Are scoring systems sufficient for predicting mortality due to sepsis in the emergency department?

High Central Venous Pressure Associated with Mortality in Intensive Care Unit

BACKGROUND: Central venous pressure (CVP) has been used as a measurement tool to assess hemodynamics, medication, and nutritional status in critically ill patients for decades. We frequently use the Acute Physiology and Chronic Health Evaluation or Sequential Organ Failure Assessment score to predict the mortality of intensive care unit (ICU) patients. Unfortunately, it requires a lot of time and procedures to measure these parameters. Moreover, not every single hospital can apply these scores. Since CVP is widely used in ICU, we can use the value of CVP to predict mortality. AIM: The aim of this study was to find the correlation between CVP and mortality rate. METHODS: This cross-sectional study was conducted in ICU of Haji Adam Malik General Hospital, Medan, in 2017. Basic demographic data, CVP measurements and mortality were recorded among all ICU patients. Patients with CVP >12 mmHg were considered high. The association between CVP and mortality was analyzed. RESULTS: One hundred patients were admitted during the study period with mortality rate of 38%. The most common cause of ICU admission was postoperative neurosurgical patients (28%). We found correlation between high CVP (>12 mmHg) and mortality among ICU patients (odds ratio: 3.372; 95% confidence interval: 1.349–8.428; p = 0.008) CONCLUSION: CVP level >12 mmHg associated with higher mortality rate in ICU patients.

Can thrombocytosis or thrombocytopenia predict complicated clinical course and 30-days mortality in patients with pneumonia?

Background/aim

While several different scoring systems aim to determine the clinical outcomes for patients with pneumonia, there is limited emphasis on the platelet count. This study investigated the relationships between thrombocyte count and 30-day mortality and complicated clinical course of patients with pneumonia.

Materials and methods

This prospective cross-sectional study enrolled patients over 18 years old with a diagnosis of pneumonia in the emergency department for six months. The primary outcome was to establish the relationship between platelet count, mortality, complicated clinical course, and initial vital parameters on admission. The secondary outcome was comparing the platelet count with mortality and complicated clinical course during the hospital stay.

Results

Four hundred-five patients were included (58.8% male, mean age 75.1 ± 12.7 years). On admission, thrombocytosis was observed in 14.1% and thrombocytopenia in 4.2%. There was no difference between the 30-day mortality according to the platelet count at admission and follow-up. Patients who developed thrombocytopenia during follow-up needed more intensive care admissions, invasive mechanical ventilation, noninvasive mechanical ventilation, and vasopressor treatment, while patients with thrombocytosis needed invasive mechanical ventