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Kannan A, Jindal A. Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score! Indian J Crit Care Med 2023; 27:150. [PMID: 36865520 PMCID: PMC9973053 DOI: 10.5005/jp-journals-10071-24401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023] Open
Abstract
How to cite this article: Kannan A, Jindal A. Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score! Indian J Crit Care Med 2023;27(2):150.
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Affiliation(s)
- Abinaya Kannan
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Atul Jindal
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India,Atul Jindal, Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India, Phone: +91 8224014667, e-mail:
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Clerk AM. Sepsis in Intensive Care Unit: Which Score Predicts Better about Outcome? Indian J Crit Care Med 2022; 26:1072-1073. [PMID: 36876204 PMCID: PMC9983663 DOI: 10.5005/jp-journals-10071-24337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Clerk AM. Sepsis in Intensive Care Unit: Which Score Predicts Better about Outcome? Indian J Crit Care Med 2022;26(10):1072-1073.
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Affiliation(s)
- Anuj M Clerk
- Department of Intensive Care, Sunshine Global Hospitals, Surat, Gujarat, India
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Dronamraju S, Agrawal S, Kumar S, Acharya S, Gaidhane S, Wanjari A, Jaiswal P, Bawiskar N. Comparison of PIRO, APACHE IV, and SOFA Scores in Predicting Outcome in Patients with Sepsis Admitted to Intensive Care Unit: A Two-year Cross-sectional Study at Rural Teaching Hospital. Indian J Crit Care Med 2022; 26:1099-1105. [PMID: 36876200 PMCID: PMC9983679 DOI: 10.5005/jp-journals-10071-24323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/03/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Though many scoring systems for prognostication of sepsis are available in the intensive care set-up, predisposition, insult, response, and organ dysfunction (PIRO) score helps to assess each patient and evaluate response to therapy. There are few studies comparing the efficacy of PIRO score with other sepsis scores. Hence, our study was planned to compare PIRO score with acute physiology and chronic health evaluation IV (APACHE IV) score and sequential (sepsis-related) organ failure assessment (SOFA) score in predicting the mortality of intensive care patients with sepsis. Materials and methods This prospective cross-sectional study was done in the medical intensive care unit (MICU) from August 2019 to September 2021 among patients above 18 years of age with the diagnosis of sepsis. Predisposition, insult, response, and organ dysfunction score, SOFA score, and APACHE IV score on admission and at day 3 were calculated and statistically analyzed in the terms of outcome. Results A total of 280 patients fulfilling the inclusion criteria were included in the study, the mean age was 59.38 ± 15.9 years. There was a significant association of PIRO score, SOFA score, and APACHE IV score on admission and at day 3 with mortality (p-value <0.05). Among all three parameters, the PIRO score on admission and at day 3 was the best predictor of mortality at cut-off points of >14 and >16 with 92.50% and 96.50% chances of correctly predicting mortality, respectively. Conclusion Predisposition, insult, response, and organ dysfunction score can be considered as a strong predictor of prognostication of patients with sepsis admitted to the intensive care unit (ICU) and predict mortality. It should be routinely used as it is a simple and comprehensive score. How to cite this article Dronamraju S, Agrawal S, Kumar S, Acharya S, Gaidhane S, Wanjari A, et al. Comparison of PIRO, APACHE IV, and SOFA Scores in Predicting Outcome in Patients with Sepsis Admitted to Intensive Care Unit: A Two-year Cross-sectional Study at Rural Teaching Hospital. Indian J Crit Care Med 2022;26(10):1099-1105.
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Affiliation(s)
- Sameera Dronamraju
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Sachin Agrawal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Shilpa Gaidhane
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Anil Wanjari
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Praraj Jaiswal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Nipun Bawiskar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
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Shankar T, Kaeley N, Nagasubramanyam V, Bahurupi Y, Bairwa A, Infimate DJL, Asokan R, Shukla K, Galagali SS. An Evaluation of the Predictive Value of Sepsis Patient Evaluation in the Emergency Department (SPEED) Score in Estimating 28-Day Mortality Among Patients With Sepsis Presenting to the Emergency Department: A Prospective Observational Study. Cureus 2022; 14:e22598. [PMID: 35355547 PMCID: PMC8957815 DOI: 10.7759/cureus.22598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective Sepsis is a life-threatening medical emergency and a significant cause of mortality. Risk stratification scores for sepsis can be unsuitable for use in the emergency department (ED) due to their complexity, and an appropriate solution has yet to be found. In this study, the predictive value of the Sepsis Patient Evaluation in the Emergency Department (SPEED) score in estimating 28-day mortality was assessed among patients with sepsis presenting to the ED, in order to determine its suitability as an efficient risk stratification system. Materials and methods This was a single-center, prospective observational study conducted at an urban tertiary care center. We included patients presenting to the ED with suspected or confirmed sepsis who met the inclusion and exclusion criteria of our study. The patients were evaluated with the following scoring systems on arrival: the SPEED score; Predisposition, Infection, Response, and Organ dysfunction (PIRO) score; and Mortality in Emergency Department Sepsis (MEDS) score; the patients were subsequently followed up on the 28th day to record the final outcomes with regard to mortality and discharge rates. Results This study included 127 patients in total. The median age of the study population was 49 years, and the 28-day mortality rate was 50.4%. The area under the receiver operating characteristic (AUROC) curve for the SPEED score for predicting mortality was 0.899 (95% CI: 0.847-0.951). In comparison, the AUROC for MEDS and PIRO scores was 0.857 (95% CI: 0.793-0.92) and 0.895 (95% CI: 0.838-0.951), respectively. Based on the DeLong test, no significant difference was found in the diagnostic performances with respect to these scores. Conclusion The SPEED score is a simple and handy parameter that can be used for the early and appropriate risk stratification of patients with sepsis in the ED.
