA score, and △SOFA score were risk factors for the severity and prognosis of patients with sepsis and had some value in diagnosing sepsis and assessing the condition and prognosis, of which the combined value of the three was higher.
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Sreekanth A, Jain A, Dutta S, Shankar G, Raj Kumar N. Accuracy of Quick Sequential Organ Failure Assessment Score & Systemic Inflammatory Response Syndrome Criteria in Predicting Adverse Outcomes in Emergency Surgical Patients With Suspected Sepsis: A Prospective Observational Study. Cureus 2022; 14:e26560. [PMID: 35936141 PMCID: PMC9348436 DOI: 10.7759/cureus.26560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/07/2022] Open
Abstract
Purpose: Due to the mixed population enrolled in different studies i.e., medical and surgical cases, conflicting data exists about the accuracy of quick sequential organ failure assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores in predicting adverse outcomes in patients with suspected sepsis presenting to the surgical emergency. Method: A prospective observational study was done in the department of surgery of a tertiary teaching hospital, India from June 2018 to July 2019. Consecutive patients who visited the surgical emergency department with suspected sepsis were included. Patients were followed up until hospital discharge or death. Results: Of the 410 patients screened, 287 were included in the analysis. The median age was 52 years (interquartile range, 41 to 61years) and 208 (72.8%) were men. Around 56.8% of patients had intra-abdominal pathology, and 43.2% had skin and soft -tissue infection. Sixty-nine (24%) patients died during their hospitalization, 98 (34.1%) patients had organ dysfunction, and 168 (58.5%) patients needed admission to the intensive care unit (ICU). A higher qSOFA score (≥2) was associated with organ dysfunction, ICU admission, and in-hospital mortality. The specificity, positive predictive value and diagnostic accuracy of qSOFA for organ dysfunction (85.7%, 67.8%, 76.3%), ICU admission (92.4%, 89.3%, 64.5%), and in-hospital mortality (81.6%, 52.4%, 77.4%) was higher than SIRS. The area under the receiver operating characteristic curve for qSOFA for these variables was also higher than for SIRS (0.826 vs. 0.524, 0.823 vs. 0.577, and 0.823 vs. 0.555, respectively). Conclusion: qSOFA is a better model for predicting adverse outcomes and mortality, organ dysfunction, and ICU admission in surgical patients. However, SIRS indicates intervention requirements in a surgical patient better than qSOFA.
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Flint M, Hamilton F, Arnold D, Carlton E, Hettle D. The timing of use of risk stratification tools affects their ability to predict mortality from sepsis. A meta-regression analysis. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.17223.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Risk stratification tools (RSTs) are used in healthcare settings to identify patients at risk of sepsis and subsequent adverse outcomes. In practice RSTs are used on admission and thereafter as ‘trigger’ tools prompting sepsis management. However, studies investigating their performance report scores at a single timepoint which varies in relation to admission. The aim of this meta-analysis was to determine if the predictive performance of RSTs is altered by the timing of their use. Methods: We conducted a systematic review and meta-regression analysis of studies published from inception to 31 October 2018, using EMBASE and PubMed databases. Any cohort studies investigating the ability of an RST to predict mortality in adult sepsis patients admitted to hospital, from which a 2x2 table was available or could be constructed, were included. The diagnostic performance of RSTs in predicting mortality was the primary outcome. Sensitivity, specificity, positive predictive value, negative predictive value and area under the receiver-operating curve (AUROC) were the primary measures, enabling further meta-regression analysis. Results: 47 studies were included, comprising 430,427 patients. Results of bivariate meta-regression analysis found tools using a first-recorded score were less sensitive than those using worst-recorded score (REML regression coefficient 0.57, 95% CI 0.07-1.08). Using worst-recorded score led to a large increase in sensitivity (summary sensitivity 0.76, 95% CI 0.67-0.83, for worst-recorded scores vs. 0.64 (0.57-0.71) for first-recorded scores). Scoring system type did not have a significant relationship with studies’ predictive ability. The most analysed RSTs were qSOFA (n=37) and EWS (n=14). Further analysis of these RSTs also found timing of their use to be associated with predictive performance. Conclusion: The timing of any RST is paramount to their predictive performance. This must be reflected in their use in practice, and lead to prospective studies in future.
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Silva LMFD, Diogo LP, Vieira LB, Michielin FDC, Santarem MD, Machado MLP. Performance of scores in the prediction of clinical outcomes in patients admitted from the emergency service. Rev Lat Am Enfermagem 2021; 29:e3479. [PMID: 34495190 PMCID: PMC8432508 DOI: 10.1590/1518-8345.4722.3479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 04/17/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: to evaluate the performance of the quickSOFA scores and Systemic Inflammatory Response Syndrome as predictors of clinical outcomes in patients admitted to an emergency service. Method: a retrospective cohort study, involving adult clinical patients admitted to the emergency service. Analysis of the ROC curve was performed to assess the prognostic indexes between scores and outcomes of interest. Multivariate analysis used Poisson regression with robust variance, evaluating the relationship between variables with biological plausibility and outcomes. Results: 122 patients were selected, 58.2% developed sepsis. Of these, 44.3% had quickSOFA ≥2 points, 87% developed sepsis, 55.6% septic shock and 38.9% died. In the evaluation of Systemic Inflammatory Response Syndrome, 78.5% obtained results >2 points; of these, 66.3% developed sepsis, 40% septic shock and 29.5% died. quickSOFA ≥2 showed greater specificity for diagnosis of sepsis in 86% of the cases, for septic shock 70% and for mortality 64%, whereas the second score showed better results for sensitivity with diagnosis of sepsis in 87.5%, septic shock in 92.7% and death in 90.3%. Conclusion: quickSOFA showed by its practicality that it can be used clinically within the emergency services, bringing clinical applicability from the risk classification of patients for the early recognition of unfavorable outcomes.
