qSOFA score for prediction of sepsis outcome in emergency department

Evaluation of Plasma-Lyte Versus Lactated Ringer's in Surgical Intensive Care Unit Trauma Patients as Fluid Resuscitation

In critically ill patients, fluid resuscitation with balanced crystalloids close to plasma osmolarity have a lower risk of electrolyte imbalances and demonstrated better clinical outcomes compared to normal saline (NS). While lactated ringer's (LR) has shown benefit over NS, plasma-lyte (PL) with a higher osmolarity and different electrolyte formulation is hypothesized to be superior. We performed a retrospective observational cohort study over 37 months at a tertiary hospital. Inclusion criteria were hospitalization in the surgical intensive care unit (SICU), trauma indication, ≥18 years old, and received either PL or LR. All PL administrations and every fifth patient with LR as resuscitation were included in order to match the sample size in each group. Primary outcomes were SICU length of stay (LOS), hospital LOS, and mortality. Secondary outcomes were biomarker changes from baseline. There were 113 patients in both PL and LR groups. The PL arm had higher APACHE II scores (16 vs 13, P = .033) and were more likely ventilated (39.3% vs 20.4%, P = .002) compared to LR. Median hospital LOS (12.0 vs 8.0, P < .001) and SICU LOS (6.0 vs 3.0, P < .001) are significantly longer in PL group compared to the LR group. However, there was no difference in in-hospital mortality (5.3% vs 3.5% P = .519) and SICU mortality (9.7% vs 5.3%, P > .208) between PL and LR. Overall, PL use was associated with prolonged hospital and SICU LOS. PL use did not demonstrate mortality benefit. However, patients were more critically ill in PL group based on higher APACHE II scores and higher rates of mechanical ventilation, which could be contributing to these unfavorable outcomes.

Factors associated with contrast-associated acute kidney injury in an emergency department: A cohort study in Lebanon

BACKGROUND

Contrast-associated acute kidney injury (CA-AKI) is a common problem in hospitals, particularly in low-middle-income countries (LMIC), due to limited resources and a high prevalence of comorbidities. Kidney function evaluation using serum creatinine levels before contrast administration leads to increased length of stay and delayed patient care. This study aimed to identify factors associated with CA-AKI in emergency department (ED) patients in an LMIC. Identifying these factors is essential for enhancing patient care and guiding clinical practice by allowing for the early detection and management of patients at risk.

METHODS

This study is a retrospective cohort study conducted at the largest tertiary care center's ED in Lebanon between November 2018 and December 2019. The study included ED patients who underwent computed-tomography (CT) with contrast. Bivariate and logistic regression analyses were performed to compare the characteristics of patients who developed AKI with those who did not by using SPSS package. The Institutional Review Board (IRB) at the American University of Beirut (AUB) approved this study under protocol ID BIO-2020-0276, which was performed per the Declaration of Helsinki. The IRB waived the need to consent patients since many of them were not followed up at the time of the study.

RESULTS

The study included 1832 patients, of whom 10.4% (n = 190) developed CA-AKI. Patients aged over 65 had a 1.6-fold higher risk of CA-AKI (aOR = 1.55, 95%CI:1.09-2.2). High blood pressure (≥140 mmHg), high respiratory rate ( ≥ 22), and chronic kidney disease were significantly associated with CA-AKI. The use of loop diuretics (aOR = 2.21, 95%CI:1.49-3.28), beta-lactams (aOR = 4.11, 95%CI:2.63-6.42), and allopurinol (aOR = 2.74, 95%CI:1.43-5.25) were significantly associated with CA-AKI.

CONCLUSIONS

Identifying factors associated with CA-AKI in an emergency setting, such as age, comorbidities, and home medications, can help identify patients at low risk of developing CA-AKI.

Comparison of the Quick Sequential Organ Failure Assessment (qSOFA) Score With the Glasgow-Blatchford Score (GBS) and Rockall Score (RS) in Predicting the Need for Intensive Care Among Acute Upper Gastrointestinal Bleeding Patients

OBJECTIVE

 The present study aims to compare the quick sequential organ failure assessment (qSOFA) score, Glasgow-Blatchford score (GBS), and Rockall score (RS) in predicting intensive care needs among patients with upper gastrointestinal bleeding at a tertiary care medical college hospital in South India, thus helping to determine the most useful scores in predicting in-hospital adverse events among the three.

