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Wixon-Genack J, Wright SW, Cobb Ortega NL, Hantrakun V, Rudd KE, Teparrukkul P, Limmathurotsakul D, West TE. Prognostic Accuracy of Screening Tools for Clinical Deterioration in Adults With Suspected Sepsis in Northeastern Thailand: A Cohort Validation Study. Open Forum Infect Dis 2024; 11:ofae245. [PMID: 38756761 PMCID: PMC11097208 DOI: 10.1093/ofid/ofae245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024] Open
Abstract
Background We sought to assess the performance of commonly used clinical scoring systems to predict imminent clinical deterioration in patients hospitalized with suspected infection in rural Thailand. Methods Patients with suspected infection were prospectively enrolled within 24 hours of admission to a referral hospital in northeastern Thailand between 2013 and 2017. In patients not requiring intensive medical interventions, multiple enrollment scores were calculated including the National Early Warning Score (NEWS), the Modified Early Warning Score, Between the Flags, and the quick Sequential Organ Failure Assessment score. Scores were tested for predictive accuracy of clinical deterioration, defined as a new requirement of mechanical ventilation, vasoactive medications, intensive care unit admission, and/or death approximately 1 day after enrollment. The association of each score with clinical deterioration was evaluated by means of logistic regression, and discrimination was assessed by generating area under the receiver operating characteristic curve. Results Of 4989 enrolled patients, 2680 met criteria for secondary analysis, and 100 of 2680 (4%) experienced clinical deterioration within 1 day after enrollment. NEWS had the highest discrimination for predicting clinical deterioration (area under the receiver operating characteristic curve, 0.78 [95% confidence interval, .74-.83]) compared with the Modified Early Warning Score (0.67 [.63-.73]; P < .001), quick Sequential Organ Failure Assessment (0.65 [.60-.70]; P < .001), and Between the Flags (0.69 [.64-.75]; P < .001). NEWS ≥5 yielded optimal sensitivity and specificity for clinical deterioration prediction. Conclusions In patients hospitalized with suspected infection in a resource-limited setting in Southeast Asia, NEWS can identify patients at risk of imminent clinical deterioration with greater accuracy than other clinical scoring systems.
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Affiliation(s)
- Jenna Wixon-Genack
- Department of Internal Medicine, Alaska Native Medical Center, Anchorage, Alaska, USA
| | - Shelton W Wright
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Natalie L Cobb Ortega
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Viriya Hantrakun
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kristina E Rudd
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Prapit Teparrukkul
- Department of Internal Medicine, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - T Eoin West
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
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Wu Y, Wu G, Li M, Chang Y, Yu M, Meng Y, Wan X. Prediction of Th17/Treg cell balance on length of stay in intensive care units of patients with sepsis. JOURNAL OF INTENSIVE MEDICINE 2024; 4:240-246. [PMID: 38681793 PMCID: PMC11043633 DOI: 10.1016/j.jointm.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 09/17/2023] [Accepted: 09/27/2023] [Indexed: 05/01/2024]
Abstract
Background Prolonged length of stay (LOS) of sepsis can drain a hospital's material and human resources. This study investigated the correlations between T helper type 17 (Th17) and regulatory T (Treg) balance with LOS in sepsis. Methods A prospective clinical observational study was designed in Changhai Hospital affiliated to Naval Medical University in Shanghai, China, from January to October 2020. The patients diagnosed with sepsis and who met the inclusion and exclusion criteria were recruited and whether the levels of cytokines, procalcitonin, subtypes, and biomarkers of T cells in the peripheral blood were detected. We analyzed the correlation between these and LOS. Results Sixty septic patients were classified into two groups according to whether their intensive care unit (ICU) stay exceeded 14 days. The patients with LOS ≥14 days were older ([72.6±7.5] years vs. [63.3±10.4] years, P=0.015) and had higher Sequential Organ Failure Assessment (SOFA) (median [interquartile range]: 6.5 [5.0-11.0] vs. 4.0 [3.0-6.0], P=0.001) and higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (16.0 [13.0-21.0] vs. 8.5 [7.0-14.0], P=0.001). There was no difference in other demographic characteristics and cytokines, interleukin-6, tumor necrosis factor-α, and interleukin-10 between the two groups. The Th17/Treg ratio of sepsis with LOS <14 days was considerably lower (0.48 [0.38-0.56] vs. 0.69 [0.51-0.98], P=0.001). For patients with LOS ≥14 days, the area under the receiver operating characteristic curve for the Th17/Treg ratio was 0.766. It improved to 0.840 and 0.850 when combined with the SOFA and APACHE II scores, respectively. Conclusions The Th17/Treg ratio was proportional to septic severity and can be used as a potential predictor of ICU stay in sepsis, presenting a new option for ICU practitioners to better care for patients with sepsis.
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Affiliation(s)
- Yu Wu
- Department of Intensive Care Medicine, Changhai Hospital, Naval Medical University, Shanghai, China
- Department of Anesthesiology, Bethune International Peace Hospital, Shijiazhuang, Hebei, China
| | - Guosheng Wu
- Department of Burns, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Minyu Li
- Department of Special Needs Clinic, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongqing Chang
- Department of Intensive Care Medicine, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Miao Yu
- Department of Intensive Care Medicine, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yan Meng
- Department of Intensive Care Medicine, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaojian Wan
- Department of Intensive Care Medicine, Changhai Hospital, Naval Medical University, Shanghai, China
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Cortellini S, DeClue AE, Giunti M, Goggs R, Hopper K, Menard JM, Rabelo RC, Rozanski EA, Sharp CR, Silverstein DC, Sinnott-Stutzman V, Stanzani G. Defining sepsis in small animals. J Vet Emerg Crit Care (San Antonio) 2024; 34:97-109. [PMID: 38351524 DOI: 10.1111/vec.13359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE To discuss the definitions of sepsis in human and veterinary medicine. DESIGN International, multicenter position statement on the need for consensus definitions of sepsis in veterinary medicine. SETTING Veterinary private practice and university teaching hospitals. ANIMALS Dogs and cats. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sepsis is a life-threatening condition associated with the body's response to an infection. In human medicine, sepsis has been defined by consensus on 3 occasions, most recently in 2016. In veterinary medicine, there is little uniformity in how sepsis is defined and no consensus on how to identify it clinically. Most publications rely on modified criteria derived from the 1991 and 2001 human consensus definitions. There is a divergence between the human and veterinary descriptions of sepsis and no consensus on how to diagnose the syndrome. This impedes research, hampers the translation of pathophysiology insights to the clinic, and limits our abilities to optimize patient care. It may be time to formally define sepsis in veterinary medicine to help the field move forward. In this narrative review, we present a synopsis of prior attempts to define sepsis in human and veterinary medicine, discuss developments in our understanding, and highlight some criticisms and shortcomings of existing schemes. CONCLUSIONS This review is intended to serve as the foundation of current efforts to establish a consensus definition for sepsis in small animals and ultimately generate evidence-based criteria for its recognition in veterinary clinical practice.