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Lee JY, Molani S, Fang C, Jade K, O'Mahony DS, Kornilov SA, Mico LT, Hadlock JJ. Ambulatory Risk Models for the Long-Term Prevention of Sepsis: Retrospective Study. JMIR Med Inform 2021; 9:e29986. [PMID: 34086596 PMCID: PMC8299345 DOI: 10.2196/29986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/02/2021] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is a life-threatening condition that can rapidly lead to organ damage and death. Existing risk scores predict outcomes for patients who have already become acutely ill. Objective We aimed to develop a model for identifying patients at risk of getting sepsis within 2 years in order to support the reduction of sepsis morbidity and mortality. Methods Machine learning was applied to 2,683,049 electronic health records (EHRs) with over 64 million encounters across five states to develop models for predicting a patient’s risk of getting sepsis within 2 years. Features were selected to be easily obtainable from a patient’s chart in real time during ambulatory encounters. Results The models showed consistent prediction scores, with the highest area under the receiver operating characteristic curve of 0.82 and a positive likelihood ratio of 2.9 achieved with gradient boosting on all features combined. Predictive features included age, sex, ethnicity, average ambulatory heart rate, standard deviation of BMI, and the number of prior medical conditions and procedures. The findings identified both known and potential new risk factors for long-term sepsis. Model variations also illustrated trade-offs between incrementally higher accuracy, implementability, and interpretability. Conclusions Accurate implementable models were developed to predict the 2-year risk of sepsis, using EHR data that is easy to obtain from ambulatory encounters. These results help advance the understanding of sepsis and provide a foundation for future trials of risk-informed preventive care.
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Affiliation(s)
- Jewel Y Lee
- Institute for Systems Biology, Seattle, WA, United States
| | - Sevda Molani
- Institute for Systems Biology, Seattle, WA, United States
| | - Chen Fang
- Institute for Systems Biology, Seattle, WA, United States
| | - Kathleen Jade
- Institute for Systems Biology, Seattle, WA, United States
| | - D Shane O'Mahony
- Swedish Center for Research and Innovation, Swedish Medical Center, Seattle, WA, United States
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Mignot-Evers L, Raaijmakers V, Buunk G, Brouns S, Romano L, van Herpt T, Gharbharan A, Dieleman J, Haak H. Comparison of SIRS criteria and qSOFA score for identifying culture-positive sepsis in the emergency department: a prospective cross-sectional multicentre study. BMJ Open 2021; 11:e041024. [PMID: 34135028 PMCID: PMC8210661 DOI: 10.1136/bmjopen-2020-041024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To compare the daily practice of two emergency departments (ED) in the Netherlands, where systemic inflammatory response syndrome (SIRS) criteria and quick Sequential Organ Failure Assessment (qSOFA) score are used differently as screening tools for culture-positive sepsis. DESIGN A prospective cross-sectional multicentre study. SETTING Two EDs at two European clinical teaching hospitals in the Netherlands. PARTICIPANTS 760 patients with suspected infection who met SIRS criteria or had a qualifying qSOFA score who were treated at two EDs in the Netherlands from 1 January to 1 March 2018 were included. METHODS SIRS criteria and qSOFA score were calculated for each patient. The first hospital treated the patients who met SIRS criteria following the worldwide Surviving Sepsis Campaign protocol. At the second hospital, only patients who met the qualifying qSOFA score received this treatment. Therefore, patients could be divided into five groups: (1) SIRS+, qSOFA-, not treated according to protocol (reference group); (2) SIRS+, qSOFA-, treated according to protocol; (3) SIRS+, qSOFA+, treated according to protocol; (4) SIRS-, qSOFA+, not treated according to protocol; (5) SIRS-, qSOFA+, treated according to protocol. PRIMARY AND SECONDARY OUTCOME MEASURES To prove culture-positive sepsis was present, cultures were used as the primary outcome. Secondary outcomes were in-hospital mortality and intensive care unit (ICU) admission. RESULTS 98.9% met SIRS criteria and 11.7% met qSOFA score. Positive predictive values of SIRS criteria and qSOFA score were 41.2% (95% CI 37.4% to 45.2%) and 48.1% (95% CI 37.4% to 58.9%), respectively. HRs were 0.79 (95% CI 0.40 to 1.56, p=0.500), 3.42 (95% CI 1.82 to 6.44, p<0.001), 18.94 (95% CI 2.48 to 144.89, p=0.005) and 4.97 (95% CI 1.44 to 17.16, p=0.011) for groups 2-5, respectively. CONCLUSION qSOFA score performed as well as SIRS criteria for identifying culture-positive sepsis and performed significantly better for predicting in-hospital mortality and ICU admission. This study shows that SIRS criteria are no longer necessary and recommends qSOFA score as the standard for identifying culture-positive sepsis in the ED. TRIAL REGISTRATION NUMBER NL8315.