METHODOLOGY

 This single-center, cross-sectional study was conducted from March 1, 2023, to February 29, 2024, after obtaining institutional review board approval from Pushpagiri Institute of Medical Sciences and Research Centre, Tiruvalla, Kerala, India. The investigator assessed the patients' characteristics (age, sex, presenting complaints, comorbidities), hemodynamic status, and laboratory variables at presentation in order to calculate the RS, GBS, and qSOFA for each patient. The patient's course in the hospital, including pre- and post-endoscopy characteristics and events such as recurrent bleeding, hematemesis, melena, mortality, intensive care, blood product transfusions, prolonged hospitalization, and the presence of hemodynamic instability, was documented.

RESULTS

 Out of the total 95 patients, 67.4% were aged over 60 years, with 66% being male. Chronic liver disease, hypertension, and diabetes mellitus were present in more than half of the patients. Hematemesis was the predominant presentation (51.6%), while tachycardia, tachypnea, and elevated blood urea nitrogen levels were noted more frequently. The patients were classified into low-risk and high-risk groups based on the three scores and were compared for intensive care unit (ICU) admissions, rebleeding, and death. A significant difference was noted between the GBS and the incidence of rebleeding (p-value: 0.043). The scores were compared for ICU admission using different parameters, and it was found that qSOFA had 100% sensitivity but very low specificity (10.59%), GBS had 92.11% sensitivity, with the lowest negative predictive value (NPV) at 33.33% and the highest positive predictive value (PPV) at 81.4%, and RS had a sensitivity of 96.08%, with intermediate NPV and PPV.

CONCLUSION

GBS provided the best overall prediction accuracy for the need for ICU admission in acute upper gastrointestinal bleeding patients, while qSOFA demonstrated extremely high sensitivity as a screening tool.

Predictive and Prognostic Importance of National Early Warning Score 2 (NEWS2) in Emergency Room Patients

Introduction The National Early Warning Score 2 (NEWS2), a modified version of its predecessor NEWS, is a screening tool developed by the Royal College of Physicians and serves as a stratification tool/scale that classifies patients based on six physiological parameters. Despite being widely recognized for its excellent accuracy, there is limited evidence regarding its application within the Indian population and its role in resource allocation to enhance patient care. This study aims to evaluate the predictive accuracy of NEWS2 in determining mortality among Indian patients, aiding in proper risk stratification and improving the quality of care.  Materials and methods This prospective observational study was conducted over six months in the emergency department of a South Indian tertiary care hospital. Out of 150 patients screened, 101 (n = 101) were included after obtaining informed consent and meeting the inclusion criteria. The study aimed to assess the predictive accuracy of NEWS2 and analyze the distribution of its individual physiological parameters. Results The study showed a significant difference in NEWS2 scores between survivors (n = 87, mean 4.36, SD 2.698) and non-survivors (n = 14, mean 13.14, SD 1.406), highlighting its potential as a valuable tool for risk stratification. Of the 101 patients, 86.1% (n = 87) survived and 13.9% (n = 14) died. Survivors (n = 87) had a lower mean NEWS2 score of 4.36 ± 2.698, whereas non-survivors (n = 14) had a significantly higher mean score of 13.14 ± 1.406. Conclusion Our findings demonstrate that higher NEWS2 scores at admission are strongly correlated with mortality rates. These results validate NEWS2's effectiveness in identifying patients at risk of deterioration, affirming its role as a critical tool for early intervention in emergency care.

The effect of serum cortisol level on the outcomes of Persistent Inflammation, Immunosuppression and Catabolism Syndrome patients in the intensive care unit

Objective

This study sought to elucidate the potential association between serum cortisol level and clinical outcomes in patients diagnosed with Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PIICS).

Methods

This prospective observational study, initiated in January 2023 and concluded in July 2023 enrolled 42 patients diagnosed with PIICS admitted to the intensive care unit (ICU) at Training and Research Hospital. For the purpose of analysis, serum cortisol levels were categorized as low (<15 μg/dL) and high (>15 μdL). To facilitate data organization and subsequent analysis, measurements were categorized into three time intervals following ICU admission: T1 (days 14-21), T2 (days 21-28), and T3 (days >28). Statistical analysis was performed using IBM-SPSS 28. A significance level of p < 0.05 was set to determine statistically significant differences between groups.

Results

Cortisol measured at T3 were significantly lower (p < 0.05) compared to T2. In contrast, SOFA scores were significantly higher (p < 0.05). No statistically significant differences were observed between the low and high cortisol level groups at T1, T2 and T3 in terms of gender, APACHE-2 score, SOFA score, ICU length of stay (days), duration of mechanical ventilation (days), mortality rate, or mechanical ventilation requirement at discharge. Patients in the low cortisol group at T3 exhibited a significantly higher mean age compared to those in the high cortisol group (p < 0.05).