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Affiliation(s)
- Stefano Cortellini
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, Hatfield, UK
| | - Amy E DeClue
- Fetch Specialty and Emergency Veterinary Center, Greenville, South Carolina, USA
| | - Massimo Giunti
- Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Robert Goggs
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, USA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Julie M Menard
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Elizabeth A Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - Claire R Sharp
- School of Veterinary Medicine, Murdoch University, Perth, Western Australia, Australia
| | - Deborah C Silverstein
- Department of Clinical Studies and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Li A, Ling L, Qin H, Arabi YM, Myatra SN, Egi M, Kim JH, Nor MBM, Son DN, Fang WF, Wahyuprajitno B, Hashmi M, Faruq MO, Patjanasoontorn B, Al Bahrani MJ, Shrestha BR, Shrestha U, Nafees KMK, Sann KK, Palo JEM, Mendsaikhan N, Konkayev A, Detleuxay K, Chan YH, Du B, Divatia JV, Koh Y, Phua J. Prognostic evaluation of quick sequential organ failure assessment score in ICU patients with sepsis across different income settings. Crit Care 2024; 28:30. [PMID: 38263076 PMCID: PMC10804657 DOI: 10.1186/s13054-024-04804-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND There is conflicting evidence on association between quick sequential organ failure assessment (qSOFA) and sepsis mortality in ICU patients. The primary aim of this study was to determine the association between qSOFA and 28-day mortality in ICU patients admitted for sepsis. Association of qSOFA with early (3-day), medium (28-day), late (90-day) mortality was assessed in low and lower middle income (LLMIC), upper middle income (UMIC) and high income (HIC) countries/regions. METHODS This was a secondary analysis of the MOSAICS II study, an international prospective observational study on sepsis epidemiology in Asian ICUs. Associations between qSOFA at ICU admission and mortality were separately assessed in LLMIC, UMIC and HIC countries/regions. Modified Poisson regression was used to determine the adjusted relative risk (RR) of qSOFA score on mortality at 28 days with adjustments for confounders identified in the MOSAICS II study. RESULTS Among the MOSAICS II study cohort of 4980 patients, 4826 patients from 343 ICUs and 22 countries were included in this secondary analysis. Higher qSOFA was associated with increasing 28-day mortality, but this was only observed in LLMIC (p < 0.001) and UMIC (p < 0.001) and not HIC (p = 0.220) countries/regions. Similarly, higher 90-day mortality was associated with increased qSOFA in LLMIC (p < 0.001) and UMIC (p < 0.001) only. In contrast, higher 3-day mortality with increasing qSOFA score was observed across all income countries/regions (p < 0.001). Multivariate analysis showed that qSOFA remained associated with 28-day mortality (adjusted RR 1.09 (1.00-1.18), p = 0.038) even after adjustments for covariates including APACHE II, SOFA, income country/region and administration of antibiotics within 3 h. CONCLUSIONS qSOFA was independently associated with 28-day mortality in ICU patients admitted for sepsis. In LLMIC and UMIC countries/regions, qSOFA was associated with early to late mortality but only early mortality in HIC countries/regions.
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Affiliation(s)
- Andrew Li
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Hanyu Qin
- State Key Laboratory of Complex, Severe and Rare Disease, Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Moritoki Egi
- Department of Anesthesiology and Intensive Care, Kyoto University Hospital, Kyoto, Japan
| | - Je Hyeong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Mohd Basri Mat Nor
- International Islamic University Malaysia Medical Center, Kuantan, Malaysia
| | - Do Ngoc Son
- Center of Critical Care Medicine, Bach Mai Hospital, Hanoi Medical University, VNU University of Medicine and Pharmacy, Hanoi, Vietnam
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Bambang Wahyuprajitno
- Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Airlangga, Intensive Care Unit, Dr Soetomo General Hospital, Surabaya, Indonesia
| | - Madiha Hashmi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Mohammad Omar Faruq
- General Intensive Care Unity and Emergency Department, United Hospital Ltd, Dhaka, Bangladesh
| | - Boonsong Patjanasoontorn
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Babu Raja Shrestha
- Department of Anesthesia and Intensive Care, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | - Ujma Shrestha
- Department of Anesthesia and Intensive Care, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | | | - Kyi Kyi Sann
- Department of Anaesthesiology and ICU, Yangon General Hospital, University of Medicine 1, Yangon, Myanmar
| | | | - Naranpurev Mendsaikhan
- Mongolia Japan Hospital, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Aidos Konkayev
- Anaesthesiology and Intensive Care Department, Astana Medical University, Astana, Kazakhstan
- Anaesthesiology and Intensive Care Department, National Scientific Center of Traumatology and Orthopedia Named After Academician N.D. Batpenov, Astana, Kazakhstan
| | | | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bin Du
- State Key Laboratory of Complex, Severe and Rare Disease, Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jason Phua
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
- FAST and Chronic Programmed, Alexandra Hospital, National University Health System, Singapore, Singapore
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Qiu X, Lei YP, Zhou RX. SIRS, SOFA, qSOFA, and NEWS in the diagnosis of sepsis and prediction of adverse outcomes: a systematic review and meta-analysis. Expert Rev Anti Infect Ther 2023; 21:891-900. [PMID: 37450490 DOI: 10.1080/14787210.2023.2237192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND We compared Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), Quick Sepsis-related Organ Failure Assessment (qSOFA), and National Early Warning Score (NEWS) for sepsis diagnosis and adverse outcomes prediction. METHODS Clinical studies that used SIRS, SOFA, qSOFA, and NEWS for sepsis diagnosis and prognosis assessment were included. Data were extracted, and meta-analysis was performed for outcome measures, including sepsis diagnosis, in-hospital mortality, 7/10/14-day mortality, 28/30-day mortality, and ICU admission. RESULTS Fifty-seven included studies showed good overall quality. Regarding sepsis prediction, SIRS demonstrated high sensitivity (0.85) but low specificity (0.41), qSOFA showed low sensitivity (0.42) but high specificity (0.98), and NEWS exhibited high sensitivity (0.71) and specificity (0.85). For predicting in-hospital mortality, SOFA demonstrated the highest sensitivity (0.89) and specificity (0.69). In terms of predicting 7/10/14-day mortality, SIRS exhibited high sensitivity (0.87), while qSOFA had high specificity (0.75). For predicting 28/30-day mortality, SOFA showed high sensitivity (0.97) but low specificity (0.14), whereas qSOFA displayed low sensitivity (0.41) but high specificity (0.88). CONCLUSIONS NEWS independently demonstrates good diagnostic capability for sepsis, especially in high-income countries. SOFA emerges as the optimal choice for predicting in-hospital mortality and can be employed as a screening tool for 28/30-day mortality in low-income countries.
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Affiliation(s)
- Xia Qiu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu-Peng Lei
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rui-Xi Zhou
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan, China
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Brotherton BJ, Joshi M, Otieno G, Wandia S, Gitura H, Mueller A, Nguyen T, Letchford S, Riviello ED, Karanja E, Rudd KE. Association of clinical prediction scores with hospital mortality in an adult medical and surgical intensive care unit in Kenya. Front Med (Lausanne) 2023; 10:1127672. [PMID: 37089585 PMCID: PMC10113620 DOI: 10.3389/fmed.2023.1127672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/16/2023] [Indexed: 04/09/2023] Open
Abstract
ImportanceMortality prediction among critically ill patients in resource limited settings is difficult. Identifying the best mortality prediction tool is important for counseling patients and families, benchmarking quality improvement efforts, and defining severity of illness for clinical research studies.ObjectiveCompare predictive capacity of the Modified Early Warning Score (MEWS), Universal Vital Assessment (UVA), Tropical Intensive Care Score (TropICS), Rwanda Mortality Probability Model (R-MPM), and quick Sequential Organ Failure Assessment (qSOFA) for hospital mortality among adults admitted to a medical-surgical intensive care unit (ICU) in rural Kenya. We performed a pre-planned subgroup analysis among ICU patients with suspected infection.Design, setting, and participantsProspective single-center cohort study at a tertiary care, academic hospital in Kenya. All adults 18 years and older admitted to the ICU January 2018–June 2019 were included.Main outcomes and measuresThe primary outcome was association of clinical prediction tool score with hospital mortality, as defined by area under the receiver operating characteristic curve (AUROC). Demographic, physiologic, laboratory, therapeutic, and mortality data were collected. 338 patients were included, none were excluded. Median age was 42 years (IQR 33–62) and 61% (n = 207) were male. Fifty-nine percent (n = 199) required mechanical ventilation and 35% (n = 118) received vasopressors upon ICU admission. Overall hospital mortality was 31% (n = 104). 323 patients had all component variables recorded for R-MPM, 261 for MEWS, and 253 for UVA. The AUROC was highest for MEWS (0.76), followed by R-MPM (0.75), qSOFA (0.70), and UVA (0.69) (p < 0.001). Predictive capacity was similar among patients with suspected infection.Conclusion and relevanceAll tools had acceptable predictive capacity for hospital mortality, with variable observed availability of the component data. R-MPM and MEWS had high rates of variable availability as well as good AUROC, suggesting these tools may prove useful in low resource ICUs.