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Capan M, Schubel LC, Pradhan I, Catchpole K, Shara N, Arnold R, Schwartz JS, Seagull J, Miller K. Display and perception of risk: Analysis of decision support system display and its impact on perceived clinical risk of sepsis-induced health deterioration. Health Informatics J 2022; 28:14604582211073075. [DOI: 10.1177/14604582211073075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite acknowledging the value of clinical decision support systems (CDSS) in identifying risk for sepsis-induced health deterioration in-hospitalized patients, the relationship between display features, decision maker characteristics, and recognition of risk by the clinical decision maker remains an understudied, yet promising, area. The objective of this study is to explore the relationship between CDSS display design and perceived clinical risk of in-hospital mortality associated with sepsis. The study utilized data collected through in-person experimental sessions with 91 physicians from the general medical and surgical floors who were recruited across 12 teaching hospitals within the United States. Results of descriptive and statistical analyses provided evidence supporting the impact of display configuration and clinical case severity on perceived risk associated with in-hospital mortality. Specifically, findings showed that a high level of information (represented by the Predisposition, Infection, Response and Organ dysfunction (PIRO) score) and Figure display (as opposed to Text or baseline) increased awareness to recognizing the risk for in-hospital mortality of hospitalized sepsis patients. A CDSS display that synthesizes the optimal features associated with information level and design elements has the potential to enhance the quantification and communication of clinical risk in complex health conditions beyond sepsis.
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Affiliation(s)
- Muge Capan
- LeBow College of Business, Drexel University, Philadelphia, PA, USA
| | - Laura C Schubel
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, DC, USA
| | - Ishika Pradhan
- LeBow College of Business, Drexel University, Philadelphia, PA, USA
| | - Ken Catchpole
- Clinical Practice and Human Factors, Medical University of South Carolina, Charleston, SC, USA
| | - Nawar Shara
- Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Washington, DC, USA
| | - Ryan Arnold
- Emergency Medicine, Santa Ynez Valley Cottage Hospital, Santa Barbara, CA, USA
| | - J Sanford Schwartz
- Department of Health Care Management, University of Pennsylvania, Philadelphia, PA, USA
| | - Jake Seagull
- MedStar Health Research Institute, Hyattsville, MD, USA
| | - Kristen Miller
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, DC, USA
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Cardoso T, Rodrigues PP, Nunes C, Almeida M, Cancela J, Rosa F, Rocha-Pereira N, Ferreira I, Seabra-Pereira F, Vaz P, Carneiro L, Andrade C, Davis J, Marçal A, Friedman ND. Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients. Ann Intensive Care 2021; 11:180. [PMID: 34950977 PMCID: PMC8702585 DOI: 10.1186/s13613-021-00966-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/04/2021] [Indexed: 11/17/2022] Open
Abstract
Background Stratifying patients with sepsis was the basis of the predisposition, infection, response and organ dysfunction (PIRO) concept, an attempt to resolve the heterogeneity in treatment response. The purpose of this study is to perform an independent validation of the PIRO staging system in an international cohort and explore its utility in the identification of patients in whom time to antibiotic treatment is particularly important. Methods Prospective international cohort study, conducted over a 6-month period in five Portuguese hospitals and one Australian institution. All consecutive adult patients admitted to selected wards or the intensive care, with infections that met the CDC criteria for lower respiratory tract, urinary, intra-abdominal and bloodstream infections were included. Results There were 1638 patients included in the study. Patients who died in hospital presented with a higher PIRO score (10 ± 3 vs 8 ± 4, p < 0.001). The observed mortality was 3%, 15%, 24% and 34% in stage I, II, III and IV, respectively, which was within the predicted intervals of the original model, except for stage IV patients that presented a lower mortality. The hospital survival rate was 84%. The application of the PIRO staging system to the validation cohort resulted in a positive predictive value of 97% for stage I, 91% for stage II, 85% for stage III and 66% for stage IV. The area under the receiver operating characteristics curve (AUROC) was 0.75 for the all cohort and 0.70 if only patients with bacteremia were considered. Patients in stage III and IV who did not have antibiotic therapy administered within the desired time frame had higher mortality rate than those who have timely administration of antibiotic. Conclusions To our knowledge, this is the first external validation of this PIRO staging system and it performed well on different patient wards within the hospital and in different types of hospitals. Future studies could apply the PIRO system to decision-making about specific therapeutic interventions and enrollment in clinical trials based on disease stage. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00966-7.
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Affiliation(s)
- T Cardoso
- Intensive Care Unit (UCIP) and Hospital Infection Control Committee, Hospital de Santo António, Oporto University Hospital Center, University of Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal.