Conclusion

Cortisol levels in ICU patients may change over time. That cortisol levels tend to decrease as the length of stay increases, in older patients, and in PIICS patients with elevated SOFA scores.

Plasma-derived extracellular vesicles (EVs) as biomarkers of sepsis in burn patients via label-free Raman spectroscopy

Sepsis following burn trauma is a global complication with high mortality, with ∼60% of burn patient deaths resulting from infectious complications. Diagnosing sepsis is complicated by confounding clinical manifestations of the burn injury, and current biomarkers lack the sensitivity and specificity required for prompt treatment. There is a strong rationale to assess circulating extracellular vesicles (EVs) from patient liquid biopsy as sepsis biomarkers due to their release by pathogens from bacterial biofilms and roles in the subsequent immune response. This study applies Raman spectroscopy to patient plasma-derived EVs for rapid, sensitive, and specific detection of sepsis in burn patients, achieving 97.5% sensitivity and 90.0% specificity. Furthermore, spectral differences between septic and non-septic burn patient EVs could be traced to specific glycoconjugates of bacterial strains associated with sepsis morbidity. This work illustrates the potential application of EVs as biomarkers in clinical burn trauma care and establishes Raman analysis as a fast, label-free method to specifically identify features of bacterial EVs relevant to infection amongst the host background.

Impact of premorbid use of beta‑blockers on survival outcomes of patients with sepsis: A systematic review and meta‑analysis

It is unclear if premorbid use of beta-blockers affects sepsis outcomes. The present systematic review aimed to assess the impact of premorbid beta-blocker use on mortality and the need for mechanical ventilation in patients with sepsis. Embase, Scopus, PubMed and Web of Science were searched for studies comparing outcomes of patients with sepsis based on the premorbid use of beta-blockers. The primary outcome was mortality, and the secondary outcome was the need for mechanical ventilation. The results were reported as odds ratios (ORs) with 95% confidence intervals (CIs). A total of 17 studies including 64,586 patients with sepsis were included. Of them, 8,665 patients received premorbid beta-blockers and 55,921 patients were not treated with premorbid beta-blockers and served as a control group. Pooled analysis of mortality rates revealed that premorbid use of beta-blockers did not affect in-hospital mortality (OR: 0.96; 95% CI: 0.78, 1.18; and I2=63%) but significantly reduced one-month mortality rates (OR: 0.83; 95% CI: 0.72, 0.96; and I2=63%). Combined analysis of adjusted data showed that premorbid beta-blockers were associated with a significant survival advantage in patients with sepsis (OR: 0.81; 95% CI: 0.72, 0.92; and I2=70%). However, there was no effect of premorbid use of beta-blockers on the need for mechanical ventilation (OR: 0.93; 95% CI: 0.66, 1.30); and I2=72%). The results of the present study indicated that premorbid use of beta-blockers is associated with improved survival in patients with sepsis. However, it does not impact the need for mechanical ventilation. The results should be interpreted with caution as the data is observational and unadjusted.

Are Deep Odontogenic Infections Associated With an Increased Risk for Sepsis?

BACKGROUND

Quick Sequential Organ Failure Assessment (qSOFA) is recommended to identify sepsis. Odontogenic infection (OI) can progress to sepsis, causing systematic inflammatory complications or organ failure.

PURPOSE

The purpose of the study was to measure the association between OI location and risk for sepsis at admission.

STUDY DESIGN, SETTING, AND SAMPLE

This retrospective cohort study included subjects treated for OI at Baylor University Medical Center in Dallas, TX, from January 9, 2019 to July 30, 2022. Subjects > 18 years old who were treated under general anesthesia were included. OI limited to periapical, vestibular, buccal, and/or canine spaces were excluded from the sample.

PREDICTOR VARIABLE

The primary predictor variable was OI anatomic location (superficial or deep). Superficial OI infection includes submental, submandibular, sublingual, submasseteric, and/or superficial temporal spaces. Deep OI includes pterygomandibular, deep temporal, lateral pharyngeal, retropharyngeal, pretracheal, and/or prevertebral.

MAIN OUTCOME VARIABLES

The primary outcome variable was risk for sepsis measured using a qSOFA score (0 to 3). A higher score (>0) indicates the patient has a high risk for sepsis.