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Affiliation(s)
- B. Jason Brotherton
- Department of Internal Medicine, AIC Kijabe Hospital, Kijabe, Kenya
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- *Correspondence: B. Jason Brotherton,
| | - Mugdha Joshi
- Department of Medicine, Stanford University, Palo Alto, CA, United States
| | - George Otieno
- Department of Internal Medicine, AIC Kijabe Hospital, Kijabe, Kenya
| | - Sarah Wandia
- Department of Internal Medicine, AIC Kijabe Hospital, Kijabe, Kenya
| | - Hannah Gitura
- Department of Emergency and Critical Care Medicine, AIC Kijabe Hospital, Kijabe, Kenya
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Tony Nguyen
- Department of Internal Medicine, AIC Kijabe Hospital, Kijabe, Kenya
| | - Steve Letchford
- Department of Internal Medicine, AIC Kijabe Hospital, Kijabe, Kenya
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Evelyn Karanja
- Department of Internal Medicine, AIC Kijabe Hospital, Kijabe, Kenya
| | - Kristina E. Rudd
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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Tiwari AK, Jamshed N, Sahu AK, Kumar A, Aggarwal P, Bhoi S, Mathew R, Ekka M. Performance of qSOFA Score as a Screening Tool for Sepsis in the Emergency Department. J Emerg Trauma Shock 2023; 16:3-7. [PMID: 37181737 PMCID: PMC10167823 DOI: 10.4103/jets.jets_99_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 03/29/2023] Open
Abstract
Introduction Sepsis is the leading cause of mortality, and various scoring systems have been developed for its early identification and treatment. The objective was to test the ability of quick sequential organ failure assessment (qSOFA) score to identify sepsis and predict sepsis-related mortality in the emergency department (ED). Methods We conducted a prospective study from July 2018 to April 2020. Consecutive patients with age ≥18 years who presented to the ED with a clinical suspicion of infection were included. Sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and odds ratio (OR) for sepsis related mortality on day 7 and 28 were measured. Results A total of 1200 patients were recruited; of which 48 patients were excluded and 17 patients were lost to follow-up. 54 (45.4%) of 119 patients with positive qSOFA (qSOFA >2) died at 7 days and 76 (63.9%) died at 28 days. A total of 103 (10.1%) of 1016 patients with negative qSOFA (qSOFA score <2) died at 7 days and 207 (20.4%) died at 28 days. Patients with positive qSOFA score were at higher odds of dying at 7 days (OR: 3.9, 95% confidence interval [CI]: 3.1-5.2, P < 0.001) and 28 days (OR: 6.9, 95% CI: 4.6-10.3, P < 0.001). The PPV and NPV with positive qSOFA score to predict 7- and 28-day mortality were 45.4%, 89.9% and 63.9%, 79.6%, respectively. Conclusion The qSOFA score can be used as a risk stratification tool in a resource-limited setting to identify infected patients at an increased risk of death.
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Affiliation(s)
- Atul Kumar Tiwari
- Departments of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayer Jamshed
- Departments of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Kumar Sahu
- Departments of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Kumar
- Departments of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Departments of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Bhoi
- Departments of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Roshan Mathew
- Departments of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Meera Ekka
- Departments of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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Developing a new sepsis screening tool based on lymphocyte count, international normalized ratio and procalcitonin (LIP score). Sci Rep 2022; 12:20002. [PMID: 36411279 PMCID: PMC9678875 DOI: 10.1038/s41598-022-16744-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/14/2022] [Indexed: 11/22/2022] Open
Abstract
Exploring an effective sepsis screening tool that can be widely implemented is important for improving the prognosis of sepsis worldwide. This study aimed to develop a new simple screening tool for sepsis (LIP scoring system) that includes the peripheral blood lymphocyte count, international normalized ratio, and procalcitonin level. In a single-center, prospective, observational study, 444 acute sepsis inpatients and 444 nonsepsis inpatients were ultimately included based on the Sepsis-3 and exclusion criteria. The differences in the Lym, INR, PCT level and other clinical biomarkers were compared between the two groups. Univariable and multivariable logistic regression analyses and receiver operating characteristic analysis were used to establish a LIP screening tool for sepsis with a combination of biomarkers. The Kappa and McNemar tests were used to evaluate the differences between the LIP screening results (LIP score ≥ 3) and Sepsis-3 criteria (SOFA score ≥ 2). Logistic regression analysis showed that the lymphocyte count, INR, PCT level, platelets, neutrophil/lymphocyte ratio (NLR) and prothrombin time (PT) were independent risk factors for the development of sepsis. The ROC analysis showed that the lymphocyte count, INR, and PCT level had high area under the ROC curve values (AUROC (95% CI): Lym 0.84 (0.810-0.860), INR 0.921 (0.902-0.938), PCT level 0.928 (0.909-0.944)). The LIP tool had satisfactory screening efficacy for sepsis (sensitivity, 92.8%; specificity, 94.1%), and a LIP score equal to or greater than 3 points had good agreement with Sepsis-3 criteria in the diagnosis of sepsis (Kappa = 0862 in the Kappa test and P = 0.512 in the McNemar test). The LIP tool has satisfactory sensitivity and specificity for sepsis screening, and it can be used for rapid screening of patients with sepsis in outpatient and emergency departments or in economically underdeveloped areas with limited resources.
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9
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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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10
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Wright SW, Hantrakun V, Rudd KE, Lau CY, Lie KC, Chau NVV, Teparrukkul P, West TE, Limmathurotsakul D. Enhanced bedside mortality prediction combining point-of-care lactate and the quick Sequential Organ Failure Assessment (qSOFA) score in patients hospitalised with suspected infection in southeast Asia: a cohort study. Lancet Glob Health 2022; 10:e1281-e1288. [PMID: 35961351 PMCID: PMC9427027 DOI: 10.1016/s2214-109x(22)00277-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 05/09/2022] [Accepted: 05/30/2022] [Indexed: 12/11/2022]
Abstract
Background Simple, bedside prediction of infection-related mortality in low-resource settings is crucial for triage and resource-utilisation decisions. We aimed to evaluate mortality prediction by combining point-of-care venous lactate with the quick Sequential Organ Failure Assessment (qSOFA) score in adult patients admitted to hospital with suspected infection in southeast Asia. Methods We performed a cohort study by prospectively enrolling patients aged 18 years or older who had been admitted to hospital within the previous 24 h for suspected infection (with at least three documented systemic manifestations of infection according to the 2012 Surviving Sepsis Campaign) at Sunpasitthiprasong Hospital in Ubon Ratchathani, Thailand (derivation cohort). Venous lactate concentration was determined by a point-of-care device and multiple scores were developed. We then evaluated candidate 28-day mortality prediction models combining qSOFA and the lactate scores. A final model was compared with the qSOFA score, a lactate score, and a modified Sequential Organ Failure Assessment (SOFA) score for mortality discrimination using the area under the receiver operating characteristic curve (AUROC). Mortality discrimination of the qSOFA-lactate score was then verified in an external, prospectively enrolled, multinational cohort in southeast Asia. Findings Between March 1, 2013, and Jan 26, 2017, 5001 patients were enrolled in the derivation cohort; 4980 had point-of-care lactate data available and were eligible for analysis, and 816 died within 28 days of enrolment. The discrimination for 28-day mortality prediction of a qSOFA-lactate score combining the qSOFA score and a lactate score was superior to that of the qSOFA score alone (AUROC 0·78 [95% CI 0·76–0·80] vs 0·68 [0·67–0·70]; p<0·0001) and similar to a modified SOFA score (0·77 [0·75–0·78]; p=0·088). A lactate score alone had superior discrimination compared with the qSOFA score (AUROC 0·76 [95% CI 0.74–0.78]; p<0·0001). 815 patients were enrolled in the external validation cohort and 792 had point-of-care lactate data and were included in the analysis; the qSOFA-lactate score (AUROC 0·77 [95% CI 0·73–0·82]) showed significantly improved 28-day mortality discrimination compared with the qSOFA score alone (0·69 [0·63–0·74]; p<0·0001). Interpretation In southeast Asia, rapid, bedside assessments based on point-of-care lactate concentration combined with the qSOFA score can identify patients at risk of sepsis-related mortality with greater accuracy than the qSOFA score alone, and with similar accuracy to a modified SOFA score. Funding National Institutes of Health, Wellcome Trust.