| | - P P Rodrigues
- Department of Community Medicine, Information and Health Decision Sciences & CINTESIS, Faculty of Medicine, University of Porto, Rua Dr. Plácido Costa, s/n, 4200-450, Porto, Portugal
| | - C Nunes
- Intensive Care Unit and Hospital Infection Control Committee, Hospital de Bragança, Northeastern Local Health Unit, Av. Abade Baçal, 5301-852, Bragança, Portugal
| | - M Almeida
- Neurocritical Care Unit and Hospital Infection Control Committee, Hospital de São Marcos, Sete Fontes - São Vitor, 4710-243, Braga, Portugal.,Intensive Care Unit (UCIP), Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - J Cancela
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - F Rosa
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - N Rocha-Pereira
- Infectious Diseases Department, São João Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - I Ferreira
- Internal Medicine Department, Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - F Seabra-Pereira
- Intensive Care Unit (UCIP), Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal.,Intensive Care Unit and Internal Medicine Department, Hospital da Prelada, Rua de Sarmento de Beires, 4250-449, Porto, Portugal
| | - P Vaz
- Internal Medicine Department and Hospital Infection Control Committee, Hospital de Bragança, Northeastern Local Health Unit, Av. Abade Baçal, 5301-852, Bragança, Portugal
| | - L Carneiro
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - C Andrade
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal.,Internal Medicine Department, Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - J Davis
- Department of Renal Medicine, Barwon Health, Geelong, VIC, 3220, Australia
| | - A Marçal
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal.,Internal Medicine Department, Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - N D Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, VIC, 3220, Australia
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Kumar S, Dronamraju S, Acharya S, Jaiswal P, Hulkoti V, Talwar D, Hepat S, Vs I, Shah D, Bhagawati J. COVID-PIRO (Predisposition, Insult, Response, Organ Dysfunction) Score: A Reliable Predictor of Outcomes in COVID-19 Patients Admitted in Intensive Care Unit. Cureus 2021; 13:e18960. [PMID: 34812327 PMCID: PMC8604422 DOI: 10.7759/cureus.18960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction To measure the severity of sepsis and pneumonia in adult patients with coronavirus disease 2019 (COVID-19), the PIRO model (predisposition, insult, response, organ dysfunction) was adopted as a scoring system. In this study, the PIRO model was modified to classify the severity of pneumonia in adults and predict mortality risk infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), admitted to a tertiary intensive care unit (ICU) in central rural India. Method This prospective, observational study was conducted in the Department of Medicine, in rural medical college at Wardha, Maharashtra, India from May 2020 to May 2021. Patients with reverse transcription-polymerase chain reaction (RT-PCR) positive for COVID-19 and whose age was more than 18 years admitted in the intensive care unit were included in the study. Results A total of 240 patients were included in the analysis having mean age of 60.27 ± 15.3 years. Number of deaths were 115 out of 240 (48.3%). Mean ICU stay was 9.09 ± 6.34 days. PIRO score ≤14.5 had a mortality rate of 1.25% as compared to the group having PIRO>14.5 which had mortality of 27.5%, with a cure rate of 26.25% and 5% respectively in both groups (p = 0.0001). Conclusion COVID-PIRO modified PIRO score was a highly sensitive and specific model in predicting in-hospital mortality but it is moderately sensitive in predicting ICU stay.
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Affiliation(s)
- Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Sameera Dronamraju
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Praraj Jaiswal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Vidyashree Hulkoti
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Dhruv Talwar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Sanyukta Hepat
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Irhsad Vs
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Divit Shah
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Jahnabi Bhagawati
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
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Caramello V, Macciotta A, Beux V, De Salve AV, Ricceri F, Boccuzzi A. Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department. Med Intensiva 2021; 45:459-469. [PMID: 34717884 DOI: 10.1016/j.medine.2020.04.012] [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: 10/17/2019] [Accepted: 04/09/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital. DESIGN, SETTING AND PARTICIPANTS We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA. RESULTS Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716-0.824) vs. AUC 0.699 (0.64-0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715-0.819) vs AUC 0.709 (0.656-0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71-0.82) at 30 d, AUC 0.754 (0.701-0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA. CONCLUSIONS We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.
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Affiliation(s)
- V Caramello
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy.
| | - A Macciotta
- Department of Clinical and Biological Science, University of Turin, Orbassano, TO, Italy
| | - V Beux
- University of Turin, Italy
| | - A V De Salve
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
| | - F Ricceri
- Department of Clinical and Biological Science, University of Turin, Orbassano, TO, Italy; Unit of Epidemiology, Regional Health Service ASL TO3, Grugliasco, TO, Italy
| | - A Boccuzzi
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
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Duque P, Calvo A, Lockie C, Schöchl H. Pathophysiology of Trauma-Induced Coagulopathy. Transfus Med Rev 2021; 35:80-86. [PMID: 34610877 DOI: 10.1016/j.tmrv.2021.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
There is no standard definition for trauma-induced coagulopathy (TIC). However, it could be defined as an abnormal hemostatic response secondary to trauma. The terms "early TIC" and "late TIC" have been recently suggested. "Early TIC" would refer to the inability to achieve effective hemostasis exacerbating an uncontrolled bleeding in a shocked patient with ischemia-reperfusion damage (bleeding phenotype) and takes place usually early after injury, whereas "late TIC" would represent a hypercoagulable state after surviving a severe tissue injury, that would contribute to thromboembolic events and multiorgan failure (MOF), (thrombotic phenotype), occurring typically hours after the trauma insult though it could be delayed for days. In addition, severe tissue injury when there is no associated shock could be followed by an early hypercoagulable state, representing an evolutionary maladaptive response of a physiologic mechanism created to increase clot formation and prevent bleeding. Therefore, TIC is not a uniform phenotype, ranging from bleeding to pro-thrombotic profiles. This current concept of TIC is mainly based on the recognition of TIC as a unique clotting disorder following trauma in which alterations in the endothelial function, fibrinolysis regulation and platelet behavior after major trauma are the main cornerstones.
