1
|
Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez-Pinto LN, Bennett TD. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024; 331:665-674. [PMID: 38245889 PMCID: PMC10900966 DOI: 10.1001/jama.2024.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
Importance Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. Objective To update and evaluate criteria for sepsis and septic shock in children. Evidence Review The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Findings Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. Conclusions and Relevance The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.
Collapse
Affiliation(s)
- Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - R. Scott Watson
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - Lauren R. Sorce
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew C. Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- University of Cape Town, Cape Town, South Africa
| | - Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Canada
- University of Ottawa, Ontario, Canada
| | - Mark W. Hall
- Division of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme, Nairobi, Kenya
| | - David J. Albers
- Departments of Biomedical Informatics, Bioengineering, Biostatistics and Informatics, University of Colorado School of Medicine, Aurora
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Elizabeth R. Alpern
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paolo Biban
- Pediatric Intensive Care Unit, Verona University Hospital, Verona, Italy
| | - Enitan D. Carrol
- University of Liverpool, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Divisions of Critical Care Medicine and Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mohammod Jobayer Chisti
- Intensive Care Unit, Dhaka Hospital, Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Peter E. DeWitt
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Idris Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - Cláudio Flauzino de Oliveira
- AMIB–Associação de Medicina Intensiva Brasileira, São Paulo, Brazil
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
| | - Christopher M. Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - David Inwald
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California, San Diego School of Medicine, La Jolla
| | - Juan Camilo Jaramillo-Bustamante
- PICU Hospital General de Medellín “Luz Castro de Gutiérrez” and Hospital Pablo Tobón Uribe, Medellín, Colombia
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London, London, United Kingdom
- Department of Paediatrics, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Blake Martin
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
- Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
| | - Simon Nadel
- Paediatric Intensive Care, St Mary’s Hospital, London, United Kingdom
- Imperial College London, London, United Kingdom
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mark J. Peters
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
- Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Suchitra Ranjit
- Pediatric Intensive Care Unit, Apollo Children’s Hospital, Chennai, India
| | - Margaret N. Rebull
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Seth Russell
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Halden F. Scott
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
- Emergency Department, Children’s Hospital Colorado, Aurora
| | - Daniela Carla de Souza
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Universitario of the University of São Paulo, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Sírio Libanês, São Paulo, Brazil
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Institute for Global Health, BC Children’s Hospital, Vancouver, Canada and Walimu, Uganda
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Jerry J. Zimmerman
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - L. Nelson Sanchez-Pinto
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Critical Care, and Department of Preventive Medicine, Division of Health & Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
| |
Collapse
|
2
|
Rojas JC, Teran M, Umscheid CA. Clinician Trust in Artificial Intelligence: What is Known and How Trust Can Be Facilitated. Crit Care Clin 2023; 39:769-782. [PMID: 37704339 DOI: 10.1016/j.ccc.2023.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Predictive analytics based on artificial intelligence (AI) offer clinicians the opportunity to leverage big data available in electronic health records (EHR) to improve clinical decision-making, and thus patient outcomes. Despite this, many barriers exist to facilitating trust between clinicians and AI-based tools, limiting its current impact. Potential solutions are available at both the local and national level. It will take a broad and diverse coalition of stakeholders, from health-care systems, EHR vendors, and clinical educators to regulators, researchers and the patient community, to help facilitate this trust so that the promise of AI in health care can be realized.
Collapse
Affiliation(s)
- Juan C Rojas
- Department of Internal Medicine, Rush University, 1725 West Harrison Street, Suite 010, Chicago, IL 60612, USA.
| | - Mario Teran
- Agency for Healthcare Research and Quality, 5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857, USA
| | - Craig A Umscheid
- Agency for Healthcare Research and Quality, 5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857, USA
| |
Collapse
|
3
|
Bateson M, Marwick CA, Staines HJ, Patton A, Stewart E, Rooney KD. Performance of bedside tools for predicting infection-related mortality and administrative data for sepsis surveillance: An observational cohort study. PLoS One 2023; 18:e0280228. [PMID: 36862700 PMCID: PMC9980760 DOI: 10.1371/journal.pone.0280228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 12/23/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Measuring sepsis incidence and associated mortality at scale using administrative data is hampered by variation in diagnostic coding. This study aimed first to compare how well bedside severity scores predict 30-day mortality in hospitalised patients with infection, then to assess the ability of combinations of administrative data items to identify patients with sepsis. METHODS This retrospective case note review examined 958 adult hospital admissions between October 2015 and March 2016. Admissions with blood culture sampling were matched 1:1 to admissions without a blood culture. Case note review data were linked to discharge coding and mortality. For patients with infection the performance characteristics of Sequential Organ Failure Assessment (SOFA), National Early Warning System (NEWS), quick SOFA (qSOFA), and Systemic Inflammatory Response Syndrome (SIRS) were calculated for predicting 30-day mortality. Next, the performance characteristics of administrative data (blood cultures and discharge codes) for identifying patients with sepsis, defined as SOFA ≥2 because of infection, were calculated. RESULTS Infection was documented in 630 (65.8%) admissions and 347 (55.1%) patients with infection had sepsis. NEWS (Area Under the Receiver Operating Characteristic, AUROC 0.78 95%CI 0.72-0.83) and SOFA (AUROC 0.77, 95%CI 0.72-0.83), performed similarly well for prediction of 30-day mortality. Having an infection and/or sepsis International Classification of Diseases, Tenth Revision (ICD-10) code (AUROC 0.68, 95%CI 0.64-0.71) performed as well in identifying patients with sepsis as having at least one of: an infection code; sepsis code, or; blood culture (AUROC 0.68, 95%CI 0.65-0.71), Sepsis codes (AUROC 0.53, 95%CI 0.49-0.57) and positive blood cultures (AUROC 0.52, 95%CI 0.49-0.56) performed least well. CONCLUSIONS SOFA and NEWS best predicted 30-day mortality in patients with infection. Sepsis ICD-10 codes lack sensitivity. For health systems without suitable electronic health records, blood culture sampling has potential utility as a clinical component of a proxy marker for sepsis surveillance.