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Affiliation(s)
- Shelton W Wright
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Viriya Hantrakun
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kristina E Rudd
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chuen-Yen Lau
- Collaborative Clinical Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Khie Chen Lie
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Nguyen Van Vinh Chau
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Department of Internal Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Prapit Teparrukkul
- Department of Internal Medicine, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - T Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA; Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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11
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Zhang L, Li B, Li W, Jiang J, Chen W, Yang H, Pan D. miR-107 Attenuates Sepsis-Induced Myocardial Injury by Targeting PTEN and Activating the PI3K/AKT Signaling Pathway. Cells Tissues Organs 2022; 212:523-534. [PMID: 35717938 DOI: 10.1159/000525476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/08/2022] [Indexed: 11/19/2022] Open
Abstract
Sepsis is a public health problem worldwide. This study investigated the mechanism of miR-107 on sepsis-induced myocardial injury. Sepsis rat models were established by cecal ligation and puncture (CLP), and the cell model was established using lipopolysaccharide (LPS)-induced cardiomyocytes. Cardiac function indexes of rats were measured using echocardiography. Pathological changes in the rat myocardium were observed using histological staining. Expression of miR-107 in the serum of rats and in cardiomyocytes was detected after the treatment with miR-107 mimic and/or pcDNA3.1-PTEN, followed by assessment of cell cycle, proliferation, and apoptosis. Binding sites of miR-107 and PTEN were predicted. PTEN, PI3K, p-PI3K, AKT, and p-AKT levels in LPS-induced cardiomyocytes were measured. miR-107 was significantly downregulated in the serum of CLP rats and LPS-induced cardiomyocytes. miR-107 overexpression remarkably improved cardiac function and histological changes, decreased inflammatory factors, and alleviated the sepsis-induced myocardial injury in rats. In LPS-induced cardiomyocytes, miR-107 overexpression increased cardiomyocyte proliferation, inhibited apoptosis, and enhanced the proportion of cardiomyocytes arrested in S and G2/M phases. miR-107 targeted PTEN. PTEN overexpression partially reversed the inhibition of miR-107 mimic on cardiomyocyte apoptosis. miR-107 overexpression activated the PI3K/AKT pathway by inhibiting PTEN. To conclude, miR-107 activates the PI3K/AKT pathway by inhibiting PTEN, thus attenuating sepsis-induced myocardial injury and LPS-induced cardiomyocyte apoptosis.
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Affiliation(s)
- Lin Zhang
- Department of Cardiology, Guilin People's Hospital, Guilin, China
| | - Bin Li
- Department of Cardiology, Guilin People's Hospital, Guilin, China
| | - Wei Li
- Department of Cardiology, Guilin People's Hospital, Guilin, China
| | - Jingbo Jiang
- Department of Cardiology, Guilin People's Hospital, Guilin, China
| | - Wei Chen
- Department of Cardiology, Guilin People's Hospital, Guilin, China
| | - Huayun Yang
- Department of Cardiology, Guilin People's Hospital, Guilin, China
| | - Diguang Pan
- Department of Cardiology, Guilin People's Hospital, Guilin, China
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12
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Rice B, Calo S, Kamugisha JB, Kamara N, Chamberlain S. Emergency care of sepsis in sub-Saharan Africa: Mortality and non-physician clinician management of sepsis in rural Uganda from 2010 to 2019. PLoS One 2022; 17:e0264517. [PMID: 35544466 PMCID: PMC9094533 DOI: 10.1371/journal.pone.0264517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 02/12/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Little data exists from sub-Saharan Africa describing incidence and outcomes of sepsis in emergency units and uncertainty exists surrounding optimal management of sepsis in low-income settings. There exists limited data regarding quality care metrics for non-physician clinicians trained in emergency care. The objective of this study was to describe changes in septic patients over time and evaluate associations between sepsis care and mortality. Methods Secondary analysis of a prospective cohort of all consecutive patients seen from 2010–2019 in a rural Ugandan emergency unit staffed by non-physician clinicians was performed using an electronic database based on paper charts. Sepsis was defined as suspected infection with a quick Sequential Organ Failure Assessment score (qSOFA)≥1. Multi-variable logistic regression was used to analyze three-day mortality. Results Overall, 48,653 patient visits from 2010–2019 yielded 17,490 encounters for patients age≥18 who had suspected infection, including 10,437 with sepsis. The annual proportion of patients with sepsis decreased from 45.0%% to 21.3% and the proportion with malarial sepsis decreased from 17.7% to 2.1% during the study period. Rates of septic patients receiving quality care (“both fluids and anti-infectives”) increased over time (21.2% in 2012 to 32.0% in 2019, p<0.001), but mortality did not significantly improve (4.5% in 2012 to 6.4% in 2019, p = 0.50). The increasing quality of non-physician clinician care was not associated with reduced mortality, and treatment with “both fluids and antibiotics” was associated with increased mortality (RR = 1.55, 95%CI 1.10–2.00). Conclusion The largest study of sepsis management and outcomes ever published in both Uganda and sub-Saharan Africa showed sepsis and malarial sepsis decreasing from 2010 to 2019. The increasing quality of non-physician clinician care did not significantly reduce mortality and treatment with “both fluids and antibiotics” increased mortality. With causal associations between antibiotics and mortality deemed implausible, associations between sepsis mortality and interventions likely represent confounding by indication. Defining optimal sepsis care regionally will likely require randomized controlled trials.
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Affiliation(s)
- Brian Rice
- Department of Emergency Medicine, Stanford University, Palo Alto, California, United States of America
- Global Emergency Care, United States of America
| | - Sal Calo
- Department of Emergency Medicine and Center for Global Health, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute—Cleveland Clinic, Cleveland, Ohio, United States of America
- * E-mail:
| | | | | | - Stacey Chamberlain
- Global Emergency Care, United States of America
- Department of Emergency Medicine and Center for Global Health, University of Illinois at Chicago, Chicago, Illinois, United States of America
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13
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Mendoza D, Ascuntar J, Rosero O, Jaimes F. Improving the diagnosis and prognosis of sepsis according to the sources of infection. Emerg Med J 2022; 39:279-283. [PMID: 35210267 DOI: 10.1136/emermed-2021-211910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/08/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The clinical presentation of sepsis is heterogeneous and largely depends on the primary site of infection. Currently, factors associated with sepsis outcomes do not differentiate between infection sites. The objective of this investigation was to identify variables associated with risk of in-hospital mortality or intensive care unit (ICU) admission, according to infection sites. METHODS This was a secondary analysis of a multicentre prospective cohort of ED patients ≥18 years old from three university hospitals in Medellín, Colombia. Multivariable logistic regression models were performed to estimate the association of factors with in-hospital mortality or ICU admission according to five infection sites: urinary tract infection (UTI), community-acquired pneumonia (CAP), intra-abdominal infection, sepsis without evident source (primary) and other sites. RESULTS The infection sites of the 1947 patients included were: UTI (n=586), CAP (n=585), intra-abdominal infection (n=213), primary (n=224) and other sites (n=339). In the multivariable model, the factors associated with in-hospital mortality or ICU admission varied by infection site: respiratory rate (RR), systolic blood pressure (SBP) and lactate for UTI; heart rate (HR), RR and temperature <38°C for CAP; Glasgow Coma Scale (GCS), lactate and age <65 for intra-abdominal infection; SBP, GCS, lactate and temperature <38°C for primary and RR, GCS and temperature <38°C for other. CONCLUSIONS Our results suggest that the diagnosis and prognosis of sepsis in emergency care should consider different clinical criteria, based on site of infection. Given the heterogeneity and interindividual variability of sepsis, a more individualised approach could help to direct treatment, monitor response and facilitate initial clinical decisions.