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Affiliation(s)
- Patricia Duque
- Anesthesiology and Critical Care Department, Gregorio Marañon Hospital, Madrid, Spain.
| | - Alberto Calvo
- Anesthesiology and Critical Care Department, Gregorio Marañon Hospital, Madrid, Spain
| | - Christopher Lockie
- Department of Anesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, and Ludwig Boltzmann Institute for experimental and clinical traumatology Vienna, Austria
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, and Ludwig Boltzmann Institute for experimental and clinical traumatology Vienna, Austria
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Molnár G, Gyarmathy VA, Takács J, Sándor S, Kiss B, Fazakas J, Kanizsai PL. Differentiating sepsis from similar groups of symptoms at triage level in emergency care. Physiol Int 2021. [PMID: 33769958 DOI: 10.1556/2060.2021.00005] [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: 02/24/2020] [Accepted: 09/08/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Conditions that have similar initial presentations as sepsis may make early recognition of sepsis in an emergency room (ER) difficult. We investigated whether selected physiologic and metabolic parameters can be reliably used in the emergency department to differentiate sepsis from other disease states that mimic it, such as dehydration and stroke. METHODS Loess regression on retrospective follow-up chart data of patients with sepsis-like symptoms (N = 664) aged 18+ in a large ER in Hungary was used to visualize/identify cutoff points for sepsis risk. A multivariate logistic regression model based on standard triage data was constructed with its corresponding receiver operating characteristic (ROC) curve and compared with another model constructed based on current sepsis guidelines. RESULTS Age, bicarbonate, HR, lactate, pH, and body temperature had U, V, W, or reverse U-shaped associations with identifiable inflexion points, but the cutoff values we identified were slightly different from guideline cutoff values. In contrast to the guidelines, no inflexion points could be observed for the association of sepsis with SBP, DPB, MAP, and RR and therefore were treated as continuous variables. Compared to the guidelines-based model, the triage data-driven final model contained additional variables (age, pH, bicarbonate) and did not include lactate. The data-driven model identified about 85% of sepsis cases correctly, while the guidelines-based model identified only about 70% of sepsis cases correctly. CONCLUSION Our findings contribute to the growing body of evidence for the necessity of finding improved tools to identify sepsis at early time points, such as in the ER.
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Affiliation(s)
- G Molnár
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - V A Gyarmathy
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
- 2EpiConsult Biomedical Consulting and Medical Communications Agency,Dover, DE, USA
- 3Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J Takács
- 4Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
| | - S Sándor
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - B Kiss
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - J Fazakas
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - P L Kanizsai
- 1Faculty of Medicine, Semmelweis University, Budapest, Hungary
- 5Department of Emergency Medicine, Clinical Centre, University of Pécs, Pécs, Hungary
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Nacul L, O'Boyle S, Palla L, Nacul FE, Mudie K, Kingdon CC, Cliff JM, Clark TG, Dockrell HM, Lacerda EM. How Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Progresses: The Natural History of ME/CFS. Front Neurol 2020; 11:826. [PMID: 32849252 PMCID: PMC7431524 DOI: 10.3389/fneur.2020.00826] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 07/01/2020] [Indexed: 12/25/2022] Open
Abstract
We propose a framework for understanding and interpreting the pathophysiology of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) that considers wider determinants of health and long-term temporal variation in pathophysiological features and disease phenotype throughout the natural history of the disease. As in other chronic diseases, ME/CFS evolves through different stages, from asymptomatic predisposition, progressing to a prodromal stage, and then to symptomatic disease. Disease incidence depends on genetic makeup and environment factors, the exposure to singular or repeated insults, and the nature of the host response. In people who develop ME/CFS, normal homeostatic processes in response to adverse insults may be replaced by aberrant responses leading to dysfunctional states. Thus, the predominantly neuro-immune manifestations, underlined by a hyper-metabolic state, that characterize early disease, may be followed by various processes leading to multi-systemic abnormalities and related symptoms. This abnormal state and the effects of a range of mediators such as products of oxidative and nitrosamine stress, may lead to progressive cell and metabolic dysfunction culminating in a hypometabolic state with low energy production. These processes do not seem to happen uniformly; although a spiraling of progressive inter-related and self-sustaining abnormalities may ensue, reversion to states of milder abnormalities is possible if the host is able to restate responses to improve homeostatic equilibrium. With time variation in disease presentation, no single ME/CFS case description, set of diagnostic criteria, or molecular feature is currently representative of all patients at different disease stages. While acknowledging its limitations due to the incomplete research evidence, we suggest the proposed framework may support future research design and health care interventions for people with ME/CFS.
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Affiliation(s)
- Luis Nacul
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- B.C. Women's Hospital and Health Centre, Vancouver, BC, Canada
| | - Shennae O'Boyle
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Luigi Palla
- Department of Medical Statistics, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Global Health, School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Flavio E. Nacul
- Pro-Cardiaco Hospital and Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Kathleen Mudie
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Caroline C. Kingdon
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jacqueline M. Cliff
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Taane G. Clark
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Hazel M. Dockrell
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Eliana M. Lacerda
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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12
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Caramello V, Macciotta A, Beux V, De Salve AV, Ricceri F, Boccuzzi A. Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department. Med Intensiva 2020; 45:S0210-5691(20)30163-7. [PMID: 32591242 DOI: 10.1016/j.medin.2020.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/13/2020] [Accepted: 04/09/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital. DESIGN, SETTING AND PARTICIPANTS We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA. RESULTS Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716-0.824) vs. AUC 0.699 (0.64-0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715-0.819) vs AUC 0.709 (0.656-0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71-0.82) at 30 d, AUC 0.754 (0.701-0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA. CONCLUSIONS We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.