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Affiliation(s)
- Lisette Mignot-Evers
- Emergency Department, Máxima Medical Centre, Veldhoven, The Netherlands
- Department of Health Services Research, Maastricht University, Care and Public Health Research Institute, Maastricht, The Netherlands
| | | | - Gerba Buunk
- Internal Medicine, Amphia Ziekenhuis, Breda, The Netherlands
| | - Steffie Brouns
- Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Lorenzo Romano
- Internal Medicine, Amphia Ziekenhuis, Breda, The Netherlands
| | - Thijs van Herpt
- Internal Medicine, Amphia Ziekenhuis, Breda, The Netherlands
| | | | - Jeanne Dieleman
- Máxima MC Academy, Máxima Medisch Centrum Veldhoven, Veldhoven, The Netherlands
| | - Harm Haak
- Department of Health Services Research, Maastricht University, Care and Public Health Research Institute, Maastricht, The Netherlands
- Internal Medicine, Máxima Medical Centre, Veldhoven, The Netherlands
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Waligora G, Gaddis G, Church A, Mills L. Rapid Systematic Review: The Appropriate Use of Quick Sequential Organ Failure Assessment (qSOFA) in the Emergency Department. J Emerg Med 2020; 59:977-983. [PMID: 32829969 DOI: 10.1016/j.jemermed.2020.06.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/06/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The concept of sepsis has recently been redefined by an International Task Force. The task force recommended the use of the quick Sequential Organ Failure Assessment (qSOFA) score instead of Systemic Inflammatory Response Syndrome (SIRS) criteria to identify patients at high risk of mortality from sepsis outside of the intensive care unit, including in emergency departments (EDs). However, the primary outcome for qSOFA is prediction of risk for mortality, which is not the principal outcome measure considered in the ED. From the ED perspective, the priorities are the identification (diagnosis) of the septic patient and then the initiation of time-sensitive, life-saving interventions. METHOD We performed a structured review of PubMed from January 2012 to December 2018, limited to reports involving human subjects and written in English language and containing relevant keywords. The highest-quality studies were then reviewed in a structured format. We utilized these studies to estimate the sensitivity and specificity of SIRS and qSOFA for diagnosis of sepsis. RESULTS Thirteen unique articles were identified for further review, and the 11 highest-grade articles (C and D) were determined to be appropriate for inclusion in this review, and the two low-grade articles were excluded (E). CONCLUSIONS Based on multiple retrospective and few prospective studies, it appears that qSOFA performs poorly in comparison with SIRS as a diagnostic tool for ED patients who may have sepsis or septic shock. However, qSOFA does have a strong prognostic accuracy for mortality in those ED patients already diagnosed with sepsis or septic shock.
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Affiliation(s)
| | - Gary Gaddis
- Division of Emergency Medicine, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Amy Church
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Lisa Mills
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
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Choo SH, Lim YS, Cho JS, Jang JH, Choi JY, Choi WS, Yang HJ. Usefulness of ischemia-modified albumin in the diagnosis of sepsis/septic shock in the emergency department. Clin Exp Emerg Med 2020; 7:161-169. [PMID: 33028058 PMCID: PMC7550814 DOI: 10.15441/ceem.19.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 10/28/2019] [Indexed: 12/29/2022] Open
Abstract
Objective No studies have evaluated the diagnostic value of ischemia-modified albumin (IMA) for the early detection of sepsis/septic shock in patients presenting to the emergency department (ED). We aimed to assess the usefulness of IMA in diagnosing sepsis/septic shock in the ED. Methods This retrospective, observational study analyzed IMA, lactate, high sensitivity C-reactive protein, and procalcitonin levels measured within 1 hour of ED arrival. Patients with suspected infection meeting at least two systemic inflammatory response syndrome criteria were included and classified into the infection, sepsis, and septic shock groups using Sepsis-3 definitions. Areas under the receiver operating characteristic curves (AUCs) with 95% confidence intervals (CIs) and multivariate logistic regression were used to determine diagnostic performance. Results This study included 300 adult patients. The AUC (95% CI) of IMA levels (cut-off ≥85.5 U/mL vs. ≥87.5 U/mL) was higher for the diagnosis of sepsis than for that of septic shock (0.729 [0.667–0.791] vs. 0.681 [0.613–0.824]) and was higher than the AUC of procalcitonin levels (cut-off ≥1.58 ng/mL, 0.678 [0.613–0.742]) for the diagnosis of sepsis. When IMA and lactate levels were combined, the AUCs were 0.815 (0.762–0.867) and 0.806 (0.754–0.858) for the diagnosis of sepsis and septic shock, respectively. IMA levels independently predicted sepsis (odds ratio, 1.05; 95% CI, 1.00–1.09; P=0.029) and septic shock (odds ratio, 1.07; 95% CI, 1.02–1.11; P=0.002). Conclusion Our findings indicate that IMA levels are a useful biomarker for diagnosing sepsis/ septic shock early, and their combination with lactate levels can enhance the predictive power for early diagnosis of sepsis/septic shock in the ED.
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Affiliation(s)
- Seung Hwa Choo
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yong Su Lim
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea.,Department of Emergency Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Jin Seong Cho
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea.,Department of Emergency Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Jae Ho Jang
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea.,Department of Emergency Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Jea Yeon Choi
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea.,Department of Emergency Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Woo Sung Choi
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyuk Jun Yang
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea.,Department of Emergency Medicine, Gachon University College of Medicine, Incheon, Korea
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Comparison of an ED triage sepsis screening tool and qSOFA in identifying CMS SEP-1 patients. Am J Emerg Med 2020; 38:1995-1999. [DOI: 10.1016/j.ajem.2020.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/30/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022] Open
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Prognostic Value of Severity Score Change for Septic Shock in the Emergency Room. Diagnostics (Basel) 2020; 10:diagnostics10100743. [PMID: 32987817 PMCID: PMC7598612 DOI: 10.3390/diagnostics10100743] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022] Open
Abstract
The vital signs or laboratory test results of sepsis patients may change before clinical deterioration. This study examined the differences in prognostic performance when systemic inflammatory response syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), quick SOFA (qSOFA) scores, National Early Warning Score (NEWS), and lactate levels were repeatedly measured. Scores were obtained at arrival to triage, 1 h after fluid resuscitation, 1 h after vasopressor prescription, and before leaving the emergency room (ER) in 165 patients with septic shock. The relationships between score changes and in-hospital mortality, mechanical ventilation, admission to the intensive care unit, and mortality within seven days were compared using areas under receiver operating characteristic curve (AUROCs). Scores measured before leaving the ER had the highest AUROCs across all variables (SIRS score 0.827 [0.737–0.917], qSOFA score 0.754 [0.627–0.838], NEWS 0.888 [0.826–0.950], SOFA score 0.835 [0.766–0.904], and lactate 0.872 [0.805–0.939]). When combined, SIRS + lactate (0.882 [0.804–0.960]), qSOFA + lactate (0.872 [0.808–0.935]), NEWS + lactate (0.909 [0.855–0.963]), and SOFA + lactate (0.885 [0.832–0.939]) showed improved AUROCs. In patients with septic shock, scoring systems show better predictive performances at the timepoints reflecting changes in vital signs and laboratory test results than at the time of arrival, and combining them with lactate values increases their predictive powers.
