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Cavaillon JM, Chousterman BG, Skirecki T. Compartmentalization of the inflammatory response during bacterial sepsis and severe COVID-19. JOURNAL OF INTENSIVE MEDICINE 2024; 4:326-340. [PMID: 39035623 PMCID: PMC11258514 DOI: 10.1016/j.jointm.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 07/23/2024]
Abstract
Acute infections cause local and systemic disorders which can lead in the most severe forms to multi-organ failure and eventually to death. The host response to infection encompasses a large spectrum of reactions with a concomitant activation of the so-called inflammatory response aimed at fighting the infectious agent and removing damaged tissues or cells, and the anti-inflammatory response aimed at controlling inflammation and initiating the healing process. Fine-tuning at the local and systemic levels is key to preventing local and remote injury due to immune system activation. Thus, during bacterial sepsis and Coronavirus disease 2019 (COVID-19), concomitant systemic and compartmentalized pro-inflammatory and compensatory anti-inflammatory responses are occurring. Immune cells (e.g., macrophages, neutrophils, natural killer cells, and T-lymphocytes), as well as endothelial cells, differ from one compartment to another and contribute to specific organ responses to sterile and microbial insult. Furthermore, tissue-specific microbiota influences the local and systemic response. A better understanding of the tissue-specific immune status, the organ immunity crosstalk, and the role of specific mediators during sepsis and COVID-19 can foster the development of more accurate biomarkers for better diagnosis and prognosis and help to define appropriate host-targeted treatments and vaccines in the context of precision medicine.
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Affiliation(s)
| | - Benjamin G. Chousterman
- Department of Anesthesia and Critical Care, Lariboisière University Hospital, DMU Parabol, APHP Nord, Paris, France
- Inserm U942, University of Paris, Paris, France
| | - Tomasz Skirecki
- Department of Translational Immunology and Experimental Intensive Care, Centre of Postgraduate Medical Education, Warsaw, Poland
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Viikinkoski E, Aittokallio J, Lehto J, Ollila H, Relander A, Vasankari T, Jalkanen J, Gunn J, Jalkanen S, Airaksinen J, Hollmén M, Kiviniemi TO. Prolonged Systemic Inflammatory Response Syndrome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:709-716. [PMID: 38220516 DOI: 10.1053/j.jvca.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/25/2023] [Accepted: 12/13/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES Cardiac surgery induces systemic inflammatory response syndrome (SIRS), leading to higher morbidity and mortality. There are no individualized predictors for worse outcomes or biomarkers for the multifactorial, excessive inflammatory response. The interest of this study was to evaluate whether a systematic use of the SIRS criteria could be used to predict postoperative outcomes beyond infection and sepsis, and if the development of an exaggerated inflammation response could be observed preoperatively. DESIGN The study was observational, with prospectively enrolled patients. SETTING This was a single institution study in a hospital setting combined with laboratory findings. PARTICIPANTS The study included a cohort of 261 volunteer patients. INTERVENTIONS Patients underwent cardiac surgery with cardiopulmonary bypass, and were followed up to 90 days. Biomarker profiling was run preoperatively. MEASUREMENTS AND MAIN RESULTS Altogether, 17 of 261 (6.4%) patients had prolonged SIRS, defined as fulfilling at least 2 criteria on 4 consecutive postoperative days. During hospitalization, postoperative atrial fibrillation (POAF) was found in 42.2% of patients, and stroke and transient ischemic attack in 3.8% of patients. Prolonged SIRS was a significant predictor of POAF (odds ratio [OR] 4.5, 95% CI 1.2-17.3), 90-day stroke (OR 4.5, 95% CI 1.1-18.0), and mortality (OR 10.7, 95% CI 1.7-68.8). Biomarker assays showed that preoperative nerve growth factor and interleukin 5 levels were associated with prolonged SIRS (OR 5.6, 95%, CI 1.4-23.2 and OR 0.7, 95%, CI 0.4-1.0, respectively). CONCLUSIONS Nerve growth factor and interleukin 5 can be used to predict prolonged systemic inflammatory response, which is associated with POAF, stroke, and mortality.
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Affiliation(s)
- Emma Viikinkoski
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Jenni Aittokallio
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Joonas Lehto
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Helena Ollila
- Turku Clinical Research Center, Turku University Hospital, Turku, Finland
| | - Arto Relander
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Juho Jalkanen
- MediCity Research Laboratory, Department of Microbiology and Immunology, InFLAMES Flagship, University of Turku, Turku, Finland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Sirpa Jalkanen
- MediCity Research Laboratory, Department of Microbiology and Immunology, InFLAMES Flagship, University of Turku, Turku, Finland
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Maija Hollmén
- MediCity Research Laboratory, Department of Microbiology and Immunology, InFLAMES Flagship, University of Turku, Turku, Finland
| | - Tuomas O Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.
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Gysling S, Shanmuganathan S, Szafranek A, Stewart ID, Caruana EJ. Validation of NEWS2, SIRS, and qSOFA in Postoperative Cardiac Patients: A Retrospective Cohort Study. J Surg Res 2024; 293:364-372. [PMID: 37806223 DOI: 10.1016/j.jss.2023.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 07/31/2023] [Accepted: 08/26/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION The 'quick Sepsis Related Organ Failure Assessment' (qSOFA), 'Systemic Inflammatory Response Syndrome' (SIRS), and 'National Early Warning Score' 2 (NEWS2) scores are yet to be comparatively validated in ward-based cardiac surgical patients despite widespread routine use in clinical practice. We sought to assess the predictive validity of NEWS, SIRS, and qSOFA in identifying postoperative, ward-level cardiac surgical patients at risk of poor short-term mortality. METHODS All adult patients who underwent cardiac surgery at a single tertiary center between November 2014 and October 2017 were identified. Data for bedside observations, hematological results, and microbiology requests were obtained from electronic health records. Survival data were acquired from a national registry. The primary outcome was the discriminatory ability, measured by the area under the receiver operating characteristic (AUROC), of each score for in-hospital mortality. RESULTS One thousand five hundred forty three (male n = 1101, 71%) patients were included. Overall in-hospital mortality was 2.4%. There was no significant difference in discriminatory ability of NEWS (AUROC 0.5060), SIRS (AUROC 0.4874), and qSOFA (AUROC 0.5139) for in-hospital mortality (P = 0.881). Sensitivity for this outcome was ubiquitously low (13.51-40.54%). CONCLUSIONS Current illness-severity scores show a low discriminatory ability for in-hospital mortality in ward-based cardiac surgical patients. Caution should be used in the application of these prognostic screening tools for early detection of poor outcomes in this population.
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Affiliation(s)
- Savannah Gysling
- Academic Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | | | - Adam Szafranek
- Cardiac Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iain D Stewart
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Edward J Caruana
- Thoracic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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Kim T, Tae Y, Yeo HJ, Jang JH, Cho K, Yoo D, Lee Y, Ahn SH, Kim Y, Lee N, Cho WH. Development and Validation of Deep-Learning-Based Sepsis and Septic Shock Early Prediction System (DeepSEPS) Using Real-World ICU Data. J Clin Med 2023; 12:7156. [PMID: 38002768 PMCID: PMC10672000 DOI: 10.3390/jcm12227156] [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: 10/18/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Successful sepsis treatment depends on early diagnosis. We aimed to develop and validate a system to predict sepsis and septic shock in real time using deep learning. METHODS Clinical data were retrospectively collected from electronic medical records (EMRs). Data from 2010 to 2019 were used as development data, and data from 2020 to 2021 were used as validation data. The collected EMRs consisted of eight vital signs, 13 laboratory data points, and three demographic information items. We validated the deep-learning-based sepsis and septic shock early prediction system (DeepSEPS) using the validation datasets and compared our system with other traditional early warning scoring systems, such as the national early warning score, sequential organ failure assessment (SOFA), and quick sequential organ failure assessment. RESULTS DeepSEPS achieved even higher area under receiver operating characteristic curve (AUROC) values (0.7888 and 0.8494 for sepsis and septic shock, respectively) than SOFA. The prediction performance of traditional scoring systems was enhanced because the early prediction time point was close to the onset time of sepsis; however, the DeepSEPS scoring system consistently outperformed all conventional scoring systems at all time points. Furthermore, at the time of onset of sepsis and septic shock, DeepSEPS showed the highest AUROC (0.9346). CONCLUSIONS The sepsis and septic shock early warning system developed in this study exhibited a performance that is worth considering when predicting sepsis and septic shock compared to other traditional early warning scoring systems. DeepSEPS showed better performance than existing sepsis prediction programs. This novel real-time system that simultaneously predicts sepsis and septic shock requires further validation.
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Affiliation(s)
- Taehwa Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Pusan National University and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (T.K.); (H.J.Y.); (J.H.J.)
| | - Yunwon Tae
- VUNO, Seoul 06541, Republic of Korea; (Y.T.); (K.C.); (D.Y.); (Y.L.)
| | - Hye Ju Yeo
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Pusan National University and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (T.K.); (H.J.Y.); (J.H.J.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Busan 46241, Republic of Korea
| | - Jin Ho Jang
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Pusan National University and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (T.K.); (H.J.Y.); (J.H.J.)
| | - Kyungjae Cho
- VUNO, Seoul 06541, Republic of Korea; (Y.T.); (K.C.); (D.Y.); (Y.L.)
| | - Dongjoon Yoo
- VUNO, Seoul 06541, Republic of Korea; (Y.T.); (K.C.); (D.Y.); (Y.L.)