Collapse
Affiliation(s)
- Meghan Bateson
- ihub, Healthcare Improvement Scotland, Glasgow, United Kingdom
- * E-mail:
| | - Charis A. Marwick
- Population Health & Genomics Division, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Harry J. Staines
- Healthcare Biometrics, Sigma Statistical Services, Balmullo, United Kingdom
| | - Andrea Patton
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Elaine Stewart
- School of Health and Life Sciences, University of the West of Scotland, Lanarkshire, United Kingdom
| | - Kevin D. Rooney
- Department of Anaesthetics and Intensive Care Medicine, Royal Alexandra Hospital, Paisley, United Kingdom
| |
Collapse
|
4
|
Morin L, Hall M, de Souza D, Guoping L, Jabornisky R, Shime N, Ranjit S, Gilholm P, Nakagawa S, Zimmerman JJ, Sorce LR, Argent A, Kissoon N, Tissières P, Watson RS, Schlapbach LJ. The Current and Future State of Pediatric Sepsis Definitions: An International Survey. Pediatrics 2022; 149:188114. [PMID: 35611643 DOI: 10.1542/peds.2021-052565] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Definitions for pediatric sepsis were established in 2005 without data-driven criteria. It is unknown whether the more recent adult Sepsis-3 definitions meet the needs of providers caring for children. We aimed to explore the use and applicability of criteria to diagnose sepsis and septic shock in children across the world. METHODS This is an international electronic survey of clinicians distributed across international and national societies representing pediatric intensive care, emergency medicine, pediatrics, and pediatric infectious diseases. Respondents stated their preferences on a 5-point Likert scale. RESULTS There were 2835 survey responses analyzed, of which 48% originated from upper-middle income countries, followed by high income countries (38%) and low or lower-middle income countries (14%). Abnormal vital signs, laboratory evidence of inflammation, and microbiologic diagnoses were the criteria most used for the diagnosis of "sepsis." The 2005 consensus definitions were perceived to be the most useful for sepsis recognition, while Sepsis-3 definitions were stated as more useful for benchmarking, disease classification, enrollment into trials, and prognostication. The World Health Organization definitions were perceived as least useful across all domains. Seventy one percent of respondents agreed that the term sepsis should be restricted to children with infection-associated organ dysfunction. CONCLUSIONS Clinicians around the world apply a myriad of signs, symptoms, laboratory studies, and treatment factors when diagnosing sepsis. The concept of sepsis as infection with associated organ dysfunction is broadly supported. Currently available sepsis definitions fall short of the perceived needs. Future diagnostic algorithms should be pragmatic and sensitive to the clinical settings.
Collapse
Affiliation(s)
- Luc Morin
- Université Paris-Saclay, AP-HP, Pediatric Intensive Care, Bicêtre Hospital, DMU 3 Santé de l'Enfant et de l'Adolescent, Le Kremlin-Bicêtre, France
| | - Mark Hall
- Nationwide Children's Hospital, Columbus, Ohio
| | - Daniela de Souza
- Hospital Universitário da Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Lu Guoping
- Children's Hospital of Fudan University, Shanghai, China
| | - Roberto Jabornisky
- Universidad Nacional del Nordeste, Corrientes, Argentina.,Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Japan
| | | | - Patricia Gilholm
- Child Health Research Centre, and Paediatric Intensive Care Unit, The University of Queensland, and Queensland Children`s Hospital, Brisbane, Australia
| | | | - Jerry J Zimmerman
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Lauren R Sorce
- Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,University of Cape Town, Cape Town, South Africa
| | - Niranjan Kissoon
- British Columbia Women and Children's Hospital, Vancouver, British Columbia, Canada.,The University of British Columbia, Vancouver, British Columbia, Canada
| | - Pierre Tissières
- Université Paris-Saclay, AP-HP, Pediatric Intensive Care, Bicêtre Hospital, DMU 3 Santé de l'Enfant et de l'Adolescent, Le Kremlin-Bicêtre, France.,Institute of Integrative Biology of the Cell, CNRS, CEA, Paris Saclay University, Gif-sur-Yvette, France
| | - R Scott Watson
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Luregn J Schlapbach
- Child Health Research Centre, and Paediatric Intensive Care Unit, The University of Queensland, and Queensland Children`s Hospital, Brisbane, Australia.,Department of Intensive Care and Neonatology, and Children`s Research Center, University Children`s Hospital Zurich, Zurich, Switzerland
| | | |
Collapse
|
5
|
Queensland Pediatric Sepsis Breakthrough Collaborative: Multicenter Observational Study to Evaluate the Implementation of a Pediatric Sepsis Pathway Within the Emergency Department. Crit Care Explor 2021; 3:e0573. [PMID: 34765981 PMCID: PMC8577679 DOI: 10.1097/cce.0000000000000573] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. To evaluate the implementation of a pediatric sepsis pathway in the emergency department as part of a statewide quality improvement initiative in Queensland, Australia.