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Shahsavarinia K, Moharramzadeh P, Arvanagi RJ, Mahmoodpoor A. qSOFA score for prediction of sepsis outcome in emergency department. Pak J Med Sci 2020; 36:668-672. [PMID: 32494253 PMCID: PMC7260919 DOI: 10.12669/pjms.36.4.2031] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: The third international consensus definition for sepsis and septic shock (sepsis 3) task force recently introduced qSOFA (quick sequential organ failure assessment) as a score for detection of patients at risk of sepsis outside of intensive care units. We performed this study to evaluate the validity of qSOFA for early detection and risk stratification of septic patients in emergency department. Methods: We conducted this study in an emergency department of the largest university affiliated hospital in northwest of Iran from Sept 2015 to Sept 2016. One hundred and forty patients who were SIRS positive with a suspected infection without alternative diagnosis and a microbiological proven infection were enrolled in this study. qSOFA was calculated for each patient and correlated with sepsis grades and mortality. Results: From 140 patients 84 (60%) had positive qSOFA score and 56 (40%) patients had negative qSOFA score. Our results showed that near half of patients with positive qSOFA expired during their stay in hospital while this was about 5% for patients with negative qSOFA. ROC curve of study regarding prediction of outcome with qSOFA showed an area under curve of 0.59. (P value: 0.04). Time spent to sepsis detection was 16 minutes shorter with qSOFA score compared to SIRS criteria in this study. Conclusion: In patients with suspected sepsis, qSOFA has acceptable value for risk stratification of severity, multi organ failure and mortality. It seems that education of medical staff and frequent screening of patients for warning signs can help to increase the value of qSOFA in prediction of mortality in critically ill septic patients.
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Affiliation(s)
- Kavous Shahsavarinia
- Kavous Shahsavarinia, Associate Professor, Road Traffic Injury Research Center, Department of Emergency Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Payman Moharramzadeh
- Payman Moharramzadeh, Associate Professor, Department of Emergency Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Jamal Arvanagi
- Reza Jamal Arvanagi, Emergency Medicine Specialist, Department of Emergency Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Prof. Dr. Ata Mahmoodpoor, Department of Anesthesiology and intensive care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Kwon YS, Baek MS. Development and Validation of a Quick Sepsis-Related Organ Failure Assessment-Based Machine-Learning Model for Mortality Prediction in Patients with Suspected Infection in the Emergency Department. J Clin Med 2020; 9:jcm9030875. [PMID: 32210033 PMCID: PMC7141518 DOI: 10.3390/jcm9030875] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/04/2020] [Accepted: 03/17/2020] [Indexed: 12/23/2022] Open
Abstract
The quick sepsis-related organ failure assessment (qSOFA) score has been introduced to predict the likelihood of organ dysfunction in patients with suspected infection. We hypothesized that machine-learning models using qSOFA variables for predicting three-day mortality would provide better accuracy than the qSOFA score in the emergency department (ED). Between January 2016 and December 2018, the medical records of patients aged over 18 years with suspected infection were retrospectively obtained from four EDs in Korea. Data from three hospitals (n = 19,353) were used as training-validation datasets and data from one (n = 4234) as the test dataset. Machine-learning algorithms including extreme gradient boosting, light gradient boosting machine, and random forest were used. We assessed the prediction ability of machine-learning models using the area under the receiver operating characteristic (AUROC) curve, and DeLong's test was used to compare AUROCs between the qSOFA scores and qSOFA-based machine-learning models. A total of 447,926 patients visited EDs during the study period. We analyzed 23,587 patients with suspected infection who were admitted to the EDs. The median age of the patients was 63 years (interquartile range: 43-78 years) and in-hospital mortality was 4.0% (n = 941). For predicting three-day mortality among patients with suspected infection in the ED, the AUROC of the qSOFA-based machine-learning model (0.86 [95% CI 0.85-0.87]) for three -day mortality was higher than that of the qSOFA scores (0.78 [95% CI 0.77-0.79], p < 0.001). For predicting three-day mortality in patients with suspected infection in the ED, the qSOFA-based machine-learning model was found to be superior to the conventional qSOFA scores.