- Department of Critical Care Medicine and Emergency Medicine, Inha University College of Medicine, Incheon 22212, Republic of Korea
| | - Yeha Lee
- VUNO, Seoul 06541, Republic of Korea; (Y.T.); (K.C.); (D.Y.); (Y.L.)
| | - Sung-Ho Ahn
- Division of Biostatistics, Department of Neurology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea;
| | - Younga Kim
- Department of Pediatrics, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea; (Y.K.); (N.L.)
| | - Narae Lee
- Department of Pediatrics, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea; (Y.K.); (N.L.)
| | - Woo Hyun Cho
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Pusan National University and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (T.K.); (H.J.Y.); (J.H.J.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Busan 46241, Republic of Korea
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Hooper GA, Klippel CJ, McLean SR, Stenehjem EA, Webb BJ, Murnin ER, Hough CL, Bledsoe JR, Brown SM, Peltan ID. Concordance Between Initial Presumptive and Final Adjudicated Diagnoses of Infection Among Patients Meeting Sepsis-3 Criteria in the Emergency Department. Clin Infect Dis 2023; 76:2047-2055. [PMID: 36806551 PMCID: PMC10273369 DOI: 10.1093/cid/ciad101] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/21/2023] [Accepted: 02/16/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Guidelines emphasize rapid antibiotic treatment for sepsis, but infection presence is often uncertain at initial presentation. We investigated the incidence and drivers of false-positive presumptive infection diagnosis among emergency department (ED) patients meeting Sepsis-3 criteria. METHODS For a retrospective cohort of patients hospitalized after meeting Sepsis-3 criteria (acute organ failure and suspected infection including blood cultures drawn and intravenous antimicrobials administered) in 1 of 4 EDs from 2013 to 2017, trained reviewers first identified the ED-diagnosed source of infection and adjudicated the presence and source of infection on final assessment. Reviewers subsequently adjudicated final infection probability for a randomly selected 10% subset of subjects. Risk factors for false-positive infection diagnosis and its association with 30-day mortality were evaluated using multivariable regression. RESULTS Of 8267 patients meeting Sepsis-3 criteria in the ED, 699 (8.5%) did not have an infection on final adjudication and 1488 (18.0%) patients with confirmed infections had a different source of infection diagnosed in the ED versus final adjudication (ie, initial/final source diagnosis discordance). Among the subset of patients whose final infection probability was adjudicated (n = 812), 79 (9.7%) had only "possible" infection and 77 (9.5%) were not infected. Factors associated with false-positive infection diagnosis included hypothermia, altered mental status, comorbidity burden, and an "unknown infection source" diagnosis in the ED (odds ratio: 6.39; 95% confidence interval: 5.14-7.94). False-positive infection diagnosis was not associated with 30-day mortality. CONCLUSIONS In this large multihospital study, <20% of ED patients meeting Sepsis-3 criteria had no infection or only possible infection on retrospective adjudication.
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Affiliation(s)
- Gabriel A Hooper
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Carolyn J Klippel
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
| | - Sierra R McLean
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Physical Medicine and Rehabilitation, University of North Carolina Health, Chapel Hill, North Carolina, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Brandon J Webb
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Emily R Murnin
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah, USA
- Department of Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Black Garlic and Thiosulfinate-Enriched Extracts as Adjuvants to Ceftriaxone Treatment in a Rat Peritonitis Model of Sepsis. Biomedicines 2022; 10:biomedicines10123095. [PMID: 36551850 PMCID: PMC9775994 DOI: 10.3390/biomedicines10123095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022] Open
Abstract
To date, there have been no new drugs or adjuvants able to decrease both morbidity and mortality in the context of sepsis and septic shock. Our objective was to evaluate the use of thiosulfinate-enriched Allium sativum and black garlic extracts as adjuvants in the management of sepsis. An experimental in vivo study was carried out with male Sprague-Dawley® rats. Animals were randomized in four treatment groups: antibiotic (ceftriaxone) treatment (group I), ceftriaxone plus thiosulfinate-enriched extract (TASE, group II), ceftriaxone plus thiosulfinate-enriched extract and black garlic extracts (TASE + BGE, group III), and ceftriaxone plus black garlic extract (BGE, group IV). All animals were housed and inoculated with 1 × 1010 CFU/15 mL of intraperitoneal Escherichia coli ATCC 25922. Subsequently, they received a daily treatment according to each group for 7 days. Clinical, analytical, microbiological, and histopathological parameters were evaluated. Statistically significant clinical improvement was observed in rats receiving garlic extracts in weight (groups II and III), ocular secretions, and piloerection (group IV). Moreover, less liver edema, vacuolization, and inflammation were observed in groups receiving adjuvant support (groups II, III, and IV). When comparing interleukins 24 h after bacteria inoculum, we found statistically significant differences in TNF-alpha levels in groups receiving BGE (groups III and IV, p ≤ 0.05). Blood and peritoneal liquid cultures were also analyzed, and we detected a certain level of Enterococcus faecalis in peritoneal cultures from all treatment groups and less bacteria presence in blood cultures in rats receiving garlic extracts (groups II, III, and IV). In conclusion, TASE and BGE could be promising nutraceutical or medicinal agents as coadjuvants in the treatment of sepsis because of its effects in modulating the inflammatory response.
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Lehman KD. Evidence-based updates to the 2021 Surviving Sepsis Campaign guidelines: Part 1: Background, pathophysiology, and emerging treatments. Nurse Pract 2022; 47:24-30. [PMID: 36287733 DOI: 10.1097/01.npr.0000884868.44595.f6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
ABSTRACT Sepsis identification and treatment has changed significantly over the last few decades. Despite this, sepsis is still associated with significant morbidity and mortality. This first of a two-part series reviews the history of modern sepsis and presents new research in pathophysiology, treatment, and postsepsis care.
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Affiliation(s)
- Karen D Lehman
- Karen D. Lehman is a hospitalist NP and PRN ED NP at NMC Health in Newton, Kan., an ED NP with Docs Who Care based in Olathe, Kan., and a hospice NP with Harry Hynes Memorial Hospice in Wichita, Kan
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Malinovska A, Hinson JS, Badaki‐Makun O, Hernried B, Smith A, Debraine A, Toerper M, Rothman RE, Kickler T, Levin S. Monocyte distribution width as part of a broad pragmatic sepsis screen in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12679. [PMID: 35252973 PMCID: PMC8886187 DOI: 10.1002/emp2.12679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 12/12/2022] Open
Abstract
Study Objective Methods Results Conclusion
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Affiliation(s)
- Alexandra Malinovska
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Department of Epidemiology Johns Hopkins University Bloomberg School of Public Health Baltimore Maryland USA
| | - Jeremiah S. Hinson
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
- StoCastic Baltimore Maryland USA
| | - Oluwakemi Badaki‐Makun
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
- Division of Pediatric Emergency Medicine, Department of Pediatrics Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Benjamin Hernried
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Aria Smith
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
| | | | - Matthew Toerper
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
- StoCastic Baltimore Maryland USA
| | - Richard E. Rothman
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Thomas Kickler
- Department of Pathology Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Scott Levin
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
- Malone Center for Engineering in Healthcare Johns Hopkins Whiting School of Engineering Baltimore Maryland USA
- StoCastic Baltimore Maryland USA
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Keeley AJ, Nsutebu E. Improving sepsis care in Africa: an opportunity for change? Pan Afr Med J 2022; 40:204. [PMID: 35136467 PMCID: PMC8783315 DOI: 10.11604/pamj.2021.40.204.30127] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/22/2021] [Indexed: 12/29/2022] Open
Abstract
Sepsis is common and represents a major public health burden with significant associated morbidity and mortality. However, despite substantial advances in sepsis recognition and management in well-resourced health systems, there remains a distinct lack of research into sepsis in Africa. The lack of evidence affects all levels of healthcare delivery from individual patient management to strategic planning at health-system level. This is particular pertinent as African countries experience some of the highest global burden of sepsis. The 2017 World Health Assembly resolution on sepsis and the creation of the Africa Sepsis Alliance provided an opportunity for change. However, progress so far has been frustratingly slow. The recurrent Ebola virus disease outbreaks and the COVID-19 pandemic on the African continent further reinforce the need for urgent healthcare system strengthening. We recommend that African countries develop national action plans for sepsis which should address the needs of all critically ill patients.
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Affiliation(s)
- Alexander James Keeley
- Florey Institute, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Emmanuel Nsutebu
- Infectious Disease Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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Shi JQ, Huan X, Lv ZG, Zhou ZR, Wu ST, Zhong HH, Yan C, Song J, Zhou L, Xu YF, Lin J, Zhu WH, Xi JY, Luo SS, Zhao CB. Pneumonia and systemic inflammatory response syndrome as predictors for difficult-/prolonged-weaning after invasive ventilation in myasthenic crisis: A retrospective analysis of a Chinese cohort. Neuromuscul Disord 2021; 32:220-229. [DOI: 10.1016/j.nmd.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
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Abstract
Purpose of Review Sepsis is a leading cause of death worldwide. Groundbreaking international collaborative efforts have culminated in the widely accepted surviving sepsis guidelines, with iterative improvements in management strategies and definitions providing important advances in care for patients. Key to the diagnosis of sepsis is identification of infection, and whilst the diagnostic criteria for sepsis is now clear, the diagnosis of infection remains a challenge and there is often discordance between clinician assessments for infection. Recent Findings We review the utility of common biochemical, microbiological and radiological tools employed by clinicians to diagnose infection and explore the difficulty of making a diagnosis of infection in severe inflammatory states through illustrative case reports. Finally, we discuss some of the novel and emerging approaches in diagnosis of infection and sepsis. Summary While prompt diagnosis and treatment of sepsis is essential to improve outcomes in sepsis, there remains no single tool to reliably identify or exclude infection. This contributes to unnecessary antimicrobial use that is harmful to individuals and populations. There is therefore a pressing need for novel solutions. Machine learning approaches using multiple diagnostic and clinical inputs may offer a potential solution but as yet these approaches remain experimental.