Collapse
|
6
|
Ranjit S, Kissoon N. Challenges and Solutions in translating sepsis guidelines into practice in resource-limited settings. Transl Pediatr 2021; 10:2646-2665. [PMID: 34765491 PMCID: PMC8578780 DOI: 10.21037/tp-20-310] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/05/2021] [Indexed: 11/24/2022] Open
Abstract
Sepsis and septic shock are major contributors to the global burden of disease, with a large proportion of patients and deaths with sepsis estimated to occur in low- and middle-income countries (LMICs). There are numerous barriers to reducing the large global burden of sepsis including challenges in quantifying attributable morbidity and mortality, poverty, inadequate awareness, health inequity, under-resourced public health, and low-resilient acute health care delivery systems. Context-specific approaches to this significant problem are necessary on account of important differences in populations at-risk, the nature of infecting pathogens, and the healthcare capacity to manage sepsis in LMIC. We review these challenges and propose an outline of some solutions to tackle them which include strengthening the healthcare systems, accurate and early identification of sepsis the need for inclusive research and context-specific treatment guidelines, and advocacy. Specifically, strengthening pediatric intensive care units (PICU) services can effectively treat the life-threatening complications of common diseases, such as diarrhoea, respiratory infections, severe malaria, and dengue, thereby improving the quality of pediatric care overall without the need for expensive interventions. A thoughtful approach to developing paediatric intensive care services in LMICs begins with basic fundamentals: training healthcare providers in knowledge and skills, selecting effective equipment that is resource-appropriate, and having an enabling leadership to provide location-appropriate care. These basics, if built in sustainable manner, have the potential to permit an efficient pediatric critical care service to be established that can significantly improve sepsis and other critical care outcomes.
Collapse
Affiliation(s)
- Suchitra Ranjit
- Senior Consultant and Head, Pediatric ICU, Apollo Children's Hospital, Chennai, India
| | - Niranjan Kissoon
- Children's and Women's Global Health, UBC & BC Children's Hospital Professor in Critical Care - Global Child Health, Department of Pediatrics and Emergency Medicine, UBC, Child and Family Research Institute, Vice President Global Sepsis Alliance, Vancouver, Canada
| |
Collapse
|
7
|
Edel A, Reinhart K, Schaller SJ. [Critical statement on selected recommendations of the new German S3 Sepsis Guideline]. Med Klin Intensivmed Notfmed 2020; 115:505-507. [PMID: 32910285 PMCID: PMC7481338 DOI: 10.1007/s00063-020-00720-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Andreas Edel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland
| | - Konrad Reinhart
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK/CCM), Charitéplatz 1, Berlin, Deutschland.
| |
Collapse
|
8
|
Schlapbach LJ, Kissoon N, Alhawsawi A, Aljuaid MH, Daniels R, Gorordo-Delsol LA, Machado F, Malik I, Nsutebu EF, Finfer S, Reinhart K. World Sepsis Day: a global agenda to target a leading cause of morbidity and mortality. Am J Physiol Lung Cell Mol Physiol 2020; 319:L518-L522. [PMID: 32812788 DOI: 10.1152/ajplung.00369.2020] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland and Queensland Children's Hospital, Brisbane, Queensland, Australia.,Department of Intensive Care Medicine and Neonatology, and Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Niranjan Kissoon
- Children's and Women's Global Health, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Maha H Aljuaid
- King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ron Daniels
- Department of Critical Care, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | | | - Imrana Malik
- Department of Critical Care, The University of Texas, Anderson Cancer Center, Houston, Texas
| | - Emmanuel Fru Nsutebu
- Infectious Diseases Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Konrad Reinhart
- Department of Anesthesia and Surgical Intensive Care Medicine, Charité Universitätsmedizin, Berlin, Germany
| |
Collapse
|
9
|
Abstract
PURPOSE OF REVIEW Sepsis remains among the leading causes of childhood mortality worldwide. This review serves to highlight key areas of knowledge gain and ongoing controversies pertinent to sepsis in children. RECENT FINDINGS Several recent publications describe the epidemiology of paediatric sepsis, demonstrating the impact on child health in terms of mortality and morbidity, and the shortcomings of current paediatric sepsis definitions. Although emerging data support the importance of organ dysfunction as a hallmark of paediatric sepsis, the understanding of host susceptibility to sepsis and to sepsis severity remains very limited. Next-generation sequencing and host transcriptomics have the potential to provide new insights into the pathogenesis of sepsis and may enable personalized medicine approaches. Despite good observational data indicating benefit of sepsis recognition and treatment bundles, the evidence for the individual bundle components remains scarce, implying an urgent need for large trials. SUMMARY Recent studies have demonstrated distinct epidemiological patterns pertinent to age groups, healthcare settings, and comorbidities in the era post meningococcal epidemics. Although sepsis quality improvement initiatives have led to substantial outcome improvements, there is urgency for innovative trials to reduce uncertainty around the optimal approach for the recognition and treatment of sepsis in children.