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Affiliation(s)
- V Caramello
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy.
| | - A Macciotta
- Department of Clinical and Biological Science, University of Turin, Orbassano, TO, Italy
| | - V Beux
- University of Turin, Italy
| | - A V De Salve
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
| | - F Ricceri
- Department of Clinical and Biological Science, University of Turin, Orbassano, TO, Italy; Unit of Epidemiology, Regional Health Service ASL TO3, Grugliasco, TO, Italy
| | - A Boccuzzi
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, Orbassano, Turin, Italy
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13
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Alves F, Prata S, Nunes T, Gomes J, Aguiar S, Aires da Silva F, Tavares L, Almeida V, Gil S. Canine parvovirus: a predicting canine model for sepsis. BMC Vet Res 2020; 16:199. [PMID: 32539830 PMCID: PMC7294767 DOI: 10.1186/s12917-020-02417-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 06/08/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Sepsis is a severe condition associated with high prevalence and mortality rates. Parvovirus enteritis is a predisposing factor for sepsis, as it promotes intestinal bacterial translocation and severe immunosuppression. This makes dogs infected by parvovirus a suitable study population as far as sepsis is concerned. The main objective of the present study was to evaluate the differences between two sets of SIRS (Systemic Inflammatory Response Syndrome) criteria in outcome prediction: SIRS 1991 and SIRS 2001. The possibility of stratifying and classifying septic dogs was assessed using a proposed animal adapted PIRO (Predisposition, Infection, Response and Organ dysfunction) scoring system. RESULTS The 72 dogs enrolled in this study were scored for each of the PIRO elements, except for Infection, as all were considered to have the same infection score, and subjected to two sets of SIRS criteria, in order to measure their correlation with the outcome. Concerning SIRS criteria, it was found that the proposed alterations on SIRS 2001 (capillary refill time or mucous membrane colour alteration) were significantly associated with the outcome (OR = 4.09, p < 0.05), contrasting with the 1991 SIRS criteria (p = 0.352) that did not correlate with the outcome. No significant statistical association was found between Predisposition (p = 1), Response (p = 0.1135), Organ dysfunction (p = 0.1135), total PIRO score (p = 0.093) and outcome. To explore the possibility of using the SIRS criteria as a fast decision-making tool, a Fast-and-Frugal tree (FFT) was created with a sensitivity of 92% and a specificity of 29%. CONCLUSION These results suggest that increasing the SIRS criteria specificity may improve their prognostic value and their clinical usefulness. In order to improve the proposed PIRO scoring system outcome prediction ability, more specific criteria should be added, mainly inflammatory and organ dysfunction biomarkers.
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Affiliation(s)
- F. Alves
- Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
| | - S. Prata
- Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
- Veterinary Teaching Hospital, Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
| | - T. Nunes
- Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
- CIISA - Centre for Interdisciplinary Research in Animal Health, Faculty of Veterinary Medicine, University of Lisbon, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
| | - J. Gomes
- Veterinary Teaching Hospital, Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
| | - S. Aguiar
- Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
- CIISA - Centre for Interdisciplinary Research in Animal Health, Faculty of Veterinary Medicine, University of Lisbon, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
| | - F. Aires da Silva
- Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
- CIISA - Centre for Interdisciplinary Research in Animal Health, Faculty of Veterinary Medicine, University of Lisbon, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
| | - L. Tavares
- Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
- CIISA - Centre for Interdisciplinary Research in Animal Health, Faculty of Veterinary Medicine, University of Lisbon, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
| | - V. Almeida
- Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
- CIISA - Centre for Interdisciplinary Research in Animal Health, Faculty of Veterinary Medicine, University of Lisbon, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
| | - S. Gil
- Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
- Veterinary Teaching Hospital, Faculty of Veterinary Medicine, ULisboa, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
- CIISA - Centre for Interdisciplinary Research in Animal Health, Faculty of Veterinary Medicine, University of Lisbon, Av. Universidade Técnica, 1300-477 Lisboa, Portugal
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Kumar S, Jangpangi G, Bhalla A, Sharma N. Role of central venous oxygen saturation in prognostication of patients with severe sepsis and septic shock in emergency medical services. Int J Crit Illn Inj Sci 2019; 9:164-171. [PMID: 31879602 PMCID: PMC6927128 DOI: 10.4103/ijciis.ijciis_19_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/05/2019] [Accepted: 10/16/2019] [Indexed: 01/20/2023] Open
Abstract
Introduction: All the components of early goal-directed therapy, especially central venous oxygen saturation (ScvO2) as one of the endpoints of resuscitation, may not have mortality benefit, more so after results of the Australasian Resuscitation of Sepsis Evaluation, A Randomized Trial of Protocol-Based Care for Early Septic Shock, and The Protocolised Management in Sepsis trials. However, extrapolating results from trials undertaken in the developed world may not be entirely appropriate. Materials and Methods: In this prospective observational study conducted in the emergency medical services, we aimed to find out the mean baseline ScvO2 in a cohort of 200 patients presenting with severe sepsis/septic shock and its prognostic significance. The measurement of ScvO2 was performed by sampling blood from the superior vena cava through the central venous catheter. Results: The mean age of patients was 46.70 ± 17.64 years. The mean ScvO2 at baseline of the study cohort was 65.95 ± 20.70%. Based on initial ScvO2 values, 104 (52%) patients had a lower ScvO2 level, a priori classified as the hypoxic group. Sixty-five (32.5%) patients had an initial ScvO2 level in between 70 and 89%, categorized as normoxic group, and the remaining 31 (15.5%) patients had high ScvO2, leveled as the hyperoxic group. Sixty-six (33%) patients had hospital mortality. Of 104 hypoxemic patients, 28 (26.9%) had hospital mortality. In this group, the mean ScvO2 value in 28 nonsurvivors at baseline and after 6 h of resuscitation was 46.21 ±16.66% and 48.82 ±18.81%, respectively. Twenty-five (38.5%) patients had hospital mortality among 65 patients with baseline ScvO2 value in the normoxic range. Hospital mortality figure stood at 13 (41.9%) patients in the hyperoxic group. Among patients in the hyperoxic group, the mean serum lactate value at baseline in nonsurvivors was 4.52 ± 2.95 mmol/L, significantly higher as compared to the mean value of 2.89 ± 1.55 mmol/L in survivors. The hyperoxia group had higher hospital mortality though it was not statistically significant. Conclusion: The mean baseline ScvO2 was lower in our study cohort. In the hypoxic group, patients with hospital mortality had persistently lower ScvO2 level during the first 6 h of resuscitation. Importantly, higher mortality in the hyperoxic group with high serum lactate emphasizes the point that ScvO2 value should be analyzed along with serum lactate levels as complimentary resuscitation endpoints.