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Chou RH, Tsai CT, Lu YW, Guo JY, Lu CT, Tsai YL, Wu CH, Lin SJ, Lien RY, Lu SF, Yang SF, Huang PH. Elevated serum galectin-1 concentrations are associated with increased risks of mortality and acute kidney injury in critically ill patients. PLoS One 2021; 16:e0257558. [PMID: 34559847 PMCID: PMC8462742 DOI: 10.1371/journal.pone.0257558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 09/05/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Galectin-1 (Gal-1), a member of the β-galactoside binding protein family, is associated with inflammation and chronic kidney disease. However, the effect of Gal-1 on mortality and acute kidney injury (AKI) in critically-ill patients remain unclear. METHODS From May 2018 to March 2020, 350 patients admitted to the medical intensive care unit (ICU) of Taipei Veterans General Hospital, a tertiary medical center, were enrolled in this study. Forty-one patients receiving long-term renal replacement therapy were excluded. Serum Gal-1 levels were determined within 24 h of ICU admission. The patients were divided into tertiles according to their serum Gal-1 levels (low, serum Gal-1 < 39 ng/ml; median, 39-70 ng/ml; high, ≥71 ng/ml). All patients were followed for 90 days or until death. RESULTS Mortality in the ICU and at 90 days was greater among patients with elevated serum Gal-1 levels. In analyses adjusted for the body mass index, malignancy, sepsis, Sequential Organ Failure Assessment (SOFA) score, and serum lactate level, the serum Gal-1 level remained an independent predictor of 90-day mortality [median vs. low: adjusted hazard ratio (aHR) 2.11, 95% confidence interval (CI) 1.24-3.60, p = 0.006; high vs. low: aHR 3.21, 95% CI 1.90-5.42, p < 0.001]. Higher serum Gal-1 levels were also associated with a higher incidence of AKI within 48 h after ICU admission, independent of the SOFA score and renal function (median vs. low: aHR 2.77, 95% CI 1.21-6.34, p = 0.016; high vs. low: aHR 2.88, 95% CI 1.20-6.88, p = 0.017). The results were consistent among different subgroups with high and low Gal-1 levels. CONCLUSION Serum Gal-1 elevation at the time of ICU admission were associated with an increased risk of mortality at 90 days, and an increased incidence of AKI within 48 h after ICU admission.
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Affiliation(s)
- Ruey-Hsing Chou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Wen Lu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiun-Yu Guo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Ting Lu
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Lin Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Hsueh Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shing-Jong Lin
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Ru-Yu Lien
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Fen Lu
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shang-Feng Yang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Po-Hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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13
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Performance of Sepsis-3 Definitions in a Middle Income Country Intensive Care Unit. Mediterr J Hematol Infect Dis 2021; 13:e2021052. [PMID: 34527204 PMCID: PMC8425348 DOI: 10.4084/mjhid.2021.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/07/2021] [Indexed: 11/08/2022] Open
Abstract
Background Since they were first published in 2016, Sepsis-3 definitions have not been universally accepted. Rather, they have become a source of controversy because the clinical and laboratory parameters used had been derived mainly from patients hospitalized in Intensive Care Units (ICU) in the United States. Purpose The aim of this study was to evaluate the performance of the Sepsis-3 definitions for the prediction of ICU-mortality in a Tunisian ICU population as compared to the 2003 Consensus Definitions (Sepsis-2 definitions). Method The study, conducted in an 18-bed medical-surgical ICU at the Military Hospital of Tunis (Tunisia), was retrospective in nature. From January 2012 to January 2016, all patients admitted to the ICU for sepsis, severe sepsis, or septic shock as defined according to the 2003 Consensus Definitions (Sepsis-2 consensus) were eligible for this study. The new Sepsis-3 definition was then used to classify the included patients. The primary area of interest was ICU mortality, defined as death before ICU discharge. Results A total of 1080 patients were included during the recruitment period. When Sepsis-2 definitions were used, there was a difference in mortality only between septic shock and sepsis patients. Sepsis-3 definitions show that mortality increased from 16 % among no-dysfunction-infected patients to 30 % among patients with qSOFA ≥ 2 and 44% and 46% for sepsis or septic shock patients, respectively. Conclusions Sepsis-3 definitions were better than sepsis-2 definitions at stratifying mortality among septic patients admitted to an ICU of a middle-income country (Tunisia).
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Zhang K, Zhang X, Ding W, Xuan N, Tian B, Huang T, Zhang Z, Cui W, Huang H, Zhang G. National Early Warning Score Does Not Accurately Predict Mortality for Patients With Infection Outside the Intensive Care Unit: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:704358. [PMID: 34336903 PMCID: PMC8319382 DOI: 10.3389/fmed.2021.704358] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/21/2021] [Indexed: 12/29/2022] Open
Abstract
Background: The prognostic value of the national early warning score (NEWS) in patients with infections remains controversial. We aimed to evaluate the prognostic accuracy of NEWS for prediction of in-hospital mortality in patients with infections outside the intensive care unit (ICU). Methods: We searched PubMed, Embase, and Scopus for related articles from January 2012 to April 2021. Sensitivity, specificity, and likelihood ratios were pooled by using the bivariate random-effects model. Overall prognostic performance was summarized by using the area under the curve (AUC). We performed subgroup analyses to assess the prognostic accuracy of NEWS in selected populations. Results: A total of 21 studies with 107,008 participants were included. The pooled sensitivity and specificity of NEWS were 0.71 and 0.60. The pooled AUC of NEWS was 0.70, which was similar to quick sequential organ failure assessment (qSOFA, AUC: 0.70) and better than systemic inflammatory response syndrome (SIRS, AUC: 0.60). However, the sensitivity (0.55) and AUC (0.63) of NEWS were poor in elder patients. The NEWS of 5 was more sensitive, which was a better threshold for activating urgent assessment and treatment. Conclusions: The NEWS had good diagnostic accuracy for early prediction of mortality in patients with infections outside the ICU, and the sensitivity and specificity were more moderate when compared with qSOFA and SIRS. Insufficient sensitivity and poor performance in the elder population may have limitations as an early warning score for adverse outcomes. NEWS should be used for continuous monitoring rather than a single time point predictive tool.
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Affiliation(s)
- Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xing Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Medical Security Bureau of Yinzhou District, Ningbo, China
| | - Wenyun Ding
- Department of Respiration and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Respiration Medicine, Community Health Service Center, Shanghai, China
| | - Nanxia Xuan
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Baoping Tian
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tiancha Huang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhaocai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Cui
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huaqiong Huang
- Department of Respiration and Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Gensheng Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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15
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Abstract
Objectives Sepsis and septic shock are leading causes of in-hospital mortality. Timely treatment is crucial in improving patient outcome, yet treatment delays remain common. Early prediction of those patients with sepsis who will progress to its most severe form, septic shock, can increase the actionable window for interventions. We aim to extend a time-evolving risk score, previously developed in adult patients, to predict pediatric sepsis patients who are likely to develop septic shock before its onset, and to determine whether or not these risk scores stratify into groups with distinct temporal evolution once this prediction is made. Design Retrospective cohort study. Setting Academic medical center from July 1, 2016, to December 11, 2020. Patients Six-thousand one-hundred sixty-one patients under 18 admitted to the Johns Hopkins Hospital PICU. Interventions None. Measurements and Main Results We trained risk models to predict impending transition into septic shock and compute time-evolving risk scores representative of a patient's probability of developing septic shock. We obtain early prediction performance of 0.90 area under the receiver operating curve, 43% overall positive predictive value, patient-specific positive predictive value as high as 62%, and an 8.9-hour median early warning time using Sepsis-3 labels based on age-adjusted Sequential Organ Failure Assessment score. Using spectral clustering, we stratified pediatric sepsis patients into two clusters differing in septic shock prevalence, mortality, and proportion of patients adequately fluid resuscitated. CONCLUSIONS We demonstrate the applicability of our methodology for early prediction and stratification for risk of septic shock in pediatric sepsis patients. Through analyses of risk score evolution over time, we corroborate our past finding of an abrupt transition preceding onset of septic shock in children and are able to stratify pediatric sepsis patients using their risk score trajectories into low and high-risk categories.
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16
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Confield LR, Black GP, Wilson BC, Lowe DJ, Theakstone AG, Baker MJ. Vibrational spectroscopic analysis of blood for diagnosis of infections and sepsis: a review of requirements for a rapid diagnostic test. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2021; 13:157-168. [PMID: 33284291 DOI: 10.1039/d0ay01991g] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Infections and sepsis represent a growing global burden. There is a widespread clinical need for a rapid, high-throughput and sensitive technique for the diagnosis of infections and detection of invading pathogens and the presence of sepsis. Current diagnostic methods primarily consist of laboratory-based haematology, biochemistry and microbiology that are time consuming, labour- and resource-intensive, and prone to both false positive and false negative results. Current methods are insufficient for the increasing demands on healthcare systems, causing delays in diagnosis and initiation of treatment, due to the intrinsic time delay in sample preparation, measurement, and analysis. Vibrational spectroscopic techniques can overcome these limitations by providing a rapid, label-free and low-cost method for blood analysis, with limited sample preparation required, potentially revolutionising clinical diagnostics by producing actionable results that enable early diagnosis, leading to improved patient outcomes. This review will discuss the challenges associated with the diagnosis of infections and sepsis, primarily within the UK healthcare system. We will consider the clinical potential of spectroscopic point-of-care technologies to enable blood analysis in the primary-care setting.
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Affiliation(s)
- L R Confield
- CDT Medical Devices, Department of Biomedical Engineering, Wolfson Centre, 106 Rottenrow, G4 0NW, UK
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17
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Ma C, Lu J, Zhu Y, Huo Y, Xia S, Shao Y. Systemic Inflammatory Response Syndrome Combined with Pre- and Postoperative White Blood Cell Ratio Is a Better Criterion to Identify Septic Shock Patients After Flexible Ureteroscopic Lithotripsy. J Endourol 2020; 35:973-978. [PMID: 33218256 DOI: 10.1089/end.2020.1002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To find out a better criterion to identify septic shock patients after flexible ureteroscopic lithotripsy (FUL). Materials and Methods: In total, 2364 patients who underwent the FUL procedure were enrolled in the study. The demographics and preoperative results of laboratory tests of the patients were collected. The postoperative white blood cell (WBC), systemic inflammatory response syndrome (SIRS), and quick sequential (sepsis-related) organ failure assessment score (qSOFA) were assessed 2 hours after FUL. The predictive efficacy was measured by sensitivity, specificity, positive and negative predictive value, and area under the receiver's operating characteristic curve (AUROC). Results: A total of 15 (0.63%) patients developed septic shock. There were 86 (3.64%) patients who were SIRS positive and 69 (2.92%) patients who were qSOFA positive. The pre- and postoperative WBC ratios in septic shock patients and normal patients were 2.50 ± 1.55 and 0.69 ± 0.24, respectively (p < 0.001). For sensitivity and negative predictive value, all reached 100%. For specificity, qSOFA was 97.70%, SIRS was 96.98%, and SIRS combining pre- and postoperative WBC ratio (the new criterion) was 99.79%. The new criterion had statistically significant higher specificity than SIRS or qSOFA (p < 0.001 for both), but when comparing SIRS and qSOFA, it had statistically insignificant specificity (p = 0.142). For positive predictive value, qSOFA was 21.73%, SIRS was 17.44%, and the new criterion was 75%. qSOFA and SIRS had similar AUROC (0.989 for qSOFA and 0.985 for SIRS), both lower than the new criterion (AUROC: 0.999). Conclusions: SIRS combined with pre- and postoperative WBC ratio has a much better specificity and positive predictive value than SIRS or qSOFA alone. It has 99.79% specificity and 75% positive predictive value, and as high as 100% sensitivity and negative predictive value.