Collapse
|
10
|
Machado FR, Cavalcanti AB, Monteiro MB, Sousa JL, Bossa A, Bafi AT, Dal-Pizzol F, Freitas FGR, Lisboa T, Westphal GA, Japiassu AM, Azevedo LCP. Predictive Accuracy of the Quick Sepsis-related Organ Failure Assessment Score in Brazil. A Prospective Multicenter Study. Am J Respir Crit Care Med 2020; 201:789-798. [PMID: 31910037 PMCID: PMC7124712 DOI: 10.1164/rccm.201905-0917oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rationale: Although proposed as a clinical prompt to sepsis based on predictive validity for mortality, the Quick Sepsis-related Organ Failure Assessment (qSOFA) score is often used as a screening tool, which requires high sensitivity. Objectives: To assess the predictive accuracy of qSOFA for mortality in Brazil, focusing on sensitivity. Methods: We prospectively collected data from two cohorts of emergency department and ward patients. Cohort 1 included patients with suspected infection but without organ dysfunction or sepsis (22 hospitals: 3 public and 19 private). Cohort 2 included patients with sepsis (54 hospitals: 24 public and 28 private). The primary outcome was in-hospital mortality. The predictive accuracy of qSOFA was examined considering only the worst values before the suspicion of infection or sepsis. Measurements and Main Results: Cohort 1 contained 5,460 patients (mortality rate, 14.0%; 95% confidence interval [CI], 13.1–15.0), among whom 78.3% had a qSOFA score less than or equal to 1 (mortality rate, 8.3%; 95% CI, 7.5–9.1). The sensitivity of a qSOFA score greater than or equal to 2 for predicting mortality was 53.9% and the 95% CI was 50.3 to 57.5. The sensitivity was higher for a qSOFA greater than or equal to 1 (84.9%; 95% CI, 82.1–87.3), a qSOFA score greater than or equal to 1 or lactate greater than 2 mmol/L (91.3%; 95% CI, 89.0–93.2), and systemic inflammatory response syndrome plus organ dysfunction (68.7%; 95% CI, 65.2–71.9). Cohort 2 contained 4,711 patients, among whom 62.3% had a qSOFA score less than or equal to 1 (mortality rate, 17.3%; 95% CI, 15.9–18.7), whereas in public hospitals the mortality rate was 39.3% (95% CI, 35.5–43.3). Conclusions: A qSOFA score greater than or equal to 2 has low sensitivity for predicting death in patients with suspected infection in a developing country. Using a qSOFA score greater than or equal to 2 as a screening tool for sepsis may miss patients who ultimately die. Using a qSOFA score greater than or equal to 1 or adding lactate to a qSOFA score greater than or equal to 1 may improve sensitivity. Clinical trial registered with www.clinicaltrials.gov (NCT03158493).
Collapse
Affiliation(s)
| | | | | | | | - Aline Bossa
- Instituto Latino-Americano de Sepsis, São Paulo, Brazil
| | | | | | | | - Thiago Lisboa
- Instituto Latino-Americano de Sepsis, São Paulo, Brazil
| | | | | | | | | |
Collapse
|
11
|
Superior performance of National Early Warning Score compared with quick Sepsis-related Organ Failure Assessment Score in predicting adverse outcomes: a retrospective observational study of patients in the prehospital setting. Eur J Emerg Med 2020; 26:433-439. [PMID: 30585862 DOI: 10.1097/mej.0000000000000589] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Early intervention and response to deranged physiological parameters in the critically ill patient improve outcomes. A National Early Warning Score (NEWS) based on physiological observations has been developed for use throughout the National Health Service in the UK. The quick Sepsis-related Organ Failure Assessment Score (qSOFA) was developed as a simple bedside criterion to identify adult patients outwith the ICU with suspected infection who are likely to have a prolonged ICU stay or die in hospital. We aim to compare the ability of NEWS and qSOFA to predict adverse outcomes in a prehospital population. PATIENTS AND METHODS All clinical observations taken by emergency ambulance crews transporting patients to a single hospital were collated along with information relating to mortality over a 2-month period. The performance of the NEWS and qSOFA in identifying the endpoints of 30-day mortality, ICU admission and a combined endpoint of 48 h. ICU admission or 30-day mortality was analysed. RESULTS Complete data were available for 1713 patients. For the primary outcome of ICU admission within 48 h or 30-day mortality, the odds ratio for a qSOFA score of 3 compared with 0 was 124.1 [95% confidence interval (CI): 13.5-1137.7] and the odds ratio for a high NEWS category, compared with the low NEWS category was 9.82 (95% CI: 5.74-16.81). Comparison of qSOFA and NEWS performance was assessed using receiver operating characteristic curves. The area under the receiver operating characteristic curve for the primary outcome for qSOFA was 0.679 (95% CI: 0.624-0.733), for NEWS category was 0.707 (95% CI: 0.654-0.761) and for NEWS total score was 0.740 (95% CI: 0.685-0.795). Comparison of the receiver operating characteristic curves between NEWS total score and qSOFA using DeLong's test showed NEWS total score to be superior to qSOFA at predicting combined ICU admission within 48 h of presentation or 30-day mortality (P = 0.011). CONCLUSION Our study shows qSOFA can identify patients at risk of adverse outcomes in the prehospital setting. However, NEWS is superior to qSOFA in a prehospital environment at identifying patients at risk of adverse outcomes.
Collapse
|
12
|
Popescu CR, Cavanagh MMM, Tembo B, Chiume M, Lufesi N, Goldfarb DM, Kissoon N, Lavoie PM. Neonatal sepsis in low-income countries: epidemiology, diagnosis and prevention. Expert Rev Anti Infect Ther 2020; 18:443-452. [PMID: 32070161 DOI: 10.1080/14787210.2020.1732818] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: Sepsis accounts for up to one-third of neonatal deaths in the world each year. The World Health Organization acknowledges neonatal sepsis as a major global health concern, and that the highest burden occurs in low- and middle-income countries (LMICs). Despite major research and clinical progress in this area, we still lack accurate diagnostic tools for neonatal sepsis, complicating the management of this condition.Areas covered: The purpose here is to review the latest data on the incidence, diagnosis, prevention, and management of neonatal sepsis in LMIC. We discuss the limitations of current diagnostic tests - including their lack of availability - and how this may influence global estimates of cases. We review the benefits of antenatal, intrapartum, and post-natal preventive measures. We briefly discuss the management, highlighting the emergence of antimicrobial resistance. Finally, we expose some high priority areas.Expert opinion: Neonatal sepsis is a challenging condition requiring a multifaceted approach to address the major diagnostic issues, but also the underlying socio-economic causes that nourish epidemic cases in LMIC. Focusing on antibiotics as a main pillar of intervention is likely to engender antimicrobial resistance, eventually hindering the appreciable gains LMICs have achieved in neonatal health outcomes.