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Affiliation(s)
- Deibie Mendoza
- Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia
| | - Johana Ascuntar
- GRAEPIC (Grupo Académico de Epidemiología Clínica), Universidad de Antioquia, Medellin, Colombia
| | - Oriana Rosero
- Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia
| | - Fabian Jaimes
- GRAEPIC (Grupo Académico de Epidemiología Clínica), Universidad de Antioquia, Medellin, Colombia .,Internal Medicine Department, Universidad de Antioquia, Medellin, Colombia
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14
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Alberto L, Marshall AP, Walker RM, Pálizas F, Aitken LM. Sensitivity and specificity of a quick sequential [Sepsis-Related] organ failure assessment sepsis screening tool. Int J Clin Pract 2021; 75:e14874. [PMID: 34529874 DOI: 10.1111/ijcp.14874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 08/06/2021] [Accepted: 09/10/2021] [Indexed: 11/30/2022] Open
Abstract
AIM There is limited evidence on the diagnostic accuracy of a quick Sequential [Sepsis-Related] Organ Failure Assessment (qSOFA) sepsis screening (SS) tool in developing nation health settings. The aim of this study was to test the diagnostic accuracy of a qSOFA-based SS tool, and the predictive validity of the qSOFA score in hospital ward patients from Argentina. METHODS Prospective observational study. Patients (≥18 years, without sepsis) were recruited within 24-48 hours of admission to a 169-bed tertiary referral private hospital in Buenos Aires. The index test was the qSOFA-based SS tool, and the reference standard sepsis diagnosed at discharge blindly evaluated with reference to the Sepsis-3. RESULTS In 1151 patients (median age 69.9 [IQR, 29.0]); 47 (4.1%) had sepsis, 413 (35.9%) had infection and 691 (60.0%) other diagnoses at discharge. The qSOFA-based SS tool (index test) had moderate sensitivity (60%), good specificity (89%), a very low positive (19%) and very high negative (98%) predictive value for sepsis diagnosed at discharge according to the Sepsis-3 criteria (reference standard). For the same outcome, the qSOFA score in isolation had a reasonable predictive validity area under receiver operating characteristics curve 0.77 (95% CI 0.70-0.83) P < 0.001. CONCLUSION The qSOFA score could reasonably discriminate patients at risk of developing sepsis; qSOFA-based screening may be valuable where no screening criteria are in place.
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Affiliation(s)
- Laura Alberto
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Andrea P Marshall
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
- Gold Coast University Hospital, Gold Coast Hospital and Health Service, Gold Coast, Australia
| | - Rachel M Walker
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
- Division of Surgery, Princess Alexandra Hospital, Brisbane, Australia
| | - Fernando Pálizas
- Intensive Care Units, Clínicas Bazterrica and Santa Isabel, Ciudad de Buenos Aires, Argentina
| | - Leanne M Aitken
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
- School of Health Sciences at City, University of London, London, UK
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15
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Guo Q, Li HY, Song WD, Liu H, Yu HQ, Li YH, Lü ZD, Liang LH, Zhao QZ, Jiang M. qSOFA predicted pneumonia mortality better than minor criteria and worse than CURB-65 with robust elements and higher convergence. Am J Emerg Med 2021; 52:1-7. [PMID: 34856439 DOI: 10.1016/j.ajem.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/13/2021] [Accepted: 11/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Limited data are available on the discriminatory capacity of quick sequential [sepsis-related] organ failure assessment (qSOFA) versus IDSA/ATS minor criteria for predicting mortality in patients with community-acquired pneumonia (CAP). METHODS An observational prospective cohort study of 2116 patients with CAP was performed. Construct validity was determined using Cronbach α. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI). RESULTS Overall in-hospital mortality was 6.43%. Mortality was 25.96% for patients with a qSOFA score of 2 or higher versus 3.05% for those with a qSOFA score less than 2 (odds ratio for mortality 6.57, P < 0.0001), and 13.85% for patients with at least 3 minor criteria versus 2.03% for those with 2 or fewer minor criteria (odds ratio for mortality 2.27, P < 0.0001). qSOFA had a higher correlation with mortality than minor criteria, as well as higher internal consistency (Cronbach alpha 0.43 versus 0.14) and diagnostic values of individual elements (larger AUROCs and higher Youden's indices). qSOFA ≥2 was less sensitive but more specific for predicting mortality than ≥3 minor criteria (qSOFA sensitivity 59.6%, specificity 88.3% and positive likelihood ratio 5.11 versus ≥3 minor criteria sensitivity 80.1%, specificity 65.8% and positive likelihood ratio 2.34). The predictive validity of qSOFA was good for mortality (AUROC = 0.868), was statistically greater than minor criteria, was equal to pneumonia severity index, and was inferior compared with CURB-65 (AUROC, 0.824, 0.902, 0.919; NRI, 0.088, -0.068, -0.103; respectively). CONCLUSIONS The qSOFA predicted mortality in CAP better than IDSA/ATS minor criteria and worse than CURB-65 with robust elements and higher convergence. qSOFA as a bedside prompt might be positioned as a proxy for minor criteria and increase the recognition and thus merit more appropriate management of CAP patients likely to fare poorly, which might have implications for more accurate clinical triage decisions.
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Affiliation(s)
- Qi Guo
- Department of Pulmonary and Critical Care Medicine, Shenzhen Hospital, Peking University, Shenzhen, 518036, Guangdong, China; Department of Pulmonary and Critical Care Medicine, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen, 518033, Guangdong, China.