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Affiliation(s)
- Cheng Ma
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
| | - Jun Lu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
| | - Yiyong Zhu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
| | - Yujia Huo
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shujie Xia
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
| | - Yi Shao
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
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18
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Koch C, Edinger F, Fischer T, Brenck F, Hecker A, Katzer C, Markmann M, Sander M, Schneck E. Comparison of qSOFA score, SOFA score, and SIRS criteria for the prediction of infection and mortality among surgical intermediate and intensive care patients. World J Emerg Surg 2020; 15:63. [PMID: 33239088 PMCID: PMC7687806 DOI: 10.1186/s13017-020-00343-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/05/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND It is crucial to rapidly identify sepsis so that adequate treatment may be initiated. Accordingly, the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) scores are used to evaluate intensive care unit (ICU) and non-ICU patients, respectively. As demand for ICU beds rises, the intermediate care unit (IMCU) carries greater importance as a bridge between the ICU and the regular ward. This study aimed to examine the ability of SOFA and qSOFA scores to predict suspected infection and mortality in IMCU patients. METHODS Retrospective data analysis included 13,780 surgical patients treated at the IMCU, ICU, or both between January 01, 2012, and September 30, 2018. Patients were screened for suspected infection (i.e., the commencement of broad-spectrum antibiotics) and then evaluated for the SOFA score, qSOFA score, and the 1992 defined systemic inflammatory response syndrome (SIRS) criteria. RESULTS Suspected infection was detected in 1306 (18.3%) of IMCU, 1365 (35.5%) of ICU, and 1734 (62.0%) of IMCU/ICU encounters. Overall, 458 (3.3%) patients died (IMCU 45 [0.6%]; ICU 250 [6.5%]; IMCU/ICU 163 [5.8%]). All investigated scores failed to predict suspected infection independently of the analyzed subgroup. Regarding mortality prediction, the qSOFA score performed sufficiently within the IMCU cohort (AUCROC SIRS 0.72 [0.71-0.72]; SOFA 0.52 [0.51-0.53]; qSOFA 0.82 [0.79-0.84]), while the SOFA score was predictive in patients of the IMCU/ICU cohort (AUCROC SIRS 0.54 [0.53-0.54]; SOFA 0.73 [0.70-0.77]; qSOFA 0.59 [0.58-0.59]). CONCLUSIONS None of the assessed scores was sufficiently able to predict suspected infection in surgical ICU or IMCU patients. While the qSOFA score is appropriate for mortality prediction in IMCU patients, SOFA score prediction quality is increased in critically ill patients.
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Affiliation(s)
- Christian Koch
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany. .,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany.
| | - Fabian Edinger
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
| | - Tobias Fischer
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Florian Brenck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Christian Katzer
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Melanie Markmann
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
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19
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Wang S, Ruan WQ, Yu Z, Zhao X, Chen ZX, Li Q. Validity of presepsin for the diagnosis and prognosis of sepsis in elderly patients admitted to the Intensive Care Unit. Minerva Anestesiol 2020; 86:1170-1179. [DOI: 10.23736/s0375-9393.20.13661-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Li D, Zhang J, Han W, Bai G, Cheng W, Cui N. Evaluation of the updated " Candida score" with Sepsis 3.0 criteria in critically ill patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:917. [PMID: 32953717 PMCID: PMC7475415 DOI: 10.21037/atm-20-995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background The Candida score proposed in 2009 was calculated on the definition of “severe sepsis”, which was removed in the Sepsis 3.0 definition. This study investigated the clinical relevance of Candida score with the updated Sepsis 3.0 definition (CS-3.0) instead of severe sepsis (CS-2009) in the new admitted critically ill patients. Methods We performed a retrospective analysis on a single center public database. All patients with ICU stay ≥72 hours were included in this study. The Candida score was calculated based on the data collected on ICU admission. The incidence of invasive candidiasis was determined and its relationship with the CS-2009 and CS-3.0 was studied. Results A total of 17,666 patients were identified after screening 58,976 hospital admissions, and 436 cases (2.5%) were diagnosed with invasive candidiasis. In the infection group, the number of patients who met the Sepsis 3.0 criteria was greater than the number of patients with severe sepsis (81.2% vs. 78.4%, P<0.005). The area under curve of the CS-2009 was 0.789 (95% CI: 0.765–0.813) and the CS-3.0 was 0.804 (95% CI: 0.782–0.827). Conclusions Our study confirmed the clinical relevance and comparative superiority of the updated Candida score model, using the Sepsis 3.0 definition, compared with the classic sepsis/severe sepsis model, in assessment of critically ill patients. Considering the clinical importance of organ dysfunction in ICI, the Sepsis 3.0 should be used as the basis for prediction of invasive candidiasis.
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Affiliation(s)
- Dongkai Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Jiahui Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Wen Han
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Guangxu Bai
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Wei Cheng
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
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21
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Bloos F. The importance of a hospital-dedicated sepsis response team. Expert Rev Anti Infect Ther 2020; 18:1235-1243. [DOI: 10.1080/14787210.2020.1794813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Frank Bloos
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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22
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Font MD, Thyagarajan B, Khanna AK. Sepsis and Septic Shock - Basics of diagnosis, pathophysiology and clinical decision making. Med Clin North Am 2020; 104:573-585. [PMID: 32505253 DOI: 10.1016/j.mcna.2020.02.011] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sepsis and septic shock are major causes of mortality among hospitalized patients. The sepsis state is due to dysregulated host response to infection, leading to inflammatory damage to nearly every organ system. Early recognition of sepsis and appropriate treatment with antibiotics, fluids, and vasopressors is essential to reducing organ system injury and mortality. This review summarizes the current understanding of the epidemiology, pathophysiology, diagnosis, and treatment of sepsis and septic shock.
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Affiliation(s)
- Michael D Font
- Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, 1, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Braghadheeswar Thyagarajan
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, 1, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, 1, Medical Center Boulevard, Winston-Salem, NC 27157, USA; Outcomes Research Consortium, Cleveland, OH 44195, USA.
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23
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Oxidative stress and ER stress may contribute to drug-induced hepatitis in tuberculous meningitis. J Neurol Sci 2020; 414:116825. [DOI: 10.1016/j.jns.2020.116825] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/04/2020] [Accepted: 04/06/2020] [Indexed: 12/20/2022]
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Hanna MOF, Abdelhameed AM, Abou-Elalla AA, Hassan RM, Kostandi I. Neutrophil and monocyte receptor expression in patients with sepsis: implications for diagnosis and prognosis of sepsis. Pathog Dis 2020; 77:5581499. [PMID: 31584643 DOI: 10.1093/femspd/ftz055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/03/2019] [Indexed: 12/16/2022] Open
Abstract
Understanding the complex immune responses in sepsis is crucial to provide insight into the clinical syndrome. We evaluated the changes in the surface receptors of the cells of innate immunity, neutrophils and monocytes, in patients with sepsis. Since sepsis remains a clinical challenge, we aimed to assess the significance of altered receptor expression in diagnosis and prognosis. Critically ill patients with sepsis (n=31) were investigated for the expression of receptors for IgG heavy chain CD64 and CD16 on neutrophils and CD64 and the lipopolysaccharide receptor CD14 on monocytes by flow cytometry and compared to 23 patients with no sepsis. Patients with sepsis had increased expression of neutrophil CD64. Neutrophil CD64 was specific for discriminating patients with sepsis but showed weak sensitivity. When integrated in a scoring system, neutrophil CD64 in combination with C-reactive protein (CRP) and SOFA score showed a diagnostic accuracy of 0.93 for sepsis and significantly predicted increased mortality risk. While neutrophil CD16 did not discriminate for sepsis, decreased expression was associated with increased mortality risk. In contrast, monocyte CD64 and CD14 expression was unaltered in sepsis and was not associated with mortality risk. Our study demonstrates that unlike monocytes, neutrophil receptor expression is altered in patients with sepsis receiving intensive care. It is promising to apply a combination approach to diagnose sepsis especially in time-limited conditions.
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Affiliation(s)
- Mariam Onsy F Hanna
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Al-Saray st., Al-Manial, 11532, Egypt
| | - Asmaa M Abdelhameed
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Al-Saray st., Al-Manial, 11532, Egypt
| | - Amany A Abou-Elalla
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Misr University for Science and Technology, 6th of October City, Al-Motamyez District, 77, Egypt
| | - Reem M Hassan
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Al-Saray st., Al-Manial, 11532, Egypt
| | - Inas Kostandi
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Al-Saray st., Al-Manial, 11532, Egypt
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25
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Haas LEM, Termorshuizen F, Lange DW, Dijk D, Keizer NF. Performance of the quick SOFA in very old ICU patients admitted with sepsis. Acta Anaesthesiol Scand 2020; 64:508-516. [PMID: 31885070 DOI: 10.1111/aas.13536] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/07/2019] [Accepted: 12/21/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND The number of very elderly ICU patients (abbreviated to VOPs; ≥80 years) with sepsis increases. Sepsis was redefined in 2016 (sepsis 3.0) using the quick SOFA (qSOFA) score. Since then, multiple studies have validated qSOFA for prognostication in different patient categories, but the prognostic value in VOPs with sepsis is still unknown. METHODS Retrospective cohort study including patients admitted to Dutch ICUs with sepsis, in the period 2012 to 2016, evaluating the outcome and the performance of qSOFA, an extended qSOFA model, SOFA, SAPS II, and APACHE IV for hospital mortality. RESULTS 5969 patients were included, of which 935 VOPs. Crude hospital mortality rates were 19%, 28%, and 39% for patients aged 18-65, 65-80, and ≥80 years respectively. Discriminative performance of qSOFA for in-hospital mortality in VOPs was poor (AUC 0.596) and lower than that of SOFA, APACHE IV, and SAPS II (0.704, 0.722, and 0.780 respectively). A qSOFA model extended with several other characteristics (AUC 0.643) was non-inferior to the full SOFA, but still inferior to APACHE IV and SAPS II, for all age groups. The Hosmer-Lemeshow goodness-of-fit test showed non-significant p-values for all models. Accuracy for both qSOFA and the extended qSOFA was lower compared to APACHE IV and SAPS II (Brier scores 0.227, 0.223, 0.184, and 0.183 respectively). CONCLUSION The qSOFA showed worse discriminative performance to predict mortality than SOFA, APACHE IV, and SAPS II in both VOPs and younger patients admitted with sepsis.