Collapse
Affiliation(s)
- Constantin Radu Popescu
- Department of Pediatrics, Division of Neonatology, Université Laval, Québec, QC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Miranda M M Cavanagh
- Division of Neonatology, BC Women's Hospital and Health Centre, Vancouver, BC, Canada
| | - Bentry Tembo
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Msandeni Chiume
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Norman Lufesi
- Directorate of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, BC, Canada
| | - Niranjan Kissoon
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Pascal M Lavoie
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Division of Neonatology, BC Women's Hospital and Health Centre, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
13
|
Abstract
Sepsis is one of the oldest and most elusive syndromes in medicine that is still incompletely understood. Biomarkers may help to transform sepsis from a physiologic syndrome to a group of distinct biochemical disorders. This will help to differentiate between systemic inflammation of infectious and noninfectious origin and aid therapeutic decision making, hence improve the prognosis for patients, guide antimicrobial therapy, and foster the development of novel adjunctive sepsis therapies. To reach this goal requires increased systematic investigation that includes twenty-first century scientific approaches and technologies and appropriate clinical evaluation.
Collapse
Affiliation(s)
- Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, D-10178 Berlin, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, D-10178 Berlin, Germany; Jena University Hospital, Carl-Zeiss-Straße 12, D-07743 Jena, Germany.
| |
Collapse
|
14
|
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.
Collapse
|
15
|
|
16
|
Schlapbach LJ, Thompson K, Finfer SR. The
WHO
resolution on sepsis: what action is needed in Australia? Med J Aust 2019; 211:395-397.e1. [DOI: 10.5694/mja2.50279] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Kelly Thompson
- The George Institute for Global HealthUniversity of New South Wales Sydney NSW
| | - Simon R Finfer
- The George Institute for Global HealthUniversity of New South Wales Sydney NSW
| |
Collapse
|
17
|
Baumann BM, Greenwood JC, Lewis K, Nuckton TJ, Darger B, Shofer FS, Troeger D, Jung SY, Kilgannon JH, Rodriguez RM. Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness. Am J Emerg Med 2019; 38:883-889. [PMID: 31320214 DOI: 10.1016/j.ajem.2019.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/20/2019] [Accepted: 07/02/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To determine if the addition of lactate to Quick Sequential Organ Failure Assessment (qSOFA) scoring improves emergency department (ED) screening of septic patients for critical illness. METHODS This was a multicenter retrospective cohort study of consecutive adult patients admitted to the hospital from the ED with infectious disease-related illnesses. We recorded qSOFA criteria and initial lactate levels in the first 6 h of ED stay. Our primary outcome was a composite of hospital death, vasopressor use, and intensive care unit stay ≤72 h of presentation. Diagnostic test characteristics were determined for: 1) lactate levels ≥2 and ≥4; 2) qSOFA scores ≥1, ≥2, and =3; and 3) combinations of these. RESULTS Of 3743 patients, 2584 had a lactate drawn ≤6 h of ED stay and 18% met the primary outcome. The qSOFA scores were ≥1, ≥2, and =3 in 59.2%, 22.0%, and 5.3% of patients, respectively, and 34.4% had a lactate level ≥2 and 7.9% had a lactate level ≥4. The combination of qSOFA ≥1 OR Lactate ≥2 had the highest sensitivity, 94.0% (95% CI: 91.3-95.9). CONCLUSIONS The combination of qSOFA ≥1 OR Lactate ≥2 provides substantially improved sensitivity for the screening of critical illness compared to isolated lactate and qSOFA thresholds.
Collapse
Affiliation(s)
- Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza Camden, NJ 08103, United States of America.
| | - John C Greenwood
- Departments of Emergency Medicine and Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - Kristin Lewis
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
| | - Thomas J Nuckton
- Department of Medicine, Sutter Eden Medical Center, 20103 Lake Chabot Road Castro Valley, CA 94546, United States of America.
| | - Bryan Darger
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - Dawn Troeger
- Department of Medicine, Sutter Eden Medical Center, 20103 Lake Chabot Road Castro Valley, CA 94546, United States of America.
| | - Soo Y Jung
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States of America.
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza Camden, NJ 08103, United States of America.
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0749, United States of America.