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Affiliation(s)
- Young Suk Kwon
- Department of Anaesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon 24253, Korea;
| | - Moon Seong Baek
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea
- Lung Research Institute of Hallym University College of Medicine, Chuncheon-si 24253, Korea
- Correspondence: ; Tel.: +82-31-8086-2292; Fax: +82-31-8086-2482
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George N, Elie-Turenne MC, Seethala RR, Baslanti TO, Bozorgmehri S, Mark K, Meurer D, Bihorac A, Aisiku IP, Hou PC. External Validation of the qSOFA Score in Emergency Department Patients With Pneumonia. J Emerg Med 2019; 57:755-764. [DOI: 10.1016/j.jemermed.2019.08.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/18/2019] [Accepted: 08/26/2019] [Indexed: 10/25/2022]
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The Effect of the Intelligent Sepsis Management System on Outcomes among Patients with Sepsis and Septic Shock Diagnosed According to the Sepsis-3 Definition in the Emergency Department. J Clin Med 2019; 8:jcm8111800. [PMID: 31717855 PMCID: PMC6912745 DOI: 10.3390/jcm8111800] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 12/29/2022] Open
Abstract
We developed a novel computer program, the Intelligent Sepsis Management System, based on Sepsis-3 definitions and 2016 Surviving Sepsis Campaign guidelines and performed a quasi-experimental pre-post study to assess its effect on compliance with the Surviving Sepsis Campaign guidelines and outcomes in patients with sepsis and septic shock. During the pre-period, patients were managed with usual care. During the post-period, patients were managed using the Intelligent Sepsis Management System upon arrival at the emergency department. A total of 631 patients were enrolled (pre-period, 316; post-period, 315). The overall compliance with the Surviving Sepsis Campaign guidelines’ bundle improved (pre-period 10.8% vs. post-period 54.6%; p < 0.001). The post-period showed significantly lower 30-day mortality than the pre-period (pre-period 37.3% vs. post-period 29.5%; p = 0.037), but was not a protective factor for 30-day mortality, with an adjusted hazard ratio (95% confidence interval) of 0.75 (0.55–1.04) (p = 0.151). The associated factors for 30-day mortality were age, sequential organ failure assessment score, overall compliance, and lactate levels. The 30-day mortality was significantly lower in the compliance group than in the non-compliance group (27.2% vs. 36.5%; p = 0.002). After implementation of the Intelligent Sepsis Management System, overall compliance with the Surviving Sepsis Campaign guidelines improved and was associated with reduced 30-day mortality. However, we could not verify the causal effect of this system on 30-day mortality.
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Nieves Ortega R, Rosin C, Bingisser R, Nickel CH. Clinical Scores and Formal Triage for Screening of Sepsis and Adverse Outcomes on Arrival in an Emergency Department All-Comer Cohort. J Emerg Med 2019; 57:453-460.e2. [PMID: 31500993 DOI: 10.1016/j.jemermed.2019.06.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 06/17/2019] [Accepted: 06/22/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Early recognition of sepsis remains a major challenge. The clinical utility of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score is still undefined. Several studies have tested its prognostic value. However, its ability to diagnose sepsis is still unknown. OBJECTIVE Our aim was to compare the performance of qSOFA, systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), and formal triage with the Emergency Severity Index (ESI) algorithm to identify patients with sepsis and predict adverse outcomes on arrival in an emergency department (ED) all-comer cohort. METHODS We included all patients presenting consecutively to the ED during a 3-week period. We used vital signs recorded at triage to calculate the study scores. Two independent assessors retrospectively assigned the primary outcome of sepsis according to Third International Consensus Definitions for Sepsis and Septic Shock criteria in a chart review process. RESULTS There were 2523 cases included in the analysis and 39 (1.6%) had the primary outcome of sepsis. The area under the curve for sepsis was 0.79 (95% confidence interval [CI] 0.71-0.86) for qSOFA, 0.81 (95% CI 0.73-0.87) for SIRS, 0.85 (95% CI 0.77-0.92) for NEWS, and 0.77 (95% CI 0.70-0.83) for ESI. CONCLUSIONS qSOFA offered high specificity for the prediction of sepsis and adverse outcomes. However, its low sensitivity does not support widespread use as a screening tool for sepsis. NEWS outperformed qSOFA for prediction of adverse outcomes and screening for sepsis.
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Affiliation(s)
| | - Christiane Rosin
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Roland Bingisser
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Christian H Nickel
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
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Baumann BM, Greenwood JC, Lewis K, Nuckton TJ, Darger B, Shofer FS, Troeger D, Jung SY, Kilgannon JH, Rodriguez RM. Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness. Am J Emerg Med 2019; 38:883-889. [PMID: 31320214 DOI: 10.1016/j.ajem.2019.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/20/2019] [Accepted: 07/02/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To determine if the addition of lactate to Quick Sequential Organ Failure Assessment (qSOFA) scoring improves emergency department (ED) screening of septic patients for critical illness. METHODS This was a multicenter retrospective cohort study of consecutive adult patients admitted to the hospital from the ED with infectious disease-related illnesses. We recorded qSOFA criteria and initial lactate levels in the first 6 h of ED stay. Our primary outcome was a composite of hospital death, vasopressor use, and intensive care unit stay ≤72 h of presentation. Diagnostic test characteristics were determined for: 1) lactate levels ≥2 and ≥4; 2) qSOFA scores ≥1, ≥2, and =3; and 3) combinations of these. RESULTS Of 3743 patients, 2584 had a lactate drawn ≤6 h of ED stay and 18% met the primary outcome. The qSOFA scores were ≥1, ≥2, and =3 in 59.2%, 22.0%, and 5.3% of patients, respectively, and 34.4% had a lactate level ≥2 and 7.9% had a lactate level ≥4. The combination of qSOFA ≥1 OR Lactate ≥2 had the highest sensitivity, 94.0% (95% CI: 91.3-95.9). CONCLUSIONS The combination of qSOFA ≥1 OR Lactate ≥2 provides substantially improved sensitivity for the screening of critical illness compared to isolated lactate and qSOFA thresholds.
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Affiliation(s)
- Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza Camden, NJ 08103, United States of America.
| | - John C Greenwood
- Departments of Emergency Medicine and Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - Kristin Lewis
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
| | - Thomas J Nuckton
- Department of Medicine, Sutter Eden Medical Center, 20103 Lake Chabot Road Castro Valley, CA 94546, United States of America.
| | - Bryan Darger
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - Dawn Troeger
- Department of Medicine, Sutter Eden Medical Center, 20103 Lake Chabot Road Castro Valley, CA 94546, United States of America.
| | - Soo Y Jung
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza Camden, NJ 08103, United States of America.