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Affiliation(s)
- Lenneke E. M. Haas
- Department of Intensive Care Diakonessenhuis Utrecht Utrecht the Netherlands
| | - Fabian Termorshuizen
- Department of Medical Informatics Amsterdam Public Health Research Institute Amsterdam UMC University of Amsterdam Amsterdam the Netherlands
- National Intensive Care Evaluation (NICE) Foundation Amsterdam the Netherlands
| | - Dylan W. Lange
- Department of Intensive Care University Medical Center University Utrecht Utrecht the Netherlands
| | - Diederik Dijk
- Department of Intensive Care University Medical Center University Utrecht Utrecht the Netherlands
| | - Nicolette F. Keizer
- Department of Medical Informatics Amsterdam Public Health Research Institute Amsterdam UMC University of Amsterdam Amsterdam the Netherlands
- National Intensive Care Evaluation (NICE) Foundation Amsterdam the Netherlands
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26
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Schubel L, Muthu N, Karavite D, Arnold R, Miller K. Design for cognitive support. DESIGN FOR HEALTH 2020:227-250. [DOI: 10.1016/b978-0-12-816427-3.00012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Yu R, Zhou Q, Jiang S, Mei Y, Wang M. Combination of 16S rRNA and procalcitonin in diagnosis of neonatal clinically suspected sepsis. J Int Med Res 2019; 48:300060519892418. [PMID: 31854218 PMCID: PMC7782951 DOI: 10.1177/0300060519892418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective To investigate the application of 16S rRNA in diagnosing patients with
neonatal sepsis. Methods We studied 60 consecutive neonatal patients with clinically suspected sepsis
and 20 non-infective cases as controls. All patients were diagnosed with
sepsis by clinical and experimental criteria. Clinical characteristics were
recorded and 16S rRNA sequencing was conducted for all patients. The
sensitivity, specificity, and accuracy of the detection methods were
analyzed. Results The detection limit of 16S rRNA sequencing was 1 × 102 CFU/mL. For
suspected sepsis, the positive rate of 16S rRNA detection was 93.3%, which
was similar to that of procalcitonin detection (85%), and was significantly
higher than that of bacterial culture (51.7%). The specificity of
procalcitonin detection (74.1%) was significantly lower than that of 16S
rRNA detection (100%). Moreover, the combination of 16S rRNA and
procalcitonin detection showed a sensitivity of 100%, specificity of 74.1%,
and accuracy of 92.0%. For proven sepsis, the sensitivity and specificity of
16S rRNA detection were both 100.0%, and those for procalcitonin were 87.1%
and 87.0%, respectively. Conclusion Detection of 16S rRNA has high sensitivity and specificity in diagnosing
sepsis. The combination of 16S rRNA and procalcitonin has even better
sensitivity with acceptable specificity.
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Affiliation(s)
- Renqiang Yu
- Department of Neonatology, The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Qin Zhou
- Department of Neonatology, The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Shanyu Jiang
- Department of Neonatology, The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Yingzi Mei
- Department of Neonatology, The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Min Wang
- Department of Neonatology, The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
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Lee J, Song JU. Performance of a quick sofa-65 score as a rapid sepsis screening tool during initial emergency department assessment: A propensity score matching study. J Crit Care 2019; 55:1-8. [PMID: 31670148 DOI: 10.1016/j.jcrc.2019.09.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/04/2019] [Accepted: 09/16/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE We sought to elucidate the performance of a Quick Sequential Organ Function Assessment-65 (qSOFA-65) score in recognizing sepsis and to compare the qSOFA-65 score to systemic inflammatory response syndrome (SIRS) and qSOFA scores. METHODS We performed a matched case-control study using propensity score matching. The number of patients meeting qSOFA-65, qSOFA, and SIRS positive criteria were calculated between the sepsis and non-sepsis groups. We compared the diagnostic performance of the three scoring systems in predicting sepsis. RESULTS A total of 2441 patients were included in the study. In propensity matched cohorts, the percentage of patients who met qSOFA-65, qSOFA, and SIRS positive criteria were 46.7%, 14.3%, and 55.6%, respectively. The sensitivity and specificity scores for the qSOFA-65, qSOFA, and SIRS positive criteria for sepsis were 0.66 and 0.73, 0.28 and 0.97, and 0.66 and 0.55, respectively. The AUC value of qSOFA-65 positive criteria in predicting sepsis was significantly higher than that of qSOFA and SIRS positive criteria (adjusted AUC 0.688 vs. 0.630 vs. 0.596, respectively). CONCLUSIONS We found that qSOFA-65 was more likely to identify patients with sepsis on the initial ED visit relative to qSOFA or SIRS. This may have quality improvement implications in predicting sepsis.
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Affiliation(s)
- Jonghoo Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, South Korea.
| | - Jae-Uk Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Comparative Usefulness of Sepsis-3, Burn Sepsis, and Conventional Sepsis Criteria in Patients With Major Burns. Crit Care Med 2019; 46:e656-e662. [PMID: 29620554 DOI: 10.1097/ccm.0000000000003144] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We evaluated the ability of new sepsis (S3) criteria (compared with previous definitions of sepsis [S1] and burn sepsis criteria) to accurately determine the mortality in severe burns patients with sepsis. DESIGN This was retrospective cohort study. SETTING The Burn ICU of Burn Center, Hangang Sacred Heart Hospital, Hallym University, Seoul, Korea. PATIENTS A total of 1,185 adult patients (mean age, 49.1 yr) were admitted between January 2009 and December 2015. INTERVENTIONS The 1,185 patients enrolled in the present study and were then re-evaluated based on S1, burn sepsis, and S3 criteria, following which 565 patients, 812 patients, and 809 patients were diagnosed with sepsis based on S1, burn sepsis, S3 criteria, respectively. MEASUREMENTS AND MAIN RESULTS For diagnostic performance, sensitivity, specificity, predictive value, and likelihood ratio were calculated. The area under the curve of the receiver operating characteristic curve was calculated to determine the accuracy of mortality prediction. The optimal cutoff value of Sequential Organ Failure Assessment score was calculated by the decision tree method. Total body surface area burned was 33.4%. Patients were identified with sepsis using S1 (812), S3 (809), and burn sepsis (565) criteria. Overall mortality was 20.3%, highest (82.2%) and lowest (26.5%) occurred with new septic shock (SH3) and S3, respectively. The sensitivity and specificity for burn sepsis (84.6% and 61.8%) and SH3 (63.1% and 96.5%) were reported. Area under the curve values for Sequential Organ Failure Assessment scores were the highest in all sepsis categories. With Sequential Organ Failure Assessment score greater than or equal to 6 (with infection), the accuracy was 0.86 (95% CI, 0.82-0.89). CONCLUSIONS The S3 criteria failed to show superior prognostic accuracy for mortality in severely burned patients. Sequential Organ Failure Assessment score greater than or equal to 6 may be a better criterion for the diagnosis of sepsis in burns patients.
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Predictive Validity of Sepsis-3 Definitions and Sepsis Outcomes in Critically Ill Patients: A Cohort Study in 49 ICUs in Argentina. Crit Care Med 2019; 46:1276-1283. [PMID: 29742584 DOI: 10.1097/ccm.0000000000003208] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The new Sepsis-3 definitions have been scarcely assessed in low- and middle-income countries; besides, regional information of sepsis outcomes is sparse. Our objective was to evaluate Sepsis-3 definition performance in Argentina. DESIGN Cohort study of 3-month duration beginning on July 1, 2016. SETTINGS Forty-nine ICUs. PATIENTS Consecutive patients admitted to the ICU with suspected infection that triggered blood cultures and antibiotic administration. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were classified as having infection, sepsis (infection + change in Sequential Organ Failure Assessment ≥ 2 points), and septic shock (vasopressors + lactate > 2 mmol/L). Patients on vasopressors and lactate less than or equal to 2 mmol/L (cardiovascular dysfunction) were analyzed separately, as those on vasopressors without serum lactate measurement. Systemic inflammatory response syndrome was also recorded. Main outcome was hospital mortality. Of 809 patients, 6% had infection, 29% sepsis, 20% cardiovascular dysfunction, 40% septic shock, and 3% received vasopressors with lactate unmeasured. Hospital mortality was 13%, 20%, 39%, 51%, and 41%, respectively (p = 0.000). Independent predictors of outcome were lactate, Sequential Organ Failure Assessment score, comorbidities, prior duration of symptoms (hr), mechanical ventilation requirement, and infection by highly resistant microorganisms. Area under the receiver operating characteristic curves for mortality for systemic inflammatory response syndrome and Sequential Organ Failure Assessment were 0.53 (0.48-0.55) and 0.74 (0.69-0.77), respectively (p = 0.000). CONCLUSIONS Increasing severity of Sepsis-3 categories adequately tracks mortality; cardiovascular dysfunction subgroup, not included in Sepsis-3, has distinct characteristics. Sequential Organ Failure Assessment score shows adequate prognosis accuracy-contrary to systemic inflammatory response syndrome. This study supports the predictive validity of Sepsis-3 definitions.