| |
Collapse
|
18
|
Moreira J, Paixão A, Oliveira J, Jaló W, Manuel O, Rodrigues R, Oliveira A, Tinoco L, Lima J, Grinsztejn B, Veloso VG, Japiassú AM, Lamas CC. Accuracy of quick sequential organ failure assessment score to predict mortality in hospitalized patients with suspected infection in an HIV/AIDS reference centre in Rio de Janeiro, Brazil. Clin Microbiol Infect 2018; 25:113.e1-113.e3. [PMID: 30118761 DOI: 10.1016/j.cmi.2018.08.003] [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: 06/20/2018] [Revised: 07/31/2018] [Accepted: 08/04/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To compare the discriminatory capacity of the quick sequential organ failure assessment (qSOFA) vs. the systemic inflammatory response syndrome (SIRS) score for predicting 30-day mortality and intensive care unit (ICU) admission in patients with suspicion of infection at an HIV reference centre. METHODS We performed a prospective cohort study including consecutive adult patients who had suspected infection and who were subsequently admitted to the medical ward. Variables related to qSOFA and SIRS were measured at admission. The performance (area under the receiver operating curve, AUROC) of qSOFA (score ≥2) and SIRS (≥2 criteria) as a predictor of 30-day mortality and ICU admission was evaluated. RESULTS One hundred seventy-three patients (mean ± standard deviation age, 42.6 ± 12.4 years) were included in the analysis; 107 (61.8%) were male, and 111 (64.2%) were HIV positive. Respiratory and gastrointestinal infections occurred in 49 (28.3%) and 23 (13.3%), respectively. The 30-day mortality rate was 9 (5.2%) of 173. The prognostic performance of qSOFA was similar compared to SIRS, with an AUROC of 0.68 (95% confidence interval, 0.55-0.81) and 0.69 (95% confidence interval, 0.53-0.86) (p 0.96). Twenty patients (11%) were admitted to the ICU; qSOFA and SIRS had a similar discriminatory capacity for ICU admission (AUROC 0.63 (95% confidence interval, 0.51-0.75) and 0.63 (95% confidence interval, 0.50-0.76)), respectively). CONCLUSIONS We found a poor prognostic accuracy of the qSOFA to predict 30-day mortality in hospitalized patients suspected of infection in a setting with a high burden of HIV infection.
Collapse
Affiliation(s)
- J Moreira
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional de Infectologia Evandro Chagas (INI), Rio de Janeiro, Brazil; Cardiovascular Research Unit, Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil.
| | - A Paixão
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional de Infectologia Evandro Chagas (INI), Rio de Janeiro, Brazil
| | - J Oliveira
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional de Infectologia Evandro Chagas (INI), Rio de Janeiro, Brazil
| | - W Jaló
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional de Infectologia Evandro Chagas (INI), Rio de Janeiro, Brazil
| | - O Manuel
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional de Infectologia Evandro Chagas (INI), Rio de Janeiro, Brazil
| | - R Rodrigues
- Faculdade de Medicina, Universidade do Grande Rio (UNIGRANRIO), Rio de Janeiro, Brazil
| | - A Oliveira
- Faculdade de Medicina, Universidade do Grande Rio (UNIGRANRIO), Rio de Janeiro, Brazil
| | - L Tinoco
- Faculdade de Medicina, Universidade do Grande Rio (UNIGRANRIO), Rio de Janeiro, Brazil
| | - J Lima
- Faculdade de Medicina, Universidade do Grande Rio (UNIGRANRIO), Rio de Janeiro, Brazil
| | - B Grinsztejn
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional de Infectologia Evandro Chagas (INI), Rio de Janeiro, Brazil
| | - V G Veloso
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional de Infectologia Evandro Chagas (INI), Rio de Janeiro, Brazil
| | - A M Japiassú
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional de Infectologia Evandro Chagas (INI), Rio de Janeiro, Brazil
| | - C C Lamas
- Fundação Oswaldo Cruz (FIOCRUZ), Instituto Nacional de Infectologia Evandro Chagas (INI), Rio de Janeiro, Brazil; Cardiovascular Research Unit, Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil; Faculdade de Medicina, Universidade do Grande Rio (UNIGRANRIO), Rio de Janeiro, Brazil
| |
Collapse
|
19
|
Mortality Risk Using a Pediatric Quick Sequential (Sepsis-Related) Organ Failure Assessment Varies With Vital Sign Thresholds. Pediatr Crit Care Med 2018; 19:e394-e402. [PMID: 29939978 DOI: 10.1097/pcc.0000000000001598] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We evaluated adapting the quick Sequential (Sepsis-Related) Organ Failure Assessment score (fast respiratory rate, altered mental status, low blood pressure) for pediatric use by selecting thresholds from three commonly used definitions: Pediatric Logistic Organ Dysfunction 2, Pediatric Advanced Life Support, and International Pediatric Sepsis Consensus Conference. We examined their respective performance in identifying children who had a discharge diagnosis of infection at high risk of mortality using PICU registry data, with additional focus on the influence of age on performance. DESIGN Analysis of retrospective data obtained from the Virtual Pediatric Systems PICU database. The performance in predicting observed mortality was assessed for the three candidate approaches using receiver operating characteristics analysis, including age group effects. SETTING The Virtual Pediatric Systems database contains data on diagnosis, clinical markers, and outcomes in prospectively collected clinical records from 130 participating PICUs in the United States and Canada. PATIENTS Children who had a discharge diagnosis of infection in a participating PICU between 2009 and 2014, for which all required data were available. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data from 40,228 children revealed an overall mortality of 4.22%. Area under the receiver operating characteristics curve (95% CI) was 0.760 (0.749-0.771) for Pediatric Logistic Organ Dysfunction 2 with mechanical ventilation, 0.700 (0.689-0.712) for Pediatric Advanced Life Support, and 0.709 (0.696-0.721) for International Pediatric Sepsis Consensus Conference. When split by age group, the performance of Pediatric Logistic Organ Dysfunction 2 with mechanical ventilation was lowest in the youngest neonates (under 1 wk old), with an area under the receiver operating characteristics curve (95% CI) of 0.724 (0.656-0.791), and in the teenagers (13-18 yr), with an area under the receiver operating characteristics curve of 0.710 (0.682-0.738), yet it still outperformed Pediatric Advanced Life Support and International Pediatric Sepsis Consensus Conference in both groups. CONCLUSIONS Among critically ill children who had a discharge diagnosis of infection in the PICU, quick Sequential (Sepsis-Related) Organ Failure Assessment score performs best when using the Pediatric Logistic Organ Dysfunction 2 age thresholds with mechanical ventilation, while all definitions performed worse at extremes of pediatric age. Thus, mortality risk varies with vital sign thresholds, and although Pediatric Logistic Organ Dysfunction 2 with mechanical ventilation performed marginally better, it is unlikely to be of use to clinicians. More work is needed to develop a robust and relevant pediatric sepsis risk score.
