Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness

OBJECTIVE

To determine if the addition of lactate to Quick Sequential Organ Failure Assessment (qSOFA) scoring improves emergency department (ED) screening of septic patients for critical illness.

METHODS

This was a multicenter retrospective cohort study of consecutive adult patients admitted to the hospital from the ED with infectious disease-related illnesses. We recorded qSOFA criteria and initial lactate levels in the first 6 h of ED stay. Our primary outcome was a composite of hospital death, vasopressor use, and intensive care unit stay ≤72 h of presentation. Diagnostic test characteristics were determined for: 1) lactate levels ≥2 and ≥4; 2) qSOFA scores ≥1, ≥2, and =3; and 3) combinations of these.

RESULTS

Of 3743 patients, 2584 had a lactate drawn ≤6 h of ED stay and 18% met the primary outcome. The qSOFA scores were ≥1, ≥2, and =3 in 59.2%, 22.0%, and 5.3% of patients, respectively, and 34.4% had a lactate level ≥2 and 7.9% had a lactate level ≥4. The combination of qSOFA ≥1 OR Lactate ≥2 had the highest sensitivity, 94.0% (95% CI: 91.3-95.9).

CONCLUSIONS

The combination of qSOFA ≥1 OR Lactate ≥2 provides substantially improved sensitivity for the screening of critical illness compared to isolated lactate and qSOFA thresholds.

EAST Multicenter Trial on targeted temperature management for hanging-induced cardiac arrest

BACKGROUND

We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of Trauma (EAST) multicenter retrospective study.

METHODS

We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome.

RESULTS

A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p < 0.05) and good neurologic outcome (19.8% vs 37.2%, p < 0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy.

CONCLUSION

Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models.

LEVEL OF EVIDENCE

Therapeutic study, level IV; prognostic study, level III.

Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness

OBJECTIVE

We sought to compare the quick sequential organ failure assessment (qSOFA) to systemic inflammatory response syndrome (SIRS), severe sepsis criteria and lactate levels for their ability to identify ED patients with sepsis with critical illness.

METHODS

We conducted this multicenter retrospective cohort study at five US hospitals, enrolling all adult patients admitted to these hospitals from their EDs with infectious disease-related illnesses from 1 January 2016 to 30 April 2016. We abstracted clinical variables for SIRS, severe sepsis and qSOFA scores, using values in the first 6 hours of ED stay. Our primary outcome was critical illness, defined as one or more of the composite outcomes of death, vasopressor use or intensive care unit (ICU) admission within 72 hours of presentation. We determined diagnostic test characteristics for qSOFA scores, SIRS, severe sepsis criteria and lactate level thresholds.

MAIN RESULTS

Of 3743 enrolled patients, 512 (13.7%) had the primary composite outcome. The qSOFA scores were ≥1, >2 and 3 in 1839 (49.1%), 626 (16.7%) and 146 (3.9%) patients, respectively; 2202 (58.8%) met SIRS criteria and 1085 (29.0%) met severe sepsis criteria. qSOFA ≥1 and SIRS had similarly high sensitivity [86.1% (95% CI 82.8% to 89.0%) vs 86.7% (95% CI 83.5% to 89.5%)], but qSOFA ≥1 had higher specificity [56.7% (95% CI 55.0% to 58.5%) vs 45.6% (43.9% to 47.3%); mean difference 11.1% (95% CI 8.7% to 13.6%)]. qSOFA ≥2 had higher specificity than severe sepsis criteria [89.1% (88.0% to 90.2%) vs 77.5% (76.0% to 78.9%); mean difference 11.6% (9.8% to 13.4%)]. qSOFA ≥1 had greater sensitivity than a lactate level ≥2 (mean difference 24.6% (19.2% to 29.9%)).

CONCLUSION

For patients admitted from the ED with infectious disease diagnoses, qSOFA criteria performed as well or better than SIRS criteria, severe sepsis criteria and lactate levels in predicting critical illness.

Effect of Therapeutic Hypothermia on Survival to Hospital Discharge in Out-of-hospital Cardiac Arrest Secondary to Nonshockable Rhythms

OBJECTIVES

Therapeutic hypothermia has been shown to improve neurologic outcome and survival in out-of-hospital cardiac arrest (OHCA) following return of spontaneous circulation (ROSC), and current guidelines recommend therapeutic hypothermia for all comatose survivors of OHCA. However, recommendations for nonshockable rhythms are not as strongly supported. Our study aims to provide further evidence on the use of therapeutic hypothermia in nonshockable rhythms.

METHODS

A multivariate analysis with propensity score matching was performed using a cardiac arrest registry maintained by the Houston Fire Department. The analysis was limited to adult patients achieving ROSC following OHCA secondary to nonshockable rhythm in Houston from 2007 to 2012 with definitive information regarding the implementation of therapeutic hypothermia. The primary outcome was survival to hospital discharge.

RESULTS

Of 9,479 records identified for analysis, 7,839 had an initial nonshockable rhythm. Of these, 2,609 (33.3%) had sustained ROSC and 1,768 (22.6%) were admitted to the hospital. Data on therapeutic hypothermia use were available for 696 patients, with 335 (48.1%) receiving therapeutic hypothermia. Propensity score matching yielded 260 case/control pairs. The odds of survival to hospital discharge was an odds ratio of 1.07 (95% confidence interval = 0.71 to 1.60) for those in the therapeutic hypothermia group versus the nontherapeutic hypothermia group (p = 0.79).

CONCLUSIONS

Based on this retrospective study, therapeutic hypothermia is not associated with improved survival in patients with OHCA secondary to nonshockable rhythms. Given the limitations of our study, further prospective trials to assess the effect of therapeutic hypothermia for OHCA with nonshockable rhythms are warranted.

Outcomes of Patients Requiring Blood Pressure Control Before Thrombolysis with tPA for Acute Ischemic Stroke

Introduction

The purpose of this study was to assess safety and efficacy of thrombolysis in the setting of aggressive blood pressure (BP) control as it compares to standard BP control or no BP control prior to thrombolysis.

Methods

We performed a retrospective review of patients treated with tissue plasminogen activator (tPA) for acute ischemic stroke (AIS) between 2004–2011. We compared the outcomes of patients treated with tPA for AIS who required aggressive BP control prior to thrombolysis to those requiring standard or no BP control prior to thrombolysis. The primary outcome of interest was safety, defined by all grades of hemorrhagic transformation and neurologic deterioration. The secondary outcome was efficacy, determined by functional status at discharge, and in-hospital deaths.

Results

Of 427 patients included in the analysis, 89 received aggressive BP control prior to thrombolysis, 65 received standard BP control, and 273 required no BP control prior to thrombolysis. Patients requiring BP control had more severe strokes, with median arrival National Institutes of Health Stroke Scale of 10 (IQR [6–17]) in patients not requiring BP control versus 11 (IQR [5–16]) and 13 (IQR [7–20]) in patients requiring standard and aggressive BP lowering therapies, respectively (p=0.048). In a multiple logistic regression model adjusting for baseline differences, there were no statistically significant differences in adverse events between the three groups (P>0.10).

Conclusion

We observed no association between BP control and adverse outcomes in ischemic stroke patients undergoing thrombolysis. However, additional study is necessary to confirm or refute the safety of aggressive BP control prior to thrombolysis.