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Affiliation(s)
- Susheel Kumar
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gauri Jangpangi
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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15
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Vafaei A, Heydari K, Hashemi-Nazari SS, Izadi N, Hassan Zadeh H. PIRO, SOFA and MEDS Scores in Predicting One-Month Mortality of Sepsis Patients; a Diagnostic Accuracy Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2019; 7:e59. [PMID: 31875213 PMCID: PMC6905425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Different scoring systems based on clinical and laboratory findings are designed for prediction of short-term mortality of patients with severe sepsis and septic shock. This study aimed to compare the screening performance characteristics of PIRO, SOFA and MEDS Scores in predicting one-month mortality of sepsis patients. METHODS This diagnostic accuracy study was performed on septic shock and severe sepsis patients referring to emergency department of Loghmane Hakim Hospital, Tehran, Iran, from 2017 to 2018. The performance of MEDS, SOFA, and PIRO models in predicting 30-day mortality of patients was evaluated using discrimination and calibration indices. RESULTS 200 patients with the mean age of 71.03±15.59 years were studied (61% male). During the 30 days, 66 patients died (mortality rate=33%). The area under the ROC curve of PIRO, MEDS, and SOFA scores were 0.83 (95% CI=0.78-0.89), 0.94 (95% CI=0.91-0.97) and 0.87 (95% CI=0.81-0.92), respectively. Based on Brier, BrierScaled and Nagelkerke's R2 of the models, the best performance in predicting one-month mortality belonged to MEDS score. C-statistic showed that MEDS score had the highest value in the differentiation between the survived and non-survived cases. CONCLUSION This study showed that MEDS score performs better than PIRO and SOFA scores in predicting one-month mortality of patients with severe sepsis and septic shock.
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Affiliation(s)
- Ali Vafaei
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Kamran Heydari
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Seyed-Saeed Hashemi-Nazari
- Prevention of Cardiovascular Disease Research Center, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Neda Izadi
- Student Research Committee, Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hassan Hassan Zadeh
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding Author: Hassan Hassan Zadeh; Loghmane-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail:
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16
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Saeed K, González Del Castillo J, Backous C, Drevet S, Ferrer R, Gavazzi G, Gluck E, Jensen JU, Kanizsai P, Ruiz-Rodríguez JC, Molnar G, Fazakas J, Umpleby H, Townsend J, Schuetz P. Hot topics on procalcitonin use in clinical practice, can it help antibiotic stewardship? Int J Antimicrob Agents 2019; 54:686-696. [PMID: 31369813 DOI: 10.1016/j.ijantimicag.2019.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/12/2019] [Accepted: 07/21/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Kordo Saeed
- Hampshire Hospitals NHS Foundation Trust and University of Southampton, UK.
| | - Juan González Del Castillo
- Emergency Department, Instituto de Investigación Sanitaria (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Craig Backous
- Swedish Covenant Hospital, Finch University Health Sciences/ The Chicago Medical School, USA
| | - Sabine Drevet
- GREPI EA 7408 University of Grenoble-Alpes, and Geriatric department, University Hospital of Grenoble-Alpes, France
| | - Ricard Ferrer
- Intensive Care Department. Vall d'Hebron University Hospital. Barcelona, Spain & Shock, Organ Dysfunction and Resuscitation Research Group. Vall d'Hebron Institute of Research, Spain
| | - Gaëtan Gavazzi
- GREPI EA 7408 University of Grenoble-Alpes, and Geriatric department, University Hospital of Grenoble-Alpes, France
| | - Eric Gluck
- Swedish Covenant Hospital, Finch University Health Sciences/ The Chicago Medical School, USA
| | - Jens-Ulrik Jensen
- CHIP & PERSIMUNE, Department of Infectious Diseases, Rigshospitalet and University of Copenhagen, Denmark; Section for Respiratory Medicine, Department of Internal Medicine, Herlev-Gentofte Hospital, Hellerup, Denmark
| | | | - Juan Carlos Ruiz-Rodríguez
- Intensive Care Department. Vall d'Hebron University Hospital. Barcelona, Spain & Shock, Organ Dysfunction and Resuscitation Research Group. Vall d'Hebron Institute of Research, Spain
| | - Gyula Molnar
- Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Janos Fazakas
- Semmelweis University, Department of Transplant Surgery, Budapest, Hungary
| | | | - Jennifer Townsend
- Johns Hopkins University, Division of Infectious Diseases, Johns Hopkins Bayview Medical Center, USA
| | - Philipp Schuetz
- Kantonsspital Aarau, Internal Medicine, Aarau, Switzerland; University of Basel, Switzerland
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18
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Implementation of the Sepsis-3 definition in German university intensive care units : A survey. Anaesthesist 2018; 67:647-653. [PMID: 29946857 DOI: 10.1007/s00101-018-0465-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 05/30/2018] [Accepted: 06/11/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND The old definition of sepsis was replaced by Sepsis-3 in February 2016. The new screening diagnostic tools sequential organ failure assessment (SOFA) score and quick SOFA (qSOFA) score were incorporated into the definition. The resulting scientific controversy led to several retrospective and prospective evaluations. In contrast no evaluation of the state of play of national implementation of Sepsis-3 has been conducted so far. OBJECTIVE The aim of this study was to capture the current situation in German academic intensive care units 1 year after the implementation of Sepsis-3. METHODS An internet-based questionnaire consisting of 22 items was developed. The identification of eligible departments was performed by an online search of the homepages of all university hospitals located in Germany. Departments regardless of the discipline with an explicit indication of involvement in intensive care were extracted. The link to the internet-based questionnaire was sent to all identified departments on 22 February 2017 and was accessible for 19 days. RESULTS Out of 259 departments 76 answered the online survey. The response rate was 29.3% from 13 specializations. Anesthesiology, internal medicine and general surgery were the three main participants in this study. The majority of intensive care units (54.75%) treated more than 100 patients with sepsis or septic shock annually and more than 30% treated more than 250 patients. While 76.7% of respondents had a standard operating procedure, 55% of those were based on the Sepsis-3 definition. When asked to rate the usefulness of the Sepsis-3 definition, answers were heterogeneous with a slight tendency towards a higher usefulness and the majority (72.9%) were in favor of Sepsis-3 being included in the national S2K guidelines. CONCLUSION The results demonstrate the heterogeneity of Sepsis-3 implementation in German intensive care units. Sepsis-3 is finding its way but there is a need for standardized implementation.