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Tai HCH, Yeh CC, Chen YA, Hsu CC, Chen JH, Chen WL, Huang CC, Chung JY. Utilization of systemic inflammatory response syndrome criteria in predicting mortality among geriatric patients with influenza in the emergency department. BMC Infect Dis 2019; 19:639. [PMID: 31324224 PMCID: PMC6642574 DOI: 10.1186/s12879-019-4288-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/15/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Systemic Inflammatory Response Syndrome (SIRS) criteria are often used to evaluate the risk of sepsis and to identify in-hospital mortality among patients with suspected infection. However, utilization of the SIRS criteria in mortality prediction among geriatric patients with influenza in the emergency department (ED) remains unclear. Therefore, we conducted a research to delineate this issue. METHODS This is a retrospective case-control study including geriatric patients (age ≥ 65 years) with influenza, who presented to the ED of a medical center between January 1, 2010 and December 31, 2015. Vital signs, past history, subtype of influenza, demographic data, and outcomes were collected from all patients and analyzed. We calculated the accuracy for predicting 30-days mortality using the SIRS criteria. We also performed covariate adjustment of the area under the receiver operating characteristic curve (AUROC) via regression modeling. RESULTS We recruited a total of 409 geriatric patients in the ED, with mean age 79.5 years and an equal sex ratio. The mean SIRS criteria score was 1.9 ± 1.1. The result of a Hosmer-Lemeshow goodness-of-fit test was 0.34 for SIRS criteria. SIRS criteria score ≥ 3 showed better mortality prediction, with odds ratio (OR) 3.37 (95% confidence interval (CI), 1.05-10.73); SIRS score ≥ 2 showed no statistical significance, with p = 0.85 (OR, 1.15; 95% CI, 0.28-4.69). SIRS score ≥ 3 had acceptable 30-days mortality discrimination, with AUROC 0.77 (95% CI, 0.68-0.87) after adjustment. SIRS score ≥ 3 also had a notable negative predictive value of 0.97 (95% CI, 0.94-0.99). CONCLUSION The presence of a higher number of SIRS criteria (≥ 3) showed greater accuracy for predicting mortality among geriatric patients with influenza.
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Affiliation(s)
| | - Chien-Chun Yeh
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Yen-An Chen
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jiann-Hwa Chen
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
- Fu Jen Catholic University School of Medicine, Taipei, Taiwan
| | - Wei-Lung Chen
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
- Fu Jen Catholic University School of Medicine, Taipei, Taiwan
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Senior Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jui-Yuan Chung
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
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Yeh CC, Chen YA, Hsu CC, Chen JH, Chen WL, Huang CC, Chung JY. Quick-SOFA score ≥ 2 predicts prolonged hospital stay in geriatric patients with influenza infection. Am J Emerg Med 2019; 38:780-784. [PMID: 31272756 DOI: 10.1016/j.ajem.2019.06.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 06/17/2019] [Accepted: 06/23/2019] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The quick Sepsis-Related Organ Failure Assessment (qSOFA) score was designed to predict mortality among sepsis patients. However, it has never been used to identify prolonged length of hospital stay (pLOS) in geriatric patients with influenza infection. We conducted this study to clarify this issue. METHODS We conducted a retrospective case-control study, including geriatric patients (aged ≥ 65 years) with influenza infection visiting the emergency department (ED) of a medical center between January 01, 2010 and December 31, 2015. The included patients were divided into two groups on the basis of their qSOFA score: qSOFA < 2, and qSOFA ≥ 2. Data regarding demographics, vital signs, qSOFA score, underlying diseases, subtypes of influenza, and outcomes were included in the analysis. We investigated the association between qSOFA score ≥ 2 and pLOS (>9 days) via logistic regression. RESULTS Four hundred and nine geriatric patients were included in this study with a mean age of 79.5 (standard deviation [SD], 8.3) years. The median length of stay (LOS) was 7.0 (interquartile range [IQR], 4-12) days, while the rate of pLOS (> 9 days) was 32%. The median LOS in the qSOFA ≥ 2 group, 11.0 (7-15) days, was longer than the qSOFA < 2 group, 6.0 (4-10) days (p-value <0.01). Logistic regression showed that qSOFA ≥ 2 predicts pLOS with an odds ratio of 3.78 (95% confidence interval, 2.04-6.97). CONCLUSION qSOFA score ≥ 2 is a prompt and simple tool to predict pLOS in geriatric patients with influenza infection.
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Affiliation(s)
- Chien-Chun Yeh
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Yen-An Chen
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan; Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jiann-Hwa Chen
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan; Fu Jen Catholic University School of Medicine, Taipei, Taiwan
| | - Wei-Lung Chen
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan; Fu Jen Catholic University School of Medicine, Taipei, Taiwan
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan; Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Senior Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jui-Yuan Chung
- Department of Emergency Medicine, Cathay General Hospital, Taipei, Taiwan.
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Nedeva C, Menassa J, Puthalakath H. Sepsis: Inflammation Is a Necessary Evil. Front Cell Dev Biol 2019; 7:108. [PMID: 31281814 PMCID: PMC6596337 DOI: 10.3389/fcell.2019.00108] [Citation(s) in RCA: 181] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/29/2019] [Indexed: 12/12/2022] Open
Abstract
Sepsis is one of the leading causes of deaths world-wide and yet there are no therapies available other than ICU treatment. The patient outcome is determined by a complex interplay between the pro and anti-inflammatory responses of the body i.e., a homeostatic balance between these two competing events to be achieved for the patient’s recovery. The initial attempts on drug development mainly focused on controlling inflammation, however, without any tangible outcome. This was despite most deaths occurring during the immune paralysis stage of this biphasic disease. Recently, the focus has been shifting to understand immune paralysis (caused by apoptosis and by anti-inflammatory cytokines) to develop therapeutic drugs. In this review we put forth an argument for a proper understanding of the molecular basis of inflammation as well as apoptosis for developing an effective therapy.
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Affiliation(s)
- Christina Nedeva
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
| | - Joseph Menassa
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
| | - Hamsa Puthalakath
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
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Kelly B, Patlak J, Shaefi S, Boone D, Mueller A, Talmor D. Evaluation of qSOFA as a Predictor of Mortality Among ICU Patients With Positive Clinical Cultures-A Retrospective Cohort Study. J Intensive Care Med 2019; 35:1278-1284. [PMID: 31208272 DOI: 10.1177/0885066619856852] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the discriminative value of the quick-sequential organ failure assessment score (qSOFA) to SOFA in a critically ill population, in which a microbial pathogen was isolated within 48 hours of admission to intensive care. DESIGN Retrospective cohort study. SETTING Academic tertiary referral center from July 2008 to June 2017. PATIENTS Hospitalized patients admitted to intensive care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was in-hospital mortality for all patients with confirmed positive microbiological cultures within 48 hours of admission to intensive care unit (ICU). Subgroup analysis was performed on patients with pathogenic bacteremia or positive cultures in cerebrospinal fluid. Of the 11 415 patients analyzed with positive microbiology specimens within 48 hours of admission, 2933 (25.7%) had a qSOFA ≥2. Of these, 16.6% reached the primary outcome of in-hospital mortality. Unsurprisingly, the discriminative value of qSOFA on admission was significantly worse than that of SOFA (0.73 vs 0.76; P = .0004), despite observing a significant association between qSOFA category and in-hospital mortality (P < .0001). In secondary analyses, similar observations were found using qSOFA within 6 and 24 hours of ICU admission. When analysis was focused on patients with pathogenic bacteremia or positive cerebrospinal fluid (CSF) cultures (n = 1646), there was no significant difference between the discriminative value of qSOFA and SOFA (0.75 vs 0.78; P = .17). CONCLUSIONS Quick-sequential organ failure assessment score at admission was not superior to SOFA in predicting in-hospital mortality in patients with positive clinical cultures within 48 hours of admission to ICU. Quick-sequential organ failure assessment score at admission to the ICU was associated with mortality and showed reasonable calibration and discrimination. When the analysis was focused on patients with pathogenic bacteremia or positive CSF cultures, qSOFA performed similarly to SOFA in discriminatory those who will die from sepsis.
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Affiliation(s)
- Barry Kelly
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Johann Patlak
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Shahzad Shaefi
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dustin Boone
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ariel Mueller
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel Talmor
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
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Mathematical modeling of septic shock: an innovative tool for assessing therapeutic hypotheses. SN APPLIED SCIENCES 2019. [DOI: 10.1007/s42452-019-0747-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Chang SH, Yeh CC, Chen YA, Hsu CC, Chen JH, Chen WL, Huang CC, Chung JY. Quick-SOFA score to predict mortality among geriatric patients with influenza in the emergency department. Medicine (Baltimore) 2019; 98:e15966. [PMID: 31169726 PMCID: PMC6571376 DOI: 10.1097/md.0000000000015966] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The quick sequential organ failure assessment (qSOFA) score is widely used to assess the risk of sepsis and predict in-hospital mortality in patients with suspected infection. However, its ability to predict mortality among geriatric patients with influenza in the emergency department (ED) remains unclear. Therefore, this study was conducted to delineate this issue.A retrospective case-control study was conducted on geriatric patients (age ≥65 years) with influenza who visited the ED of a medical center between January 01, 2010, and December 31, 2015. Demographic data, vital signs, past histories, influenza subtypes, and treatment outcomes were included in the analysis. We assessed the accuracy of the qSOFA score in predicting 30-day mortality via logistic regression. Covariate adjustment of the area under the receiver operating characteristic curve (AUROC) via regression modeling was performed too.In total, 409 geriatric ED patients with mean age of 79.5 years and nearly equal sex ratio were recruited. The mean qSOFA score was 0.55 ± 0.7. The Hosmer-Lemeshow goodness-of-fit test was 0.79 for qSOFA score. Patients with qSOFA score of ≥2 (odds ratio, 4.21; 95% confidence interval [CI], 1.56-11.40) had increased in-hospital mortality. qSOFA score of ≥2 also had excellent in-hospital mortality discrimination with an adjusted AUROC of 0.81 (95% CI, 0.71-0.90). A qSOFA of ≥2 had prominent specificity of 0.89 (95% CI, 0.86-0.92).An increase in qSOFA score of 2 greatly predicts mortality in geriatric patients with influenza.