COVARIATES

Covariates were demographics, clinical, laboratory, and radiological findings, antibiotic route, postoperative endotracheal intubation, tracheostomy, intensive care unit, admission, and length of stay.

ANALYSES

Descriptive and bivariate analyses were performed. A χ2 test was used for categorical variables. The Mann-Whitney U test was used for continuous variables. Statistical significance was P < .05.

RESULTS

The sample was composed of 168 subjects with a mean age of 42.8 ± 21.5 and 69 (48.6%) subjects were male. There were 11 (6.5%) subjects with a qSOFA score > 0. The relative risk of a qSOFA > 0 for a deep OI is 5.4 times greater than for a superficial OI (136 (95.8) versus 21 (80.8%): RR (95% confidence interval): 5.4 (1.51 to 19.27), P = .004). After adjusting for age, sex, American Society of Anesthesiologists score, and involved anatomical spaces, there was a significant correlation between laterality and the number of involved anatomical spaces and qSOFA score (odd ratio = 9.13, 95% confidence interval: 2.48 to 33.55, adjusted P = <.001).

CONCLUSION AND RELEVANCE

The study findings suggest that the OI location is associated with the qSOFA score >0.

The Usefulness of Strain Echocardiography as Diagnostic and Prognostic Index of Cardiac Dysfunction in Septic Patients in Correlation with Cardiac Biomarkers

Background

Compared to standard echocardiography, speckle tracking echocardiography (STE) looks more accurate for the detection of subclinical dysfunction of the myocardium. The aim of our work was to assess the value of STE in the diagnosis of subclinical ventricular dysfunction and as a prognostic index in sepsis patients.

Patients and Methods

An observational prospective study involving critically ill patients aged ≥ 18 years diagnosed with sepsis or septic shock. All patients were subjected to full history-taking, clinical assessment, and scoring system, including Acute Physiology and Chronic Health (APACHE) II score and quick sequential organ failure assessment score. Investigations were done for all patients, including laboratory (complete blood count, C-reactive protein, N-terminal pro-brain natriuretic peptide [NT-proBNP], and troponin-I and serum lactate level), ECG, and echocardiographic examination (conventional and speckle tracking) for measurement of global left ventricular strain.

Results

This study involved 50 patients, nine patients with sepsis and 41 patients with septic shock. Regarding cardiac biomarkers, the mean value of troponin-I was 0.18 ± 0.05 ng/L and for NT-proBNP was 1228.2 ± 832.9 pmol/L. All patients in the study had elevated lactate levels. There was a significant correlation between global longitudinal strain (GLS) and troponin I, NT-proBNP, and lactate levels after 3 days of admission. GLS, lactate, NT-proBNP, troponin levels, and APACHE II Score were significant predictors of mortality with a sensitivity of 76.5%, 88.2%, 88.2%, 76.5%, and 88.2%, respectively.

Conclusion

GLS measured by speckle tracking echocardiography looks to be a sensitive diagnostic tool for early detection of subclinical left ventricular dysfunction in patients with sepsis in addition to be a sensitive predictor of in-hospital mortality.

Time‑dependent ROC curve analysis to determine the predictive capacity of seven clinical scales for mortality in patients with COVID‑19: Study of a hospital cohort with very high mortality

Clinical data from hospital admissions are typically utilized to determine the prognostic capacity of Coronavirus disease 2019 (COVID-19) indices. However, as disease status and severity markers evolve over time, time-dependent receiver operating characteristic (ROC) curve analysis becomes more appropriate. The present analysis assessed predictive power for death at various time points throughout patient hospitalization. In a cohort study involving 515 hospitalized patients (General Hospital Number 1 of Mexican Social Security Institute, Colima, Mexico from February 2021 to December 2022) with COVID-19, seven severity indices [Pneumonia Severity Index (PSI) PaO2/FiO2 arterial oxygen pressure/fraction of inspired oxygen (Kirby index), the Critical Illness Risk Score (COVID-GRAM), the National Early Warning Score 2 (NEWS-2), the quick Sequential Organ Failure Assessment score (qSOFA), the Fibrosis-4 index (FIB-4) and the Viral Pneumonia Mortality Score (MuLBSTA were evaluated using time-dependent ROC curves. Clinical data were collected at admission and at 2, 4, 6 and 8 days into hospitalization. The study calculated the area under the curve (AUC), sensitivity, specificity, and predictive values for each index at these time points. Mortality was 43.9%. Throughout all time points, NEWS-2 demonstrated the highest predictive power for mortality, as indicated by its AUC values. PSI and COVID-GRAM followed, with predictive power increasing as hospitalization duration progressed. Additionally, NEWS-2 exhibited the highest sensitivity (>96% in all periods) but showed low specificity, which increased from 22.9% at admission to 58.1% by day 8. PSI displayed good predictive capacity from admission to day 6 and excellent predictive power at day 8 and its sensitivity remained >80% throughout all periods, with moderate specificity (70.6-77.3%). COVID-GRAM demonstrated good predictive capacity across all periods, with high sensitivity (84.2-87.3%) but low-to-moderate specificity (61.5-67.6%). The qSOFA index initially had poor predictive power upon admission but improved after 4 days. FIB-4 had a statistically significant predictive capacity in all periods (P=0.001), but with limited clinical value (AUC, 0.639-0.698), and with low sensitivity and specificity. MuLBSTA and IKIRBY exhibited low predictive power at admission and no power after 6 days. In conclusion, in COVID-19 patients with high mortality rates, NEWS-2 and PSI consistently exhibited predictive power for death during hospital stay, with PSI demonstrating the best balance between sensitivity and specificity.