| | - Hai-Yan Li
- Department of General Medicine, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen, 518033, Guangdong, China
| | - Wei-Dong Song
- Department of Pulmonary and Critical Care Medicine, Shenzhen Hospital, Peking University, Shenzhen, 518036, Guangdong, China
| | - Hui Liu
- Department of Pulmonary and Critical Care Medicine, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen, 518033, Guangdong, China
| | - Hai-Qiong Yu
- Department of Pulmonary and Critical Care Medicine, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen, 518033, Guangdong, China
| | - Yan-Hong Li
- Department of Pulmonary and Critical Care Medicine, Shenzhen Hospital, Peking University, Shenzhen, 518036, Guangdong, China
| | - Zhong-Dong Lü
- Department of Pulmonary and Critical Care Medicine, Shenzhen Hospital, Peking University, Shenzhen, 518036, Guangdong, China
| | - Li-Hua Liang
- Department of Radiology, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen 518033, Guangdong, China
| | - Qing-Zhou Zhao
- Department of Radiology, The Eighth Affiliated Hospital (Shenzhen Futian), Sun Yat-sen University, Shenzhen 518033, Guangdong, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, 510120, Guangdong, China
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16
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Schenck EJ, Hoffman KL, Oromendia C, Sanchez E, Finkelsztein EJ, Hong KS, Kabariti J, Torres LK, Harrington JS, Siempos II, Choi AMK, Campion TR. A Comparative Analysis of the Respiratory Subscore of the Sequential Organ Failure Assessment Scoring System. Ann Am Thorac Soc 2021; 18:1849-1860. [PMID: 33760709 PMCID: PMC8641830 DOI: 10.1513/annalsats.202004-399oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 03/23/2021] [Indexed: 11/20/2022] Open
Abstract
Rationale: The Sequential Organ Failure Assessment (SOFA) tool is a commonly used measure of illness severity. Calculation of the respiratory subscore of SOFA is frequently limited by missing arterial oxygen pressure (PaO2) data. Although missing PaO2 data are commonly replaced with normal values, the performance of different methods of substituting PaO2 for SOFA calculation is unclear. Objectives: The study objective was to compare the performance of different substitution strategies for missing PaO2 data for SOFA score calculation. Methods: This retrospective cohort study was performed using the Weill Cornell Critical Care Database for Advanced Research from a tertiary care hospital in the United States. All adult patients admitted to an intensive care unit (ICU) from 2011 to 2019 with an available respiratory SOFA score were included. We analyzed the availability of the PaO2/fraction of inspired oxygen (FiO2) ratio on the first day of ICU admission. In those without a PaO2/FiO2 ratio available, the ratio of oxygen saturation as measured by pulse oximetry to FiO2 was used to calculate a respiratory SOFA subscore according to four methods (linear substitution [Rice], nonlinear substitution [Severinghaus], modified respiratory SOFA, and multiple imputation by chained equations [MICE]) as well as the missing-as-normal technique. We then compared how well the different total SOFA scores discriminated in-hospital mortality. We performed several subgroup and sensitivity analyses. Results: We identified 35,260 unique visits, of which 9,172 included predominant respiratory failure. PaO2 data were available for 14,939 (47%). The area under the receiver operating characteristic curve for each substitution technique for discriminating in-hospital mortality was higher than that for the missing-as-normal technique (0.78 [0.77-0.79]) in all analyses (modified, 0.80 [0.79-0.81]; Rice, 0.80 [0.79-0.81]; Severinghaus, 0.80 [0.79-0.81]; and MICE, 0.80 [0.79-0.81]) (P < 0.01). Each substitution method had a higher accuracy for discriminating in-hospital mortality (MICE, 0.67; Rice, 0.67; modified, 0.66; and Severinghaus, 0.66) than the missing-as-normal technique. Model calibration for in-hospital mortality was less precise for the missing-as-normal technique than for the other substitution techniques at the lower range of SOFA and among the subgroups. Conclusions: Using physiologic and statistical substitution methods improved the total SOFA score's ability to discriminate mortality compared with the missing-as-normal technique. Treating missing data as normal may result in underreporting the severity of illness compared with using substitution. The simplicity of a direct oxygen saturation as measured by pulse oximetry/FiO2 ratio-modified SOFA technique makes it an attractive choice for electronic health record-based research. This knowledge can inform comparisons of severity of illness across studies that used different techniques.
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Affiliation(s)
- Edward J Schenck
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, New York; and
| | | | | | - Elizabeth Sanchez
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine
| | - Eli J Finkelsztein
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine
| | - Kyung Sook Hong
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine
- Department of Surgery and Critical Care Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | | | - Lisa K Torres
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, New York; and
| | - John S Harrington
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, New York; and
| | - Ilias I Siempos
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine
| | - Augustine M K Choi
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, New York; and
| | - Thomas R Campion
- Department of Population Health Sciences
- Information Technologies and Services, and
- Clinical and Translational Science Center, Weill Cornell Medicine, Cornell University, New York, New York
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17
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Dellinger RP, Levy MM, Schorr CA, Townsend SR. 50 Years of Sepsis Investigation/Enlightenment Among Adults-The Long and Winding Road. Crit Care Med 2021; 49:1606-1625. [PMID: 34342304 DOI: 10.1097/ccm.0000000000005203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- R Phillip Dellinger
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | | | - Christa A Schorr
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | - Sean R Townsend
- University of California Pacific Medical Center, (Sutter Health), San Francisco, CA
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18
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Khemani RG, Lee JT, Wu D, Schenck EJ, Hayes MM, Kritek PA, Mutlu GM, Gershengorn HB, Coudroy R. Update in Critical Care 2020. Am J Respir Crit Care Med 2021; 203:1088-1098. [PMID: 33734938 DOI: 10.1164/rccm.202102-0336up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Robinder G Khemani
- Pediatric ICU, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jessica T Lee
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Wu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Edward J Schenck
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York.,NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Patricia A Kritek
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of Washington Seattle, Washington
| | - Gökhan M Mutlu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Rémi Coudroy
- Institut National de la Santé et de la Recherche Médicale, Poitiers, France; and.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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19
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Abdullah SMOB, Sørensen RH, Nielsen FE. Prognostic Accuracy of SOFA, qSOFA, and SIRS for Mortality Among Emergency Department Patients with Infections. Infect Drug Resist 2021; 14:2763-2775. [PMID: 34321893 PMCID: PMC8313375 DOI: 10.2147/idr.s304952] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/20/2021] [Indexed: 12/16/2022] Open
Abstract
Objective This study aimed to determine the prognostic accuracy of SOFA in comparison to quick-SOFA (qSOFA) and systemic inflammatory response syndrome (SIRS) in predicting 28-day mortality in the emergency department (ED) patients with infections. Methods A secondary analysis of data from a prospective study of adult patients with documented or suspected infections admitted to an ED in Denmark from Oct-2017 to Mar-2018. The SOFA scores were calculated after adjustment for chronic diseases. The prognostic accuracy was assessed by analysis of sensitivity, specificity, predictive values, likelihood ratios, and area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals (CI). Results A total of 2045 patients with a median age of 73.2 (IQR: 60.9-82.1) years were included. The overall 28-day mortality was 7.7%. In patients meeting a SOFA score ≥2, qSOFA score ≥2, and SIRS criteria ≥2 the 28-day mortality was 13.6% (11.2-16.3), 17.8% (12.4-24.3) and 8.3% (6.7-10.2), respectively. SOFA ≥2 had a sensitivity of 61.4% (53.3-69.0) and specificity of 67.3% (65.1-69.4), qSOFA ≥2 had a sensitivity of 19.6% (13.7-26.7) and specificity of 92.4% (91.1-93.6), and SIRS ≥2 had a sensitivity of 52.5% (44.4-60.5) and specificity of 51.5% (49.2-53.7). The AUROC for SOFA compared to SIRS was: 0.68 vs 0.52; p<0.001 and compared to qSOFA: 0.68 vs 0.63; p=0.018. Conclusion A SOFA score of at least two had better prognostic accuracy for 28-day mortality than SIRS and qSOFA. However, the overall accuracy of SOFA was poor for the prediction of 28-day mortality.