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
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Garbero RDF, Simões AA, Martins GA, Cruz LVD, von Zuben VGM. SOFA and qSOFA at admission to the emergency department: Diagnostic sensitivity and relation with prognosis in patients with suspected infection. Turk J Emerg Med 2019; 19:106-110. [PMID: 31321343 PMCID: PMC6612625 DOI: 10.1016/j.tjem.2019.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/25/2019] [Accepted: 05/29/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To evaluate the adequacy of SOFA and qSOFA for predicting unfavorable outcomes, and of qSOFA as a screening tool for sepsis in patients admitted to the emergency department (ED) of a Brazilian public hospital. METHODS This was a single-center retrospective study conducted on a cohort of patients admitted to a Brazilian public hospital between August 2016 and November 2017 due to suspected infection. Exclusion criteria were: age <18 years, admission to the ED after 24 h of hospitalization, lack of information in the medical records, advanced comorbidities, or request of limited invasive care. RESULTS A total of 184 patients were included; 84.24% had a SOFA score of 2 or higher. The relative risk of death, need for intensive care unit (ICU) and mechanical ventilation (MV) related to a positive SOFA on admission were: 5.17 (2.11-12.87), 1.45 (1.09-2.15) and 2.74 (1.63-5.16), respectively; sensitivity was 93.7% for death, 88.5% for ICU need and 93.6% for undergoing MV. The mean length of hospital stay was 38.83 days for patients with a positive SOFA score and 8.95 days for patients with a negative score (p = 0.02). The median SOFA value was higher for the patients who died; 41% of the patients had a positive qSOFA and its sensitivity for a positive SOFA was 46.4%. The relative risk of death, ICU and MV need related to qSOFA at admission were 1.83 (1.39-2.44), 0.98 (0.82-1.16) and 1.60 (1.23-1.97), respectively, and its sensitivity was 56.8% for death, 41.4% for ICU need and 53.6% for MV. CONCLUSION qSOFA did not perform well as a screening tool for sepsis and for predicting a poor prognosis in the ED. SOFA, on the other hand, showed reasonable sensitivity for predicting unfavorable outcomes and scores ≥2 were related to a poor prognosis.
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Abdullah SMOB, Grand J, Sijapati A, Puri PR, Nielsen FE. qSOFA is a useful prognostic factor for 30-day mortality in infected patients fulfilling the SIRS criteria for sepsis. Am J Emerg Med 2019; 38:512-516. [PMID: 31171438 DOI: 10.1016/j.ajem.2019.05.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/09/2019] [Accepted: 05/19/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The "quick Sequential Organ Failure Assessment" (qSOFA) score is a bedside risk-stratification tool to predict the likelihood of organ dysfunction. This study evaluated the qSOFA score as a prognostic factor for 30-day mortality in emergency department (ED) patients with sepsis identified by the Systemic Inflammatory Response Syndrome (SIRS) criteria. METHODS A historical cohort study was conducted reviewing patients admitted to a single-center ED from November 1, 2013, to October 31, 2014. All patients with suspected or proven infections who fulfilled two or more SIRS criteria were included. Data of SIRS, qSOFA and baseline clinical data were obtained from triage forms and patient records. RESULTS A total of 434 patients with sepsis of any severity were included. A total of 73 (16.8%) had a qSOFA score of ≥2 and were more frequently transferred to the intensive care unit (ICU) (26.0 vs. 6.7%; 95% confidence interval (CI) of the difference 8.9-29.7%) and had increased 30-day mortality (32.9 vs. 9.1%, 95% CI of the difference 12.6-35.0%) compared to patients with a qSOFA score of <2. In an adjusted logistic regression model, a qSOFA score of ≥2 was independently associated with 30-day mortality (odds ratio 4.83; 95% CI 2.11-11.02). CONCLUSION Almost one third of the patients with a qSOFA score of ≥2 had died within 30 days and a qSOFA score of ≥2 was independently associated with mortality. This study indicated that qSOFA score of at least two could provide useful prognostic information for septic patients defined by the SIRS criteria.
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Affiliation(s)
| | - Johannes Grand
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Astha Sijapati
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Pushpa Raj Puri
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Finn Erland Nielsen
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark; Department of Emergency Medicine, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
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20
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Prabhakar SM, Tagami T, Liu N, Samsudin MI, Ng JCJ, Koh ZX, Ong MEH. Combining quick sequential organ failure assessment score with heart rate variability may improve predictive ability for mortality in septic patients at the emergency department. PLoS One 2019; 14:e0213445. [PMID: 30883595 PMCID: PMC6422271 DOI: 10.1371/journal.pone.0213445] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 02/21/2019] [Indexed: 12/22/2022] Open
Abstract
Background Although the quick Sequential Organ Failure Assessment (qSOFA) score was recently introduced to identify patients with suspected infection/sepsis, it has limitations as a predictive tool for adverse outcomes. We hypothesized that combining qSOFA score with heart rate variability (HRV) variables improves predictive ability for mortality in septic patients at the emergency department (ED). Methods This was a retrospective study using the electronic medical record of a tertiary care hospital in Singapore between September 2014 and February 2017. All patients aged 21 years or older who were suspected with infection/sepsis in the ED and received electrocardiography monitoring with ZOLL X Series Monitor (ZOLL Medical Corporation, Chelmsford, MA) were included. We fitted a logistic regression model to predict the 30-day mortality using one of the HRV variables selected from one of each three domains those previously reported as strong association with mortality (i.e. standard deviation of NN [SDNN], ratio of low frequency to high frequency power [LF/HF], detrended fluctuation analysis α-2 [DFA α-2]) in addition to the qSOFA score. The predictive accuracy was assessed with other scoring systems (i.e. qSOFA alone, National Early Warning Score, and Modified Early Warning Score) using the area under the receiver operating characteristic curve. Results A total of 343 septic patients were included. Non-survivors were significantly older (survivors vs. non-survivors, 65.7 vs. 72.9, p <0.01) and had higher qSOFA (0.8 vs. 1.4, p <0.01) as compared to survivors. There were significant differences in HRV variables between survivors and non-survivors including SDNN (23.7s vs. 31.8s, p = 0.02), LF/HF (2.8 vs. 1.5, p = 0.02), DFA α-2 (1.0 vs. 0.7, P < 0.01). Our prediction model using DFA-α-2 had the highest c-statistic of 0.76 (95% CI, 0.70 to 0.82), followed by qSOFA of 0.68 (95% CI, 0.62 to 0.75), National Early Warning Score at 0.67 (95% CI, 0.61 to 0.74), and Modified Early Warning Score at 0.59 (95% CI, 0.53 to 0.67). Conclusions Adding DFA-α-2 to the qSOFA score may improve the accuracy of predicting in-hospital mortality in septic patients who present to the ED. Further multicenter prospective studies are required to confirm our results.