Outcomes of patients with pneumatosis intestinalis and/or portal venous gas: a study of factors associated with survival and surgical intervention

BACKGROUNDS

This study investigated the incidence of, and mortality and management outcomes following, pneumatosis intestinalis and/or portal venous gas on computed tomography.

METHODS

A retrospective study of patients identified with pneumatosis intestinalis and/or portal venous gas on computed tomography at a quaternary centre (2013-2021) was performed. Data relating to clinical presentation (including quick sequential organ failure assessment score), co-morbidities (Charlson Comorbidity Index), biochemical data (including peak lactate level), and radiological findings, were obtained. Factors associated with these were assessed by logistic regression.

RESULTS

From 16 428 scans, 107 (0.65%) demonstrated pneumatosis intestinalis and/or portal venous gas (mean 65.2 years [SD 15.2]; 60 [56%] male). Overall, 37 patients (35%) had both findings present. Thirty-three deaths (31%) were recorded. Fifty-four patients (51%) underwent surgery. Death was associated with quick sequential organ failure assessment score (score 1: OR 5.71, 95% CI 1.31-24.87; score 2: OR 10.00, 95% CI 1.94-51.54), Charlson Comorbidity Index ≥5 (OR 2.86, 95% CI 1.19-6.84), peak lactate ≥2.6 mmol/L (OR 14.53, 95% CI 4.39-48.14), and concomitant pneumatosis intestinalis and portal venous gas (OR 8.25, 95% CI 3.04-22.38). The presence of free peritoneal fluid (OR 3.23, 95% CI 1.44-7.28) or perforated viscus (OR 5.10, 95% CI 1.05-24.85) were the only predictors for surgery.

CONCLUSION

Pneumatosis intestinalis and portal venous gas are rare findings. Despite traditionally portending a poor prognosis, mortality occurred in only one-third of patients. There were clear indicators of mortality viz. sepsis severity, comorbidities, and concomitant pneumatosis intestinalis and portal venous gas. Factors predicting surgery warrant further investigation.

Prognostic accuracy of early warning scores for predicting serious illness and in-hospital mortality in patients with COVID-19

A simple bedside triage tool is essential to stratify COVID-19 patients in the emergency department (ED). This study aimed to identify an early warning score (EWS) that could best predict the clinical outcomes in COVID-19 patients. Data were obtained from medical records of 219 laboratory-confirmed COVID-19 positive patients. We calculated 13 EWSs based on the admission characteristics of the patients. Receiver operating characteristic (ROC) curve analysis was used to assess the performance of the scores in predicting serious illness and in-hospital mortality. The median patient age was 51 (38, 60) years, and 25 (11.4%) patients died. Among patients admitted with mild to moderate illness (n = 175), 61 (34.9%) developed serious illness. Modified National Early Warning Score (m-NEWS) (AUROC 0.766; 95% CI: 0.693, 0.839) and Rapid Emergency Medicine Score (REMS) (AUROC 0.890; 95% CI: 0.818, 0.962) demonstrated the highest AUROC point estimates in predicting serious illness and in-hospital mortality, respectively. Both m-NEWS and REMS demonstrated good accuracy in predicting both the outcomes. However, no significant difference was found between m-NEWS (p = 0.983) and REMS (p = 0.428) as well as some other EWSs regarding the AUROCs in predicting serious illness and in-hospital mortality. We propose m-NEWS could be used as a triage score to identify COVID-19 patients at risk of disease progression and death especially in resource-poor settings because it has been explicitly developed for risk stratification of COVID-19 patients in some countries like China and Italy. However, this tool needs to be validated by further large-scale prospective studies.