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Affiliation(s)
| | | | - Finn Erland Nielsen
- Department of Emergency Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Slagelse, Denmark.,Copenhagen Center for Translational Research, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Slagelse, Denmark
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20
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Ward A Maia I, Oliveira J E Silva L, Herpich H, Diogo L, Batista Santana JC, Pedrollo D, Castro Alvarez Perez M, Nicolaidis R. Prognostic accuracy of qSOFA at triage in patients with suspected infection in a Brazilian emergency department. Am J Emerg Med 2021; 50:41-45. [PMID: 34273866 DOI: 10.1016/j.ajem.2021.06.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/24/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To evaluate the prognostic accuracy of qSOFA for predicting in-hospital mortality among patients with suspected infection presenting to the ED of a public tertiary hospital in Brazil. METHODS We performed a retrospective cohort study of consecutive adult patients (age ≥ 18 years) with suspected infection who presented to an academic tertiary ED in Porto Alegre (Southern Brazil) during an 18-month period. The qSOFA was calculated by using information collected at triage and patients were followed throughout hospitalization for the primary outcome of in-hospital mortality. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratios with corresponding 95% CIs were calculated for the qSOFA and qSOFA65. RESULTS A total of 7523 ED visits of patients with suspected infection in which an intravenous antibiotic was administered within 24 h were included, which resulted in 908 in-hospital deaths (12.1%). There were 690 (9.2%) patients whose triage qSOFA was ≥2 points. When such cutoff was used, the sensitivity for in-hospital death was 24.6% (95% CI 21.8 to 27.4%) and the specificity was 92.9% (95% CI 92.3% to 93.5%). The sensitivity increased to 67.4% (95% CI 64.2% to 70.3%) when a cutoff of ≥1 was tested, but the specificity decreased to 55.3% (95% CI 54.1% to 56.5%). Using a cutoff of ≥2, the qSOFA65 had a sensitivity of 51.0% (95% CI 47.7% to 54.3%) and a specificity of 75.7% (95% CI 74.6% to 76.7%). CONCLUSIONS The qSOFA score yielded very low sensitivity in predicting in-hospital mortality. Emergency physicians or ED triage nurses in low-to-middle income countries should not be using qSOFA or qSOFA65 as "rule-out" screening tools in the initial evaluation of patients with suspected infection.
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Affiliation(s)
- Ian Ward A Maia
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Department of Emergency Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil; Emergency and Acute Care Medicine Research Group, Hospital de Clínicas de Porto alegre, Porto Alegre, RS, Brazil.
| | | | - Henrique Herpich
- School of Medicine, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Luciano Diogo
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Emergency and Acute Care Medicine Research Group, Hospital de Clínicas de Porto alegre, Porto Alegre, RS, Brazil
| | - João Carlos Batista Santana
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Emergency and Acute Care Medicine Research Group, Hospital de Clínicas de Porto alegre, Porto Alegre, RS, Brazil
| | - Daniel Pedrollo
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Emergency and Acute Care Medicine Research Group, Hospital de Clínicas de Porto alegre, Porto Alegre, RS, Brazil
| | - Mario Castro Alvarez Perez
- Department of Internal Medicine, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, RJ, Brazil; Fundação Educacional Serra dos Órgãos, UNIFESO, Teresópolis, RJ, Brazil
| | - Rafael Nicolaidis
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Emergency and Acute Care Medicine Research Group, Hospital de Clínicas de Porto alegre, Porto Alegre, RS, Brazil
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21
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Miller WD, Han X, Peek ME, Charan Ashana D, Parker WF. Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care. JAMA Netw Open 2021; 4:e2113891. [PMID: 34143190 PMCID: PMC8214156 DOI: 10.1001/jamanetworkopen.2021.13891] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Crisis Standards of Care (CSC) are guidelines for rationing health care resources during public health emergencies. The CSC adopted by US states ration intensive care unit (ICU) admission using the Sequential Organ Failure Assessment (SOFA) score, which is used to compare expected in-hospital mortality among eligible patients. However, it is unknown if Black and White patients with equivalent SOFA scores have equivalent in-hospital mortality. OBJECTIVE To investigate whether reliance on SOFA is associated with bias against Black patients in CSC. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using data from the eICU Collaborative Research Database of patients admitted to 233 US ICUs in 2014 to 2015. Included individuals were Black and White adult patients in the ICU, who were followed up to hospital discharge. Data were analyzed from May 2020 through April 2021. EXPOSURE SOFA scores at ICU admission. MAIN OUTCOMES AND MEASURES Hierarchical logistic regression with hospital fixed effects was used to measure the interaction between race and SOFA as a factor associated with in-hospital mortality, as well as the odds of death among Black and White patients with equivalent priority for resource allocation according to the SOFA-based ranking rules of 3 statewide CSC (denoted A, B, and C) under shortage conditions that were severe (ie, only patients with the highest priority would be eligible for allocation), intermediate (ie, patients in the highest 2 tiers would be eligible for allocation), or low (ie, only patients with the lowest priority would be at risk of exclusion). RESULTS Among 111 885 ICU encounters representing 95 549 patients, there were 16 688 encounters with Black patients (14.9%) and 51 464 (46.0%) encounters with women and the mean (SD) age was 63.3 (16.9) years. The median (interquartile range) SOFA score was not statistically significantly different between Black and White patients (4 [2-6] for both groups; P = .19), but mortality was lower among Black individuals compared with White individuals with equivalent SOFA scores (odds ratio [OR], 0.98; 95% CI, 0.97-0.99; P < .001). This was associated with lower mortality among Black patients compared with White patients prioritized for resource allocation in 3 CSC under shortage conditions that were severe (system A: OR, 0.65; 95% CI, 0.58-0.74; P < .001; system B: OR, 0.70; 95% CI, 0.64-0.78; P < .001; system C: OR, 0.73; 95% CI, 0.67-0.80; P < .001), intermediate (system A: OR, 0.73; 95% CI, 0.67-0.80; P < .001; system B: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.82; 95% CI, 0.77-0.89; P < .001), and low (system A: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.86; 95% CI, 0.81-0.92; P < .001; not applicable for system B, which had fewer tiers). When SOFA-based ranking rules were adjusted for Black patients to simulate equitable allocation based on observed mortality, the proportion upgraded to higher priority ranged from 379 Black patient encounters (2.3%) in low shortage conditions to 2601 Black patient encounters (15.6%) in severe shortage conditions. CONCLUSIONS AND RELEVANCE This study found that SOFA scores were associated with overestimated mortality among Black patients compared with White patients, and this was associated with a structural disadvantage for Black patients in CSC allocation systems. These findings suggest that guidelines should be revised to correct this inequity and alternative methods should be developed for more equitable triage.
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Affiliation(s)
- William Dwight Miller
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Xuan Han
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Monica E. Peek
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
- Center for the Study of Race, Politics, and Culture, University of Chicago, Chicago, Illinois
| | - Deepshikha Charan Ashana
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, North Carolina
| | - William F. Parker
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
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22
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Klinger A, Mueller A, Sutherland T, Mpirimbanyi C, Nziyomaze E, Niyomugabo JP, Niyonsenga Z, Rickard J, Talmor DS, Riviello E. Predicting mortality in adults with suspected infection in a Rwandan hospital: an evaluation of the adapted MEWS, qSOFA and UVA scores. BMJ Open 2021; 11:e040361. [PMID: 33568365 PMCID: PMC7878147 DOI: 10.1136/bmjopen-2020-040361] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RATIONALE Mortality prediction scores are increasingly being evaluated in low and middle income countries (LMICs) for research comparisons, quality improvement and clinical decision-making. The modified early warning score (MEWS), quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA), and Universal Vital Assessment (UVA) score use variables that are feasible to obtain, and have demonstrated potential to predict mortality in LMIC cohorts. OBJECTIVE To determine the predictive capacity of adapted MEWS, qSOFA and UVA in a Rwandan hospital. DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES We prospectively collected data on all adult patients admitted to a tertiary hospital in Rwanda with suspected infection over 7 months. We calculated an adapted MEWS, qSOFA and UVA score for each participant. The predictive capacity of each score was assessed including sensitivity, specificity, positive and negative predictive value, OR, area under the receiver operating curve (AUROC) and performance by underlying risk quartile. RESULTS We screened 19 178 patient days, and enrolled 647 unique patients. Median age was 35 years, and in-hospital mortality was 18.1%. The proportion of data missing for each variable ranged from 0% to 11.7%. The sensitivities and specificities of the scores were: adapted MEWS >4, 50.4% and 74.9%, respectively; qSOFA >2, 24.8% and 90.4%, respectively; and UVA >4, 28.2% and 91.1%, respectively. The scores as continuous variables demonstrated the following AUROCs: adapted MEWS 0.69 (95% CI 0.64 to 0.74), qSOFA 0.65 (95% CI 0.60 to 0.70), and UVA 0.71 (95% CI 0.66 to 0.76); there was no statistically significant difference between the discriminative capacities of the scores. CONCLUSION Three scores demonstrated a modest ability to predict mortality in a prospective study of inpatients with suspected infection at a Rwandan tertiary hospital. Careful consideration must be given to their adequacy before using them in research comparisons, quality improvement or clinical decision-making.