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Affiliation(s)
| | - Takashi Tagami
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
- * E-mail: (TT); (NL)
| | - Nan Liu
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
- * E-mail: (TT); (NL)
| | | | - Janson Cheng Ji Ng
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
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Application of The Sepsis-3 Consensus Criteria in a Geriatric Acute Care Unit: A Prospective Study. J Clin Med 2019; 8:jcm8030359. [PMID: 30871231 PMCID: PMC6463250 DOI: 10.3390/jcm8030359] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 12/20/2022] Open
Abstract
The prognostic value of quick Sepsis-related Organ Failure Assessment (qSOFA) score in geriatric patients is uncertain. We aimed to compare qSOFA vs. Systemic Inflammatory Response Syndrome (SIRS) criteria for mortality prediction in older multimorbid subjects, admitted for suspected sepsis in a geriatric ward. We prospectively enrolled 272 patients (aged 83.7 ± 7.4). At admission, qSOFA and SIRS scores were calculated. Mortality was assessed during hospital stay and three months after discharge. The predictive capacity of qSOFA and SIRS was assessed by calculating the Area Under the Receiver Operating Characteristic Curve (AUROC), through pairwise AUROC comparison, and multivariable logistic regression analysis. Both qSOFA and SIRS exhibited a poor prognostic performance (AUROCs 0.676, 95% CI 0.609⁻0.738, and 0.626, 95% CI 0.558⁻0.691 for in-hospital mortality; 0.684, 95% CI 0.614⁻0.748, and 0.596, 95% CI 0.558⁻0.691 for pooled three-month mortality, respectively). The predictive capacity of qSOFA showed no difference to that of SIRS for in-hospital mortality (difference between AUROCs 0.05, 95% CI -0.05 to 0.14, p = 0.31), but was superior for pooled three-month mortality (difference between AUROCs 0.09, 95% CI 0.01⁻0.17, p = 0.029). Multivariable logistic regression analysis, accounting for possible confounders, including frailty, showed that both scores were not associated with in-hospital mortality, although qSOFA, unlike SIRS, was associated with pooled three-month mortality. In conclusion, neither qSOFA nor SIRS at admission were strong predictors of mortality in a geriatric acute-care setting. Traditional geriatric measures of frailty may be more useful for predicting adverse outcomes in this setting.
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Peyrony O, Dumas G, Legay L, Principe A, Franchitti J, Simonetta M, Verrat A, Amami J, Milacic H, Bragança A, Gillet A, Resche-Rigon M, Fontaine JP, Azoulay E. Central venous oxygen saturation is not predictive of early complications in cancer patients presenting to the emergency department. Intern Emerg Med 2019; 14:281-289. [PMID: 30306323 DOI: 10.1007/s11739-018-1966-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/06/2018] [Indexed: 12/14/2022]
Abstract
Central venous oxygen saturation (ScvO2) is easily observable in oncology patients with long-term central venous catheters (CVC), and has been studied as a prognostic factor in patients with sepsis. We sought to investigate the association between ScvO2 and early complications in cancer patients presenting to the ED. We prospectively enrolled adult cancer patients with pre-existing CVC who presented to the ED. ScvO2 was measured on their CVC. The outcome was admission to the intensive care unit (ICU) or mortality by day 7. ScvO2 was first studied as a continuous variable (%) with a ROC analysis and as a categorical variable (cut-off at < 70%) with a multivariate analysis. A total of 210 cancer patients were enrolled. At baseline, ScvO2 showed no significant difference between patients who were admitted to the ICU or died before day 7, and patients who did not (67%; IQR 62-68% vs. 71%; IQR 65-78% respectively, P = 0.3). The ROC analysis showed the absence of discrimination accuracy for ScvO2 to predict the outcome (AUC = 0.56). By multivariate analysis, ScvO2 < 70% was not associated with the outcome (OR 1.67; 95% CI 0.64-4.36). Variables that were associated with ICU admission or death by day 7 included a shock-index (heart rate/systolic blood pressure) > 1 and a performance status > 2 (OR 4.76; 95% CI 1.81-12.52 and OR 6.23, 95% CI 2.40-16.17, respectively). This study does not support the use of ScvO2 to risk stratify cancer patients presenting to the ED.