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Development and External Validation of an Automated Computer-Aided Risk Score for Predicting Sepsis in Emergency Medical Admissions Using the Patient’s First Electronically Recorded Vital Signs and Blood Test Results*. Crit Care Med 2018; 46:612-618. [DOI: 10.1097/ccm.0000000000002967] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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20
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Todd A, Blackley S, Burton JK, Stott DJ, Ely EW, Tieges Z, MacLullich AMJ, Shenkin SD. Reduced level of arousal and increased mortality in adult acute medical admissions: a systematic review and meta-analysis. BMC Geriatr 2017; 17:283. [PMID: 29216846 PMCID: PMC5721682 DOI: 10.1186/s12877-017-0661-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/09/2017] [Indexed: 12/20/2022] Open
Abstract
Background Reduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality. Methods We conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model. Results From 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias). Conclusions Reduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium. Electronic supplementary material The online version of this article (10.1186/s12877-017-0661-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy Todd
- Medicine of the Elderly, NHS Lothian, Royal Infirmary, Edinburgh, Scotland
| | - Samantha Blackley
- Medicine of the Elderly, NHS Lothian, Royal Infirmary, Edinburgh, Scotland
| | - Jennifer K Burton
- Alzheimer Scotland Dementia Research Centre, Edinburgh, Scotland.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences University of Glasgow, Glasgow, Scotland
| | - E Wesley Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education and Clinical Centre (GRECC), Nashville, TN, USA.,Vanderbilt University Medical Centre, Nashville, TN, USA
| | - Zoë Tieges
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - Alasdair M J MacLullich
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland.,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland
| | - Susan D Shenkin
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, Scotland. .,Edinburgh Delirium Research Group, Geriatric Medicine, Edinburgh University, Edinburgh, Scotland.
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Biyikli E, Kayipmaz AE, Kavalci C. Effect of platelet-lymphocyte ratio and lactate levels obtained on mortality with sepsis and septic shock. Am J Emerg Med 2017; 36:647-650. [PMID: 29225011 DOI: 10.1016/j.ajem.2017.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 07/22/2017] [Accepted: 12/05/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Sepsis is a potentially fatal condition with high treatment costs, and is especially common among the elderly population. The emergency management of septic patients has gained importance. OBJECTIVE Herein, we investigated the effect of admission lactate levels and the platelet-lymphocyte ratio (PLR) on the 30-day mortality among patients older than 65years who were diagnosed with sepsis and septic shock according to the qSOFA criteria at our hospital's emergency department. METHODS This observational study was conducted retrospectively. We obtained information regarding patients' demographic characteristics, comorbid conditions, hemodynamic parameters at admission, initial treatment needs at the emergency department. RESULTS 131 patients received a diagnosis of sepsis and septic shock at our emergency department in two years. Among these, 45% (n=59) of the patients died within 30days of admission. Forty (30.5%) patients required mechanical ventilation. There was a significant difference between the survival and non-survival groups with regard to systolic and diastolic blood pressures (p=0.013 and 0.045, respectively). There were significant differences between the two groups with respect to the Glasgow Coma Scale score (p<0.001) and BUN levels (p<0.001). The mortality status according to qSOFA scores was revealed a significant difference between the two groups (p<0.001). CONCLUSION Our results showed that the patients who died within 30days of admission and those who did not had comparable PLR and lactate levels (p=0.821 and 0.120, respectively). We opine that serial lactate measurements would be more useful than a single admission lactate measurement for the prediction of mortality.
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Affiliation(s)
- Ebru Biyikli
- Baskent University Faculty of Medicine, Department of Emergency, Ankara, Turkey
| | - Afsin Emre Kayipmaz
- Baskent University Faculty of Medicine, Department of Emergency, Ankara, Turkey.