Collapse
|
20
|
Shetty A, MacDonald SP, Williams JM, van Bockxmeer J, de Groot B, Esteve Cuevas LM, Ansems A, Green M, Thompson K, Lander H, Greenslade J, Finfer S, Iredell J. Lactate ≥2 mmol/L plus qSOFA improves utility over qSOFA alone in emergency department patients presenting with suspected sepsis. Emerg Med Australas 2018; 29:626-634. [PMID: 29178274 DOI: 10.1111/1742-6723.12894] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/16/2017] [Accepted: 10/04/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The Sepsis-3 task force recommends the use of the quick Sequential Organ Failure Assessment (qSOFA) score to identify risk for adverse outcomes in patients presenting with suspected infection. Lactate has been shown to predict adverse outcomes in patients with suspected infection. The aim of the study is to investigate the utility of a post hoc lactate threshold (≥2 mmol/L) added qSOFA score (LqSOFA(2) score) to predict primary composite adverse outcomes (mortality and/or ICU stay ≥72 h) in patients presenting to ED with suspected sepsis. METHODS Retrospective cohort study was conducted on a merged dataset of suspected or proven sepsis patients presenting to ED across multiple sites in Australia and The Netherlands. Patients are identified as candidates for quality improvement initiatives or research studies at respective sites based on local screening procedures. Data-sharing was performed across sites of demographics, qSOFA, SOFA, lactate thresholds and outcome data for included patients. LqSOFA(2) scores were calculated by adding an extra point to qSOFA score in patients who met lactate thresholds of ≥2 mmol/L. RESULTS In a merged dataset of 12 555 patients where a full qSOFA score and outcome data were available, LqSOFA(2) ≥2 identified more patients with an adverse outcome (sensitivity 65.5%, 95% confidence interval 62.6-68.4) than qSOFA ≥2 (sensitivity 47.6%, 95% confidence interval 44.6- 50.6). The post hoc addition of lactate threshold identified higher proportion of patients at risk of adverse outcomes. CONCLUSIONS The lactate ≥2 mmol/L threshold-based LqSOFA(2) score performs better than qSOFA alone in identifying risk of adverse outcomes in ED patients with suspected sepsis.
Collapse
Affiliation(s)
- Amith Shetty
- Westmead Institute for Medical Research, NHMRC Centre for Research Excellence in Critical Infection, Sydney, New South Wales, Australia.,Westmead Emergency Medical Research Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen Pj MacDonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Julian M Williams
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - John van Bockxmeer
- Western Australia Country Health Service, South Hedland, Western Australia, Australia
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Annemieke Ansems
- Emergency Department, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | - Malcolm Green
- Clinical Excellence Commission, Sydney, New South Wales, Australia
| | - Kelly Thompson
- Critical Care and Trauma Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Harvey Lander
- Clinical Excellence Commission, Sydney, New South Wales, Australia
| | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Biostatistics, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Simon Finfer
- Critical Care and Trauma Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Jonathan Iredell
- Westmead Institute for Medical Research, NHMRC Centre for Research Excellence in Critical Infection, Sydney, New South Wales, Australia
| |
Collapse
|
21
|
Rudd KE, Seymour CW, Aluisio AR, Augustin ME, Bagenda DS, Beane A, Byiringiro JC, Chang CCH, Colas LN, Day NPJ, De Silva AP, Dondorp AM, Dünser MW, Faiz MA, Grant DS, Haniffa R, Van Hao N, Kennedy JN, Levine AC, Limmathurotsakul D, Mohanty S, Nosten F, Papali A, Patterson AJ, Schieffelin JS, Shaffer JG, Thuy DB, Thwaites CL, Urayeneza O, White NJ, West TE, Angus DC. Association of the Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Score With Excess Hospital Mortality in Adults With Suspected Infection in Low- and Middle-Income Countries. JAMA 2018; 319:2202-2211. [PMID: 29800114 PMCID: PMC6134436 DOI: 10.1001/jama.2018.6229] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 04/23/2018] [Indexed: 12/29/2022]
Abstract
Importance The quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score has not been well-evaluated in low- and middle-income countries (LMICs). Objective To assess the association of qSOFA with excess hospital death among patients with suspected infection in LMICs and to compare qSOFA with the systemic inflammatory response syndrome (SIRS) criteria. Design, Settings, and Participants Retrospective secondary analysis of 8 cohort studies and 1 randomized clinical trial from 2003 to 2017. This study included 6569 hospitalized adults with suspected infection in emergency departments, inpatient wards, and intensive care units of 17 hospitals in 10 LMICs across sub-Saharan Africa, Asia, and the Americas. Exposures Low (0), moderate (1), or high (≥2) qSOFA score (range, 0 [best] to 3 [worst]) or SIRS criteria (range, 0 [best] to 4 [worst]) within 24 hours of presentation to study hospital. Main Outcomes and Measures Predictive validity (measured as incremental hospital mortality beyond that predicted by baseline risk factors, as a marker of sepsis or analogous severe infectious course) of the qSOFA score (primary) and SIRS criteria (secondary). Results The cohorts were diverse in enrollment criteria, demographics (median ages, 29-54 years; males range, 36%-76%), HIV prevalence (range, 2%-43%), cause of infection, and hospital mortality (range, 1%-39%). Among 6218 patients with nonmissing outcome status in the combined cohort, 643 (10%) died. Compared with a low or moderate score, a high qSOFA score was associated with increased risk of death overall (19% vs 6%; difference, 13% [95% CI, 11%-14%]; odds ratio, 3.6 [95% CI, 3.0-4.2]) and across cohorts (P < .05 for 8 of 9 cohorts). Compared with a low qSOFA score, a moderate qSOFA score was also associated with increased risk of death overall (8% vs 