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Affiliation(s)
- Amanda Klinger
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ariel Mueller
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tori Sutherland
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christophe Mpirimbanyi
- Department of Surgery, Kigali University Teaching Hospital, Kigali, Rwanda
- University of Rwanda College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Elie Nziyomaze
- Department of Surgery, Kigali University Teaching Hospital, Kigali, Rwanda
- University of Rwanda College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Jean-Paul Niyomugabo
- University of Rwanda College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Zack Niyonsenga
- University of Rwanda College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Jennifer Rickard
- Department of Surgery, Kigali University Teaching Hospital, Kigali, Rwanda
- Division of Critical Care/Acute Care Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Daniel S Talmor
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Elisabeth Riviello
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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23
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Abstract
PURPOSE OF REVIEW A major challenge in the ICU is optimization of antibiotic use. This review assesses current understanding of core best practices supporting and promoting astute antibiotic decision-making. RECENT FINDINGS Limiting exposure to the shortest effective duration is the cornerstone of antibiotic decision-making. The decision to initiate antibiotics should include assessment of risk for resistance. This requires synthesis of patient-level data and environmental factors to determine whether delayed initiation could be considered in some patients with suspected sepsis until sensitivity data is available. Until improved stratification scores and clinically meaningful cut-off values to identify MDR are available and externally validated, decisions as to which empiric antibiotic is used should rely on syndromic antibiograms and institutional guidance. Optimization of initial and maintenance doses is another enabler of enhanced outcome. Stewardship practices must be streamlined by re-assessment to minimize negative effects, such as a potential increase in duration of therapy and increased risk of collateral damage from exposure to multiple, sequential antibiotics that may ensue from de-escalation. SUMMARY Multiple challenges and research priorities for antibiotic optimization remain; however, the best stewardship practices should be identified and entrenched in daily practice. Reducing unnecessary exposure remains a vital strategy to limit resistance development.
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24
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Maximous S, Brotherton BJ, Achilleos A, Akrami KM, Barros LM, Cobb N, Misango D, Papali A, Park C, Shetty VU, Schultz MJ, Taran S, Lee BW. Pragmatic Recommendations for the Management of COVID-19 Patients with Shock in Low- and Middle-Income Countries. Am J Trop Med Hyg 2020; 104:72-86. [PMID: 33350378 PMCID: PMC7957233 DOI: 10.4269/ajtmh.20-1105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
As some patients infected with the novel coronavirus progress to critical illness, a subset will eventually develop shock. High-quality data on management of these patients are scarce, and further investigation will provide valuable information in the context of the pandemic. A group of experts identify a set of pragmatic recommendations for the care of patients with SARS-CoV-2 and shock in resource-limited environments. We define shock as life-threatening circulatory failure that results in inadequate tissue perfusion and cellular dysoxia/hypoxia, and suggest that it can be operationalized via clinical observations. We suggest a thorough evaluation for other potential causes of shock and suggest against indiscriminate testing for coinfections. We suggest the use of the quick Sequential Organ Failure Assessment (qSOFA) as a simple bedside prognostic score for COVID-19 patients and point-of-care ultrasound (POCUS) to evaluate the etiology of shock. Regarding fluid therapy for the treatment of COVID-19 patients with shock in low-middle-income countries, we favor balanced crystalloids and recommend using a conservative fluid strategy for resuscitation. Where available and not prohibited by cost, we recommend using norepinephrine, given its safety profile. We favor avoiding the routine use of central venous or arterial catheters, where availability and costs are strong considerations. We also recommend using low-dose corticosteroids in patients with refractory shock. In addressing targets of resuscitation, we recommend the use of simple bedside parameters such as capillary refill time and suggest that POCUS be used to assess the need for further fluid resuscitation, if available.
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Affiliation(s)
- Stephanie Maximous
- 1Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian Jason Brotherton
- 2Department of Internal Medicine, Kijabe Medical Center, Kijabe, Kenya.,3Critical Care Medicine Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Achilleos
- 4Department of Critical Care, Sunnybrook Health Sciences Center, Toronto, Canada
| | - Kevan M Akrami
- 5Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,6Divisions of Infectious Disease and Critical Care Medicine, University of California San Diego, San Diego, California
| | - Lia M Barros
- 7Department of Cardiology, University of Washington Medical Center, Seattle, Washington
| | - Natalie Cobb
- 8Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington Medical Center, Seattle, Washington
| | - David Misango
- 9Department of Anaesthesiology and Critical Care Medicine, Aga Khan University Hospital, Nairobi, Kenya
| | - Alfred Papali
- 10Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - Casey Park
- 11Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto, Canada
| | - Varun U Shetty
- 3Critical Care Medicine Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marcus J Schultz
- 12Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,13Nuffield Department of Medicine, Mahidol University, Bangkok, Thailand.,14Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Shaurya Taran
- 11Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto, Canada
| | - Burton W Lee
- 1Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,15Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland
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25
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Bakr M, Abdelhalim KM. Response to Maheshwari and Arora re: "Safety and Efficacy of Emergency Ureteroscopy with Intracorporeal Lithotripsy in Patients Presented with Urinary Tract Infection with Mild Sepsis" by Bakr and Abdelhalim. J Endourol 2020; 34:1273-1274. [PMID: 33090048 DOI: 10.1089/end.2020.29100.mba] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mohamed Bakr
- Urology Department, Port-Said University, Port-Said, Egypt
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26
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Edel A, Reinhart K, Schaller SJ. [Critical statement on selected recommendations of the new German S3 Sepsis Guideline]. Med Klin Intensivmed Notfmed 2020; 115:505-507. [PMID: 32910285 PMCID: PMC7481338 DOI: 10.1007/s00063-020-00720-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Andreas Edel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland
| | - Konrad Reinhart
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland.
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27
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Topeli A, Baspinar B, Ortac Ersoy E. In Search of the Ideal Risk Score in Sepsis. Am J Respir Crit Care Med 2020; 202:152-153. [PMID: 32250644 PMCID: PMC7328329 DOI: 10.1164/rccm.202002-0315le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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Akinosoglou K, deLastic AL, Niarou V, Ziazias D, Davoulos C, Kolosaka M, Kosmopoulou F, Theodoraki S, Koutsouri CP, Gogos C. Could the Quick Sequential Organ Failure Assessment Predictive Accuracy Be Affected by Site of Infection? Am J Respir Crit Care Med 2020; 202:153-154. [PMID: 32250647 PMCID: PMC7328318 DOI: 10.1164/rccm.202003-0552le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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29
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DeMerle KM, Rudd KE. The Quick Sepsis-related Organ Failure Assessment Score in Brazil: Insights for Future Use in Diverse Settings. Am J Respir Crit Care Med 2020; 201:755-756. [PMID: 31968174 PMCID: PMC7124709 DOI: 10.1164/rccm.202001-0058ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Kimberley M DeMerle
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center.,Division of Pulmonary, Allergy, and Critical Care MedicineUniversity of PittsburghPittsburgh, Pennsylvania
| | - Kristina E Rudd
- CRISMA Centerand.,Department of Critical Care MedicineUniversity of PittsburghPittsburgh, Pennsylvania
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