| | - Cemil Kavalci
- Baskent University Faculty of Medicine, Department of Emergency, Ankara, Turkey
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Tomescu DR. Let's Talk about Sepsis. ACTA ACUST UNITED AC 2017; 3:139-140. [PMID: 29967886 PMCID: PMC5769910 DOI: 10.1515/jccm-2017-0031] [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)
- Dana R Tomescu
- Department of Anaesthesiology and Critical Care III, Fundeni Clinical Institute, Bucharest, Romania.,University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
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Frattari A, Parruti G, Erasmo R, Guerra L, Polilli E, Zocaro R, Iervese G, Fazii P, Spina T. Recurring septic shock in a patient with blunt abdominal and pelvic trauma: how mandatory is source control surgery?: a case report. J Med Case Rep 2017; 11:49. [PMID: 28222811 PMCID: PMC5320692 DOI: 10.1186/s13256-017-1206-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/07/2017] [Indexed: 12/29/2022] Open
Abstract
Background In critically ill patients with colonization/infection of multidrug-resistant organisms, source control surgery is one of the major determinants of clinical success. In more complex cases, the use of different tools for sepsis management may allow survival until complete source control. Case presentation A 42-year-old white man presented with traumatic hemorrhagic shock. Unstable pelvic fractures led to emergency stabilization surgery. Fever ensued with diarrhea, followed by septic shock. Two weeks later, an abdominal computed tomography scan revealed suprapubic and ischiatic abscesses at surgical sites, as well as dilated bowel. Debridement of both surgical sites, performed with vacuum-assisted closure therapy, yielded isolates of carbapenem and colistin-resistant Klebsiella pneumoniae. Antibiotic treatment was de-escalated after 21 days; 4 days later fever, leukocytosis, hypotension and acute renal failure relapsed. Blood purification techniques were started, for the removal of endotoxin and inflammatory mediators, with sequential hemodialysis. Clinical improvement ensued; blood cultures yielded Candida albicans and multidrug-resistant Acinetobacter baumannii; panresistant carbapenemase-producing Klebsiella pneumoniae grew from wound swabs. In spite of shock reversal, our patient remained febrile, with diarrhea. Control blood cultures yielded Candida albicans, Acinetobacter baumannii and carbapenem-resistant Klebsiella pneumoniae. His abdominal pain increased, paralleled by a right flank palpable mass. Colonoscopy revealed patchy serpiginous ulcers. At exploratory laparotomy, an inflammatory post-traumatic pseudotumor of his right colon was removed. Blood cultures turned negative after surgery. Septic shock, however, relapsed 4 days later. A blood purification cycle was repeated and combination antimicrobial therapy continued. Surgical wounds and blood cultures were persistently positive for carbapenem-resistant Klebsiella pneumoniae. Removal of pelvic synthesis media was therefore anticipated. Three weeks later, clinical, microbiological, and biochemical evidence of infection resolved. Conclusions High quality intensive assistance for sepsis episodes needs a clear plan of cure, aimed to complete infection source control, in a complex multidisciplinary interplay of specialists and intensive care physicians.
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Affiliation(s)
- Antonella Frattari
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy.
| | - Giustino Parruti
- Unit of Infectious Diseases, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Rocco Erasmo
- Unit of Orthopedics and Traumatology, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Luigi Guerra
- Unit of Orthopedics and Traumatology, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Ennio Polilli
- Unit of Infectious Diseases, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Rosamaria Zocaro
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Giuliano Iervese
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Paolo Fazii
- Unit of Microbiology, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
| | - Tullio Spina
- Unit of Anaesthesia and Intensive Care, Santo Spirito Hospital, Via Fonte Romana 8, Pescara, Italy
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24
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Johnston ANB, Park J, Doi SA, Sharman V, Clark J, Robinson J, Crilly J. Effect of Immediate Administration of Antibiotics in Patients With Sepsis in Tertiary Care: A Systematic Review and Meta-analysis. Clin Ther 2017; 39:190-202.e6. [PMID: 28062114 DOI: 10.1016/j.clinthera.2016.12.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 12/01/2016] [Accepted: 12/02/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE The goal of this review was to synthesize existing evidence regarding outcomes (mortality) for patients who present to the emergency department, are administered antibiotics immediately (within 1 hour) or later (>1 hour), and are diagnosed with sepsis. METHODS A search of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL, using the MeSH descriptors "sepsis," "systemic inflammatory response syndrome," "mortality," "emergency," and "antibiotics," was performed to identify studies reporting time to antibiotic administration and mortality outcome in patients with sepsis. The included studies (published in English between 1990 and 2016) listed patient mortality based on time to antibiotic administration. Studies were evaluated for methodologic quality, and data were extracted by using a data extraction form tailored to this study. From an initial pool of 582 potentially relevant studies, 11 studies met our inclusion criteria, 10 of which had quantitative data for meta-analysis. Three different models (a random effects model, a bias-adjusted quality-effects [synthetic bias] model, and an inverse variance heterogeneity model) were used to perform the meta-analysis. FINDINGS The pooled results suggest a significant 33% reduction in mortality odds for immediate (within 1 hour) compared with later (>1 hour) antibiotic administration (OR, 0.67 [95% CI, 0.59-0.75]) in patients with sepsis. IMPLICATIONS Immediate antibiotic administration (<1 hour) seemed to reduce patient mortality. There was some minor negative asymmetry suggesting that the evidence may be biased toward the direction of effect. Nevertheless, this study provides strong evidence for early, comprehensive, sepsis management in the emergency department.
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Affiliation(s)
- Amy N B Johnston
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Menzies Health Institute Queensland, Griffith University Gold Coast Campus, Queensland, Australia.
| | - Joon Park
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Suhail A Doi
- Research School of Population Health, Australian National University, Canberra, Australia; College of Medicine, Qatar University, Doha, Qatar
| | - Vicki Sharman
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Pharmacy Department, Gold Coast University Hospital, Queensland, Australia
| | - Justin Clark
- Centre for Research in Evidence-Based Practice, Bond University, Southport, Queensland, Australia
| | - Jemma Robinson
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Pharmacy Department, Gold Coast University Hospital, Queensland, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; Menzies Health Institute Queensland, Griffith University Gold Coast Campus, Queensland, Australia
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