3%; difference, 5% [95% CI, 4%-6%]; odds ratio, 2.8 [95% CI, 2.0-3.9]), but not in every cohort (P < .05 in 2 of 7 cohorts). High, vs low or moderate, SIRS criteria were associated with a smaller increase in risk of death overall (13% vs 8%; difference, 5% [95% CI, 3%-6%]; odds ratio, 1.7 [95% CI, 1.4-2.0]) and across cohorts (P < .05 for 4 of 9 cohorts). qSOFA discrimination (area under the receiver operating characteristic curve [AUROC], 0.70 [95% CI, 0.68-0.72]) was superior to that of both the baseline model (AUROC, 0.56 [95% CI, 0.53-0.58; P < .001) and SIRS (AUROC, 0.59 [95% CI, 0.57-0.62]; P < .001). Conclusions and Relevance When assessed among hospitalized adults with suspected infection in 9 LMIC cohorts, the qSOFA score identified infected patients at risk of death beyond that explained by baseline factors. However, the predictive validity varied among cohorts and settings, and further research is needed to better understand potential generalizability.
Collapse
Affiliation(s)
- Kristina E. Rudd
- Department of Medicine and the International Respiratory and Severe Illness Center (INTERSECT), University of Washington, Seattle
| | - Christopher W. Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam R. Aluisio
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Danstan S. Bagenda
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha
| | - Abi Beane
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Jean Claude Byiringiro
- Division of Clinical Education and Research, University Teaching Hospital of Kigali, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Chung-Chou H. Chang
- Departments of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford, United Kingdom
| | - A. Pubudu De Silva
- National Intensive Care Surveillance, Colombo, Sri Lanka
- Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford, United Kingdom
| | - Martin W. Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - M. Abul Faiz
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Dev Care Foundation, Dhaka, Bangladesh
| | - Donald S. Grant
- Kenema Government Hospital, Ministry of Health and Sanitation, Kenema, Sierra Leone
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Rashan Haniffa
- National Intensive Care Surveillance, Colombo, Sri Lanka
| | - Nguyen Van Hao
- Adult Intensive Care Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Department of Infectious Diseases, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Jason N. Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam C. Levine
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford, United Kingdom
| | - Sanjib Mohanty
- Ispat General Hospital, Rourkela, Odisha, India
- Center for Emerging Infectious Diseases, Asian Institute of Public Health, Bhubaneswar, Odisha, India
| | - François Nosten
- Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Alfred Papali
- Division of Pulmonary & Critical Care Medicine and Institute for Global Health, University of Maryland School of Medicine, Baltimore
- Division of Pulmonary & Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | | | - John S. Schieffelin
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana
| | - Jeffrey G. Shaffer
- Department of Global Biostatistics and Data Science, Tulane University, New Orleans, Louisiana
| | - Duong Bich Thuy
- Adult Intensive Care Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - C. Louise Thwaites
- Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford, United Kingdom
- Oxford University Clinical Research Unit (OUCRU), Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford, United Kingdom
| | - T. Eoin West
- Department of Medicine and the International Respiratory and Severe Illness Center (INTERSECT), University of Washington, Seattle
| | - Derek C. Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
22
|
Affiliation(s)
- Luregn J Schlapbach
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Niranjan Kissoon
- University of British Columbia, Vancouver, British Columbia, Canada.,British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| |
Collapse
|
23
|
Macdonald SP, Williams JM, Shetty A, Bellomo R, Finfer S, Shapiro N, Keijzers G. Review article: Sepsis in the emergency department - Part 1: Definitions and outcomes. Emerg Med Australas 2017; 29:619-625. [PMID: 29094474 DOI: 10.1111/1742-6723.12886] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 09/19/2017] [Indexed: 01/21/2023]
Abstract
Sepsis has recently been redefined as acute organ dysfunction due to infection. The ED plays a critical role in identifying patients with sepsis. This is challenging due to the heterogeneity of the syndrome, and the lack of an objective standard diagnostic test. While overall mortality rates from sepsis appear to be falling, there is an increasing burden of morbidity among survivors. This largely reflects the growing proportion of older patients with comorbid illnesses among those treated for sepsis.
Collapse
Affiliation(s)
- Stephen Pj Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Julian M Williams
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Amith Shetty
- Department of Emergency Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,Centre for Research in Critical Infection, Westmead Millennium Institute, Sydney, New South Wales, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Simon Finfer
- The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Nathan Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Centre, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| |
Collapse
|
24
|
Sjoding MW, Dickson RP. Economic disparities and survival from critical illness. THE LANCET RESPIRATORY MEDICINE 2017. [PMID: 28624386 DOI: 10.1016/s2213-2600(17)30237-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, 1150 W Medical Center Drive, Ann Arbor, MI 48109-5642, USA; Institute for Health Policy and Innovation, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA
| | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, 1150 W Medical Center Drive, Ann Arbor, MI 48109-5642, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA.
| |
Collapse
|