Procalcitonin and qSOFA as a Marker of Mortality in Sepsis

BACKGROUND

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The qSOFA and procalcitonin are currently used for both diagnostic as well as prognostic purposes.

OBJECTIVE

To explore the combined use of day one procalcitonin level and qSOFA scores for prognostication of sepsis-related mortality.

DESIGN

This was a prospective observational study.

PARTICIPANTS

All patients who fulfilled the inclusion criteria for sepsis with an age of more than 16 years were enrolled in the study.

RESULTS

In this study of 211 patients, 15 patients died (7.1%) during hospital stay. Among the 15 patients who died, the highest mortality of 29.4% was seen in patients with qSOFA of "3", qSOFA of "2" had a mortality of 12.8%, qSOFA of "1" had a mortality of 1% and qSOFA of "0" had zero mortality. In this study, procalcitonin had a statistically significant positive correlation/association with both qSOFA and mortality.

CONCLUSION

The qSOFA and procalcitonin at presentation to the emergency department in septic patients have a significant correlation with mortality in patients hospitalized with sepsis. Obtaining these two parameters at presentation will help in managing aggressively these patients who at presentation have higher qSOFA and procalcitonin levels.

Quick Sequential Organ Failure Assessment Score, Lactate, and Neutrophil-Lymphocyte Ratio Help in Diagnosis and Mortality Prediction during Golden Hour of Sepsis in Emergency Department

Introduction

Sepsis is a life-threatening condition with a very narrow golden period in which confirmatory diagnosis may change the outcome dramatically. No confirmatory biomarker is available till date for early diagnosis of sepsis. This study aimed to evaluate the combined and independent role of quick sequential organ failure assessment (qSOFA) score, lactate, and neutrophil-lymphocyte ratio (NLR) in diagnosis and mortality prediction in early sepsis.

Methods

This was a hospital-based, single-center, prospective cohort study conducted in a tertiary care institute, Karnataka, India. Three hundred adult sepsis patients were recruited during 10-month period, and demographic data, qSOFA score, lactate, NLR, and culture samples were collected in ED within 1 h of admission. Outcome groups (survivor and nonsurvivor) were statistically analyzed with relative frequencies (%), median, mean ± standard deviation with 95% confidence interval (CI), univariate, bivariate, and multivariate logistic regression analysis, and Receiver -operating characteristic curve (ROC) curve to test the predictive ability of initial levels of three biomarkers.

Results

Sepsis was more prevalent among middle-aged male patients. Male gender (odds ratio [OR], 6.9; 95% CI: 1.61-30.1), qSOFA (OR, 154; 95% CI: 15-1565), and lactate (OR, 1.36; 95% CI: 22-833) show 97% (area under the curve) predictive accuracy of the model for sepsis on bivariate and multivariate logistic regression analysis. A significant rise in NLR was a poor outcome indicator on univariate analysis (P = 0.773).

Conclusion

All three biomarkers are good outcome predictors whereas qSOFA and lactate have diagnostic significance in early sepsis. These markers can be used for patient triaging, minimizing culture report dependence for treatment and ultimately the outcome.

The prognostic utility of prehospital qSOFA in addition to emergency department qSOFA for sepsis in patients with suspected infection: A retrospective cohort study

BACKGROUND

The quick sequential organ failure assessment (qSOFA) was widely used to estimate the risks of sepsis in patients with suspected infection in the prehospital and emergency department (ED) settings. Due to the insufficient sensitivity of qSOFA on arrival at the ED (ED qSOFA), the Surviving Sepsis Campaign 2021 recommended against using qSOFA as a single screening tool for sepsis. However, it remains unclear whether the combined use of prehospital and ED qSOFA improves its sensitivity for identifying patients at a higher risk of sepsis at the ED.

METHODS

We retrospectively analyzed the data from the ED of a tertiary medical center in Japan from April 2018 through March 2021. Among all adult patients (aged ≥18 years) transported by ambulance to the ED with suspected infection, we identified patients who were subsequently diagnosed with sepsis based on the Sepsis-3 criteria. We compared the predictive abilities of prehospital qSOFA, ED qSOFA, and the sum of prehospital and ED qSOFA (combined qSOFA) for sepsis in patients with suspected infection at the ED.