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Affiliation(s)
- Su-Hen Chang
- Department of Emergency Medicine, Cathay General Hospital
| | - Chien-Chun Yeh
- Department of Emergency Medicine, Cathay General Hospital
| | - Yen-An Chen
- Department of Emergency Medicine, Cathay General Hospital
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi-Mei Medical Center
- Department of Biotechnology, Southern Taiwan University of Science and Technology
| | - Jiann-Hwa Chen
- Department of Emergency Medicine, Cathay General Hospital
- Fu Jen Catholic University School of Medicine
| | - Wei-Lung Chen
- Department of Emergency Medicine, Cathay General Hospital
- Fu Jen Catholic University School of Medicine
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi-Mei Medical Center
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University
- Department of Senior Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jui-Yuan Chung
- Department of Emergency Medicine, Cathay General Hospital
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Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:196. [PMID: 31151462 PMCID: PMC6545004 DOI: 10.1186/s13054-019-2478-6] [Citation(s) in RCA: 229] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/15/2019] [Indexed: 12/20/2022]
Abstract
Background Septic shock is the most severe form of sepsis, in which profound underlying abnormalities in circulatory and cellular/metabolic parameters lead to substantially increased mortality. A clear understanding and up-to-date assessment of the burden and epidemiology of septic shock are needed to help guide resource allocation and thus ultimately improve patient care. The aim of this systematic review and meta-analysis was therefore to provide a recent evaluation of the frequency of septic shock in intensive care units (ICUs) and associated ICU and hospital mortality. Methods We searched MEDLINE, Embase, and the Cochrane Library from 1 January 2005 to 20 February 2018 for observational studies that reported on the frequency and mortality of septic shock. Four reviewers independently selected studies and extracted data. Disagreements were resolved via consensus. Random effects meta-analyses were performed to estimate pooled frequency of septic shock diagnosed at admission and during the ICU stay and to estimate septic shock mortality in the ICU, hospital, and at 28 or 30 days. Results The literature search identified 6291 records of which 71 articles met the inclusion criteria. The frequency of septic shock was estimated at 10.4% (95% CI 5.9 to 16.1%) in studies reporting values for patients diagnosed at ICU admission and at 8.3% (95% CI 6.1 to 10.7%) in studies reporting values for patients diagnosed at any time during the ICU stay. ICU mortality was 37.3% (95% CI 31.5 to 43.5%), hospital mortality 39.0% (95% CI 34.4 to 43.9%), and 28-/30-day mortality 36.7% (95% CI 32.8 to 40.8%). Significant between-study heterogeneity was observed. Conclusions Our literature review reaffirms the continued common occurrence of septic shock and estimates a high mortality of around 38%. The high level of heterogeneity observed in this review may be driven by variability in defining and applying the diagnostic criteria, as well as differences in treatment and care across settings and countries. Electronic supplementary material The online version of this article (10.1186/s13054-019-2478-6) contains supplementary material, which is available to authorized users.
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CE: A Review of the Revised Sepsis Care Bundles. Am J Nurs 2019; 118:40-49. [PMID: 30004905 DOI: 10.1097/01.naj.0000544139.63510.b5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
: Sepsis is an extreme response to infection that can cause tissue damage, organ failure, and death if not treated promptly and appropriately. Each year in the United States, sepsis affects more than 1.5 million people and kills roughly 250,000. Prompt recognition and treatment of sepsis are essential to saving lives, and nurses play a critical role in the early detection of sepsis, as they are often first to recognize the signs and symptoms of infection. Here, the authors review recent revisions to the sepsis care bundles and discuss screening and assessment tools nurses can use to identify sepsis in the ICU, in the ED, on the medical-surgical unit, and outside the hospital.
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Luo J, Jiang W, Weng L, Peng J, Hu X, Wang C, Liu G, Huang H, Du B. Usefulness of qSOFA and SIRS scores for detection of incipient sepsis in general ward patients: A prospective cohort study. J Crit Care 2019; 51:13-18. [PMID: 30685579 DOI: 10.1016/j.jcrc.2019.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE To prospectively assess the diagnostic value of quick Sequential Organ Failure Assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores for sepsis in ward patients with infections. MATERIALS AND METHODS Consecutive patients admitted with infection or developing infection during hospital stay were included. All variables for calculating qSOFA, SIRS, and SOFA scores were collected, and the maximum scores were determined until hospital discharge, death, or day 28, whichever occurred earlier. The primary outcome was sepsis at 28 days. Diagnostic and prognostic values were assessed using the area under the receiver operating characteristic curve (AUROC) with the conventional cutoff value of 2. RESULTS Of 409 general ward patients, 146 patients and 371 patients met qSOFA and SIRS criteria, 229 patients developed sepsis. Although qSOFA score had a better overall diagnostic performance of sepsis (AUROC 0.75 vs. 0.69), it had a much lower sensitivity (53% vs. 98%) and higher specificity (87% vs. 18%) than SIRS score. In addition, qSOFA score had a better prognostic value than SIRS score (AUROC 0.86 vs. 0.67). CONCLUSIONS Neither SIRS score nor qSOFA score could serve as an ideal screening tool for early identification sepsis, whereas qSOFA score might help to identify patients with higher risk of poor clinical outcome. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02930070.
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Affiliation(s)
- Jingchao Luo
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China; Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - Wei Jiang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Li Weng
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Jinmin Peng
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Xiaoyun Hu
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Chunyao Wang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Guangyun Liu
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Huibin Huang
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China.
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Abstract
Sepsis is defined as organ dysfunction resulting from the host's deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.
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Affiliation(s)
- Jason T Poston
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago
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42
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Yeh CF, Wu CC, Liu SH, Chen KF. Comparison of the accuracy of neutrophil CD64, procalcitonin, and C-reactive protein for sepsis identification: a systematic review and meta-analysis. Ann Intensive Care 2019; 9:5. [PMID: 30623257 PMCID: PMC6325056 DOI: 10.1186/s13613-018-0479-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 12/26/2018] [Indexed: 12/12/2022] Open
Abstract
Background Neutrophil CD64 is widely described as an accurate biomarker for the diagnosis of infection in patients with septic syndrome. We performed a systematic review and meta-analysis to evaluate the diagnostic accuracy of neutrophil CD64, comparing it with C-reactive protein (CRP) and procalcitonin (PCT) for the diagnosis of infection in adult patients with septic syndrome, based on sepsis-2 criteria. We searched the PubMed and Embase databases and Google Scholar. Original studies reporting the performance of neutrophil CD64 for sepsis diagnosis in adult patients were retained. The pooled sensitivity, specificity, diagnostic odds ratio (DOR), and hierarchical summary receiver operating characteristic (SROC) curve were calculated. Results We included 14 studies (2471 patients) from 2006 to 2017 in the meta-analysis. The pooled sensitivity and specificity of neutrophil CD64 for diagnosing infection in adult patients with septic syndrome were 0.87 (95% CI 0.80–0.92) and 0.89 (95% CI 0.82–0.93), respectively. The area under the SROC curve and the DOR were 0.94 (95% CI 0.92–0.96) and 53 (95% CI 22–128), respectively. There was significant heterogeneity between the studies included. Subgroup analyses showed that this heterogeneity was due to differences in sample size and the proportions of patients with sepsis included in the studies. Six studies (927 patients) compared neutrophil CD64 and CRP determinations, and six studies (744 patients) compared neutrophil CD64 and PCT determinations. The area under the SROC curve was larger for neutrophil CD64 than for CRP (0.89 [95% CI 0.87–0.92] vs. 0.84 [95% CI 0.80–0.88], P < 0.05) or PCT (0.89 [95% CI 0.84–0.95] vs. 0.84 [95% CI 0.79–0.89], P < 0.05). Conclusions In adult patients with septic syndrome, neutrophil CD64 levels are an excellent biomarker with moderate accuracy outperforming both CRP and PCT determinations. Electronic supplementary material The online version of this article (10.1186/s13613-018-0479-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chun-Fu Yeh
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chin-Chieh Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Su-Hsun Liu
- Health Management Center, Far Eastern Memorial Hospital, New Taipei, Taiwan.,International Health Program, National Yang Ming University, Taipei, Taiwan
| | - Kuan-Fu Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan. .,Clinical Informatics and Medical Statistics Research Center, Chang Gung University, 5 Fu-Shin Street, Gueishan District, Taoyuan, 333, Taiwan. .,Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.
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43
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Automated Deterioration Detection Using Electronic Medical Record Data in Intensive Care Unit Patients: A Systematic Review. Comput Inform Nurs 2018; 36:323-330. [PMID: 29990313 DOI: 10.1097/cin.0000000000000430] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Timely detection of deterioration in status for intensive care unit patients can be problematic due to variation in data availability and the necessity of integrating data from multiple sources. This can lead to opaqueness of clinical trends and failure to rescue. Automated deterioration detection using electronic medical record data can reduce the risk of failure to rescue. This review describes the automated use of electronic medical record data in identifying deterioration in intensive care unit patients. PubMed and Google Scholar were used to retrieve publications between January 1, 2006, and March 31, 2016. Six studies met inclusion criteria: intensive care unit patient focus, description of electronic medical record data use in automated patient deterioration detection, and presence of predictive, sensitivity, and/or specificity values. Detection focused on specific clinical events such as infection; data sources were electronic medical record-populated databases. Detection algorithms incorporated laboratory results, vital signs, medication orders, and respiratory therapy and radiology documentation. Positive and negative predictive values and sensitivity and specificity measures varied across studies. Three systems generated clinician alerts. Automated deterioration detection using electronic medical record data may be an important aid in caring for intensive care unit patients, but its usefulness is limited by variable electronic medical record detection approaches and performance.