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Affiliation(s)
- Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
| | - Guillaume Dumas
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Léa Legay
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alessandra Principe
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jessica Franchitti
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Marie Simonetta
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Anne Verrat
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jihed Amami
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Hélène Milacic
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Adélia Bragança
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Ariane Gillet
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Matthieu Resche-Rigon
- Biostatistics and Medical Information Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS-INSERM-UMR1153), ECSTRRA Team, Paris, France
- Paris Diderot University, Paris, France
| | - Jean-Paul Fontaine
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Elie Azoulay
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS-INSERM-UMR1153), ECSTRRA Team, Paris, France
- Paris Diderot University, Paris, France
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Luo J, Jiang W, Weng L, Peng J, Hu X, Wang C, Liu G, Huang H, Du B. Usefulness of qSOFA and SIRS scores for detection of incipient sepsis in general ward patients: A prospective cohort study. J Crit Care 2019; 51:13-18. [PMID: 30685579 DOI: 10.1016/j.jcrc.2019.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE To prospectively assess the diagnostic value of quick Sequential Organ Failure Assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores for sepsis in ward patients with infections. MATERIALS AND METHODS Consecutive patients admitted with infection or developing infection during hospital stay were included. All variables for calculating qSOFA, SIRS, and SOFA scores were collected, and the maximum scores were determined until hospital discharge, death, or day 28, whichever occurred earlier. The primary outcome was sepsis at 28 days. Diagnostic and prognostic values were assessed using the area under the receiver operating characteristic curve (AUROC) with the conventional cutoff value of 2. RESULTS Of 409 general ward patients, 146 patients and 371 patients met qSOFA and SIRS criteria, 229 patients developed sepsis. Although qSOFA score had a better overall diagnostic performance of sepsis (AUROC 0.75 vs. 0.69), it had a much lower sensitivity (53% vs. 98%) and higher specificity (87% vs. 18%) than SIRS score. In addition, qSOFA score had a better prognostic value than SIRS score (AUROC 0.86 vs. 0.67). CONCLUSIONS Neither SIRS score nor qSOFA score could serve as an ideal screening tool for early identification sepsis, whereas qSOFA score might help to identify patients with higher risk of poor clinical outcome. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02930070.
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Affiliation(s)
- Jingchao Luo
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China; Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - Wei Jiang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Li Weng
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Jinmin Peng
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Xiaoyun Hu
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Chunyao Wang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Guangyun Liu
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Huibin Huang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China.
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Froom P, Shimoni Z. The uncertainties of the diagnosis and treatment of a suspected urinary tract infection in elderly hospitalized patients. Expert Rev Anti Infect Ther 2018; 16:763-770. [DOI: 10.1080/14787210.2018.1523006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Paul Froom
- Clinical Utility Department Sanz Medical Center, Laniado Hospital, Netanya, Israel and School of Public Health, University of Tel Aviv, Ramat Aviv, Israel
| | - Zvi Shimoni
- Department of Internal Medicine B, Laniado Hospital, Netanya, Israel;and Ruth and Bruce Rappaport School of Medicine, Haifa, Israel
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Rothrock SG, Cassidy DD, Bienvenu D, Heine E, Guetschow B, Briscoe JG, Isaak SF, Chang K, Devaux M. Derivation of a screen to identify severe sepsis and septic shock in the ED-BOMBARD vs. SIRS and qSOFA. Am J Emerg Med 2018; 37:1260-1267. [PMID: 30245079 DOI: 10.1016/j.ajem.2018.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/04/2018] [Accepted: 09/15/2018] [Indexed: 12/29/2022] Open
Abstract
STUDY OBJECTIVE To predict severe sepsis/septic shock in ED patients. METHODS We conducted a retrospective case-control study of patients ≥18 admitted to two urban hospitals with a combined ED census of 162,000. Study cases included patients with severe sepsis/septic shock admitted via the ED. Controls comprised admissions without severe sepsis/septic shock. Using multivariate logistic regression, a prediction rule was constructed. The model's AUROC was internally validated using 1000 bootstrap samples. RESULTS 143 study and 286 control patients were evaluated. Features predictive of severe sepsis/septic shock included: SBP ≤ 110 mm Hg, shock index/SI ≥ 0.86, abnormal mental status or GCS < 15, respirations ≥ 22, temperature ≥ 38C, assisted living facility residency, disabled immunity. Two points were assigned to SI and temperature with other features assigned one point (mnemonic: BOMBARD). BOMBARD was superior to SIRS criteria (AUROC 0.860 vs. 0.798, 0.062 difference, 95% CI 0.022-0.102) and qSOFA scores (0.860 vs. 0.742, 0.118 difference, 95% CI 0.081-0.155) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was more sensitive than SIRS ≥ 2 (74.8% vs. 49%, 25.9% difference, 95% CI 18.7-33.1) and qSOFA ≥ 2 (74.8% vs. 33.6%, 41.2% difference, 95% CI 33.2-49.3) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was superior to SIRS ≥ 2 (76% vs. 45%, 32% difference, 95% CI 10-50) and qSOFA ≥ 2 (76% vs. 29%, 47% difference, 95% CI 25-63) at predicting sepsis mortality. CONCLUSION BOMBARD was more accurate than SIRS and qSOFA at predicting severe sepsis/septic shock and sepsis mortality.
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Affiliation(s)
- Steven G Rothrock
- Department of Emergency Medicine, Dr. P. Phillips Hospital, Orlando Health, United States of America
| | - David D Cassidy
- Department of Emergency Medicine, Orlando Regional Medical Center (ORMC), Orlando Health, United States of America; Department of Emergency Medicine, Residency in Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Drew Bienvenu
- Department of Emergency Medicine, Residency in Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Erich Heine
- Department of Emergency Medicine, Residency in Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Brian Guetschow
- Department of Emergency Medicine, Residency in Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Joshua G Briscoe
- Department of Emergency Medicine, Orlando Regional Medical Center (ORMC), Orlando Health, United States of America; Department of Emergency Medicine, South Lake Hospital, Orlando Health, United States of America; Department of Emergency Medicine, Residency in Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Sean F Isaak
- Department of Emergency Medicine, South Seminole Hospital, Orlando Health, United States of America
| | - Kenneth Chang
- Department of Emergency Medicine, Residency in Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Mikaela Devaux
- Department of Emergency Medicine, Residency in Emergency Medicine, Orlando Health, Orlando, FL, United States of America
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