RESULTS

Among 2,407 patients with suspected infection transported to the ED by ambulance, 369 (15%) patients were subsequently diagnosed with sepsis, and 217 (9%) died during hospitalization. The sensitivity of prehospital qSOFA ≥2 and ED qSOFA ≥2 were comparable (c-statistics for sepsis [95%CI], 0.57 [0.52-0.62] vs. 0.55 [0.50-0.60]). However, combined qSOFA (cutoff, ≥3 [max 6]) was more sensitive than ED qSOFA (cutoff, ≥2) for identifying sepsis (0.67 [95%CI, 0.62-0.72] vs. 0.55 [95%CI, 0.50-0.60]). Using combined qSOFA, we identified 44 (12%) out of 369 patients who were subsequently diagnosed with sepsis, which would have been missed using ED qSOFA alone.

CONCLUSIONS

Using both prehospital and ED qSOFA could improve the screening ability of sepsis among patients with suspected infection at the ED.

Efficacy of multiple Biomarkers: NGAL, KIM1, Cystatin C and IL18 in predicting pregnancy related acute kidney injury

Objective

Several biomarkers like NGAL, KIM-1, IL-18, and Cystatin C has been previously reported as reliable marker to predict AKI. However, their predictive accuracy varies widely. We aim to observe the efficacy of multiple markers, NGAL, KIM-1, Cystatin C and IL-18, in obstetric population who are at risk of developing AKI.

Methods

This prospective study was carried out between June 2021 to March 2022 at Department of Obstetrics & Gynecology Unit II, Ruth Pfau KM Civil Hospital and Sindh Institute of Urology & Transplant (SIUT), Karachi Pakistan. On women brought to OBGYN-ER with the diagnosis of hemorrhage (antepartum and postpartum), hypertension (pre-eclampsia and eclampsia) and sepsis. The urine samples and 3cc blood was collected at the time of admission, blood sample processed for biochemistry at time of admission and repeat blood samples for serum creatinine at 24 and 48 hours. Urine was stored at -80ºC and later evaluated for NGAL, KIM-1, Cystatin C and IL-18. Serum Cystatin C was also processed for the time zero sample. The biomarkers were tested using ELISA assays.

Results

A total of 149 women were included in the study, 83% of these women were non-booked. Twenty-six (17%) women developed AKI. Serum Cystatin C, urinary Cystatin C and urinary NGAL were found significantly raised in women who developed AKI. While KIM-1 and IL-18 were not raised to statistical significance in this population. However, urinary KIM-1 along with urinary Cystatin C were significantly raised in women with positive quick sequential organ failure assessment (qSOFA).

Conclusion

This study validates the use of serum and urinary Cystatin C and urinary NGAL as highly predictable biomarkers for the development of AKI and nullifies urinary IL-18 and KIM-1 in this regard.

Effect of a tailored sepsis treatment protocol on patient outcomes in the Tikur Anbessa Specialized Hospital, Ethiopia: results of an interrupted time series analysis

BACKGROUND

Despite improvement, sepsis mortality rates remain high, with an estimated 11 million sepsis-related deaths globally in 2017 (Rudd et. al, Lancet 395:200-211, 2020). Low- and middle-income countries (LMICs) are estimated to account for 85% of global sepsis mortality; however, evidence for improved sepsis mortality in LMICs is lacking. We aimed to improve sepsis care and outcomes through development and evaluation of a sepsis treatment protocol tailored to the Tikur Anbessa Specialized Hospital Emergency Department, Ethiopia, context.

METHODS

We employed a mixed methods design, including an interrupted times series study, pre-post knowledge testing, and process evaluation. The primary outcome was the proportion of patients receiving appropriate sepsis care (blood culture collection before antibiotics and initiation of appropriate antibiotics within 1 h of assessment). Secondary outcomes included time to antibiotic administration, 72-h sepsis mortality, and 90-day all-cause mortality. Due to poor documentation, we were unable to assess our primary outcome and time to antibiotic administration. We used segmented regression with outcomes as binomial proportions to assess the impact of the intervention on mortality. Pre-post knowledge test scores were analyzed using the Student's t-test to compare group means for percentage of scenarios with correct diagnosis.