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44
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Fernando SM, Rochwerg B, Reardon PM, Thavorn K, Seely AJE, Perry JJ, Barnaby DP, Tanuseputro P, Kyeremanteng K. Emergency Department disposition decisions and associated mortality and costs in ICU patients with suspected infection. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:172. [PMID: 29976238 PMCID: PMC6034286 DOI: 10.1186/s13054-018-2096-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/15/2018] [Indexed: 12/29/2022]
Abstract
Background Following emergency department (ED) assessment, patients with infection may be directly admitted to the intensive care unit (ICU) or alternatively admitted to hospital wards or sent home. Those admitted to the hospital wards or sent home may experience future deterioration necessitating ICU admission. Methods We used a prospectively collected registry from two hospitals within a single tertiary care hospital network between 2011 and 2014. Patient information, outcomes, and costs were stored in the hospital data warehouse. Patients were categorized into three groups: (1) admitted directly from the ED to the ICU; (2) initially admitted to the hospital wards, with ICU admission within 72 hours of initial presentation; or (3) sent home from the ED, with ICU admission within 72 hours of initial presentation. Using multivariable logistic regression, we sought to compare outcomes and total costs between groups. Total costs were evaluated using a generalized linear model. Results A total of 657 patients were included; of these, 338 (51.4%) were admitted directly from the ED to the ICU, 246 (37.4%) were initially admitted to the wards and then to the ICU, and 73 (11.1%) were initially sent home and then admitted to the ICU. In-hospital mortality was lowest among patients admitted directly to the ICU (29.5%), as compared with patients admitted to the ICU from wards (42.7%) or home (61.6%) (P < 0.001). As compared with direct ICU admission, disposition to the ward was associated with an adjusted OR of 1.75 (95% CI, 1.22–2.50; P < 0.01) for mortality, and disposition home was associated with an adjusted OR of 4.02 (95% CI, 2.32–6.98). Mean total costs were lowest among patients directly admitted to the ICU ($26,748), as compared with those admitted from the wards ($107,315) and those initially sent home ($71,492) (P < 0.001). Cost per survivor was lower among patients directly admitted to the ICU ($37,986) than either those initially admitted to the wards ($187,230) or those sent home ($186,390) (P < 0.001). Conclusions In comparison with direct admission to the ICU, patients with suspected infection admitted to the ICU who have previously been discharged home or admitted to the ward are associated with higher in-hospital mortality and costs. Electronic supplementary material The online version of this article (10.1186/s13054-018-2096-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Peter M Reardon
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Andrew J E Seely
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Douglas P Barnaby
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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45
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Jain S. Sepsis: An Update on Current Practices in Diagnosis and Management. Am J Med Sci 2018; 356:277-286. [PMID: 30286823 DOI: 10.1016/j.amjms.2018.06.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 12/15/2022]
Abstract
Despite several advancements in care over the last few decades, sepsis continues to carry a high morbidity and mortality burden in the United States. With its varied presentations, cases of sepsis are likely to be encountered by general practitioners in both inpatient and outpatient settings. In the recent years, there has been much debate about the appropriate criteria to diagnose patients with sepsis with a concurrent change in management guidelines. This article reviews definitions, diagnosis and treatment guidelines in current practice in the management of patients with sepsis.
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Affiliation(s)
- Snigdha Jain
- Division of Hospital Medicine, UT Southwestern Medical Center, Dallas, Texas.
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46
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Arora R, Sahni N. Can serum Procalcitonin aid in the diagnosis of blood stream infection in patients on immunosuppressive medications? Clin Chim Acta 2018; 483:204-208. [PMID: 29730396 DOI: 10.1016/j.cca.2018.05.002] [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: 01/12/2018] [Revised: 04/27/2018] [Accepted: 05/01/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients on immunosuppressive medications may not exhibit the systemic inflammatory response syndrome (SIRS) in the setting of bacterial infection. Our study examines the relationship between serum PCT levels and the odds of manifesting SIRS and BSI in patients on immunosuppressive medications and examines whether this relationship is altered from patients who are not on these medications. The diagnostic performance of Procalcitonin (PCT) detecting BSI in patients on immunosuppressive agents is compared to that in non-immunosuppressed patients. METHODS We tested the association between BSI, serum PCT levels, contemporaneous SIRS scores using logisitic regression in a dataset of 4279 patients. The diagnostic performance of these variables for detecting BSI was assessed. RESULTS In patients on immunosuppressive medications, multivariate logistic regression models demonstrate that while the serum PCT level is associated with BSI (OR: 2.48, p < .05) - the SIRS score is not. At any given serum PCT level, patients on immunosuppressive agents have lower odds of exhibiting SIRS despite having the same odds of having BSI as non-immunosuppressed patients. PCT (AUC: 0.68) performs better than SIRS (AUC: 0.52) in detecting the presence of BSI in patients on immunosuppressive medications. The diagnostic performance of PCT for detecting BSI in immunosuppressed patients is not significantly different from the non-immunosuppressed cohort. CONCLUSIONS As PCT levels rise, patients on immunosuppressive agents are less likely to mount a SIRS response, despite having a high probability of BSI. PCT might prove helpful in this setting as immunosuppressive agents do not alter the diagnostic performance of serum PCT in detecting BSI.
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Affiliation(s)
- Rashi Arora
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Nishant Sahni
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States.
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47
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Cheng B, Li Z, Wang J, Xie G, Liu X, Xu Z, Chu L, Zhao J, Yao Y, Fang X. Comparison of the Performance Between Sepsis-1 and Sepsis-3 in ICUs in China: A Retrospective Multicenter Study. Shock 2018; 48:301-306. [PMID: 28448400 PMCID: PMC5516667 DOI: 10.1097/shk.0000000000000868] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The definition of sepsis was updated to sepsis-3 in February 2016. However, the performance of the previous and new definition of sepsis remains unclear in China. This was a retrospective multicenter study in six intensive care unit (ICUs) from five university-affiliated hospitals to compare the performance between sepsis-1 and sepsis-3 in China. From May 1, 2016 to June 1, 2016, 496 patients were enrolled consecutively. Data were extracted from the electronic clinical records. We evaluated the performance of sepsis-1 and sepsis-3 by measuring the area under the receiver operating characteristic curves (AUROC) to predict 28-day mortality rates. Of 496 enrolled patients, 186 (37.5%) were diagnosed with sepsis according to sepsis-1, while 175 (35.3%) fulfilled the criteria of sepsis-3. The AUROC of systemic inflammatory response syndrome (SIRS) is significantly smaller than that of sequential organ failure assessment (SOFA) (0.55 [95% confidence interval, 0.46–0.64] vs. 0.69 (95% confidence interval, 0.61–0.77], P = 0.008) to predict 28-day mortality rates of infected patients. Moreover, 5.9% infected patients (11 patients) were diagnosed as sepsis according to sepsis-1 but not to sepsis-3. The APACHE II, SOFA scores, and mortality rate of the 11 patients were significantly lower than of patients whose sepsis was defined by both the previous and new criteria (8.6±3.5 vs. 16.3±6.2, P = < 0.001; 1 (0–1) vs. 6 (4–8), P = <0.001; 0.0 vs. 33.1%, P = 0.019). In addition, the APACHE II, length of stay in ICU, and 28-day mortality rate of septic patients rose gradually corresponding with the raise in SOFA score (but not the SIRS score). Sepsis-3 performed better than sepsis-1 in the study samples in ICUs in China.
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Affiliation(s)
- Baoli Cheng
- *Department of Anesthesiology, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China †Trauma Research Center, The First Hospital Affiliated to the PLA General Hospital, Beijing, China
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Nakayama I, Izawa J, Mouri H, Kitamura T, Shiotsuka J. Mortality and detailed characteristics of pre-ICU qSOFA-negative patients with suspected sepsis: an observational study. Ann Intensive Care 2018; 8:44. [PMID: 29616433 PMCID: PMC5882475 DOI: 10.1186/s13613-018-0389-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 03/21/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Recent studies have suggested that quick Sequential Organ Failure Assessment (qSOFA) scores have limited utility in early prognostication in high-mortality populations. The purpose of this study was to investigate the association between pre-ICU qSOFA scores and in-hospital mortality among patients admitted to the ICU with suspected sepsis. This study also aimed to describe detailed clinical characteristics of qSOFA-negative (< 2) patients. METHODS This single center, observational study, conducted in a Japanese tertiary care teaching hospital between May 2012 and June 2016, enrolled all consecutive adult patients admitted to the ICU with suspected sepsis. We assessed pre-ICU qSOFA scores with the most abnormal vital signs during the 24-h period before ICU admission. The primary outcome was in-hospital mortality censored at 90 days. We analyzed the association between pre-ICU qSOFA scores and in-hospital mortality. RESULTS Among 185 ICU patients with suspected sepsis, 14.1% (26/185) of patients remained qSOFA-negative at the time of ICU admission and 29.2% (54/185) of patients died while in hospital. In-hospital mortality was similar between the groups (qSOFA-positive [≥ 2]: 30.2% [48/159] vs qSOFA-negative: 23.1% [6/26], p = 0.642). The Cox proportional hazard regression model revealed that being qSOFA-positive was not significantly associated with in-hospital mortality (adjusted hazard ratio 1.35, 95% confidence interval 0.56-3.22, p = 0.506). Bloodstream infection, immunosuppression, and hematologic malignancy were observed more frequently in qSOFA-negative patients. CONCLUSIONS Among ICU patients with suspected sepsis, we could not find a strong association between pre-ICU qSOFA scores and in-hospital mortality. Our study suggested high mortality and bacterial diversity in pre-ICU qSOFA-negative patients.
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Affiliation(s)
- Izumi Nakayama
- Intensive Care Unit, Department of Internal Medicine, Okinawa Chubu Hospital, 281 Miyazato, Uruma, Okinawa, 904-2293, Japan
| | - Junichi Izawa
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18 Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan. .,The Center for Critical Care Nephrology, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA.
| | - Hideyuki Mouri
- Department of Anesthesiology and Critical Care, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma, Oomiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 1-1 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Junji Shiotsuka
- Department of Anesthesiology and Critical Care, Jichi Medical University, Saitama Medical Center, 1-847 Amanuma, Oomiya-ku, Saitama, Saitama, 330-8503, Japan
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Dunitz M, Verghese G, Heldt T. Predicting hyperlactatemia in the MIMIC II database. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2015:985-8. [PMID: 26736429 DOI: 10.1109/embc.2015.7318529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Sepsis, which occurs when an infection leads to a systemic inflammatory response, is believed to contribute to one in two to three hospital deaths in the United States. Using the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC II) database of electronic medical records from Boston's Beth Israel Deaconess Medical Center (BIDMC), we worked to characterize sepsis at BIDMC's intensive care units. Additionally, we developed a real-time algorithm to stratify patients with infectious complaints into different risk categories for progressing to septic shock. From time series of heart rate and arterial blood pressure, as well as estimates of cardiac output and total peripheral resistance, we developed a variety of classifiers to predict high serum lactate levels, a proxy for hypoperfusion and imminent circulatory shock. The records from 146 patients met our selection criteria. In discriminating patients whose measured serum lactate stays below 2.5 mmol/L from those whose value drifts above, the best of our classifiers perform with area under the receiver operating characteristic exceeding 0.8 on test data.
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50
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Kumar M, Kalita J, Tripathi A, Misra UK. Is drug-induced hepatitis related to the severity of tuberculous meningitis? Trans R Soc Trop Med Hyg 2018; 111:520-526. [DOI: 10.1093/trstmh/try006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 01/15/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mritunjai Kumar
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, UP-226014
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, UP-226014
| | - Abhilasha Tripathi
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, UP-226014
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, UP-226014
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