RESULTS

A total of 113 and 300 patients were enrolled in the pre-implementation and post-implementation phases respectively. While age and gender were similar across the phases, a higher proportion (31 vs. 57%) of patients had malignancies in the post-implementation phase. We found a significant change in trend between the phases, with a trend for increasing odds of survival in the pre-implementation phase (OR 1.24, 95% CI 0.98-1.56), and a shift down, with odds of survival virtually flat (OR 0.95, 95% CI. 0.88-1.03) in the post-implementation phases for 72-h mortality, and trends for survival pre- and post-implementation are virtually flat for 90-day mortality. We found no significant difference in pre-post knowledge test scores, with interpretation limited by response rate. Implementation quality was negatively impacted by resource challenges.

CONCLUSION

We found no improvement in sepsis outcomes, with a trend for increasing odds of survival lost post-implementation and no significant change in knowledge pre- and post-implementation. Variable availability of resources was the principal barrier to implementation.

TRIAL REGISTRATION

Open Science Framework osf.io/ju4ga . Registered June 28, 2017.

Trends in bacterial sepsis incidence and mortality in France between 2015 and 2019 based on National Health Data System (Système National des données de Santé (SNDS)): a retrospective observational study

OBJECTIVE

This study aims to provide a case definition of sepsis of presumed bacterial aetiology based on 10th revision of the International Classification of Diseases (ICD-10) codes, to assess trends in sepsis incidence and mortality between 2015 and 2019 in France, and to describe the characteristics of affected patients and hospital stays.

DESIGN

Nationwide, population-based, retrospective observational study.

SETTING

Metropolitan France between 2015 and 2019.

PARTICIPANTS

Between 2015 and 2019, 1 224 433 patients with sepsis of presumed bacterial aetiology were selected from the French National Hospital Discharge Database (Programme de Médicalisation des Systèmes d'Information) and were identified from corresponding ICD-10 codes for explicit sepsis or implicit sepsis.

MAIN OUTCOMES MEASURES

Annual overall and age-specific and gender-specific incidence and 95% CI, as well as trends in sepsis incidence and mortality, were estimated. Comorbidities, length of hospital stay and outcomes were described.

RESULTS

The sex-standardised and age-standardised incidence per 100 000 (95% CI) increased from 357 (356.0 to 359.0) in 2015 to 403 (401.9 to 405.0) in 2019 and remained higher for males compared with females. Children under 1 year and patients over 75 years consistently had the highest incidence. The most common comorbidities were cancer and chronic heart failure. The median hospital length of stay was 12 days. Most patients came from home, but only half returned home after their hospital stay and approximately 15% were discharged to long-term care. In-hospital mortality was about 25% and declined along the study period.

CONCLUSIONS

Medico-administrative databases can be used to provide nationwide estimates of the in-hospital burden of bacterial sepsis. The results confirm the high burden of sepsis in France. These data should be complemented by estimating the additional burden associated with fungal and viral infections during the COVID-19 pandemic.

Association of Serum Calprotectin Concentrations with Mortality in Critically Ill and Septic Patients

Background: Calprotectin is present in the cytosol of neutrophil granulocytes and released upon activation. Fecal calprotectin is applied in the clinical management of inflammatory bowel disease whereas serum calprotectin has been discussed as a biomarker in inflammatory disorders. However, its long-term prognostic relevance in critical illness remains unclear. Our aim was to investigate serum calprotectin concentrations as a prognostic biomarker in critically ill and septic patients. Methods: Serum calprotectin concentrations were analyzed in 165 critically ill patients (108 with sepsis, 57 without sepsis) included in our observational study. Patients were enrolled upon admission to the medical intensive care unit (ICU) of the RWTH Aachen University Hospital. Calprotectin concentrations were compared to 24 healthy controls and correlated with clinical parameters, therapeutic interventions, and survival. Results: Serum calprotectin concentrations were significantly increased in ICU patients as well as in septic patients compared to respective controls (p < 0.001 for ICU patients and p = 0.001 for septic patients). Lower calprotectin concentrations were measured in patients with comorbidities i.e., coronary artery disease. Calprotectin concentrations strongly correlated with the C-reactive protein (p < 0.001) and were closely associated to parameters of mechanical ventilation (i.a. inspiratory oxygen fraction, FiO2; p < 0.001). The overall survival was significantly impaired in septic patients with high baseline calprotectin concentrations (p = 0.036). However, patients with increasing calprotectin serum concentrations within the first week of ICU admission showed an improved overall survival (p = 0.009). Conclusions: In summary, serum calprotectin concentrations are significantly increased in critically ill patients with sepsis. High calprotectin concentrations at ICU admission predict long-term mortality risk, whereas increasing calprotectin concentrations are associated with a favorable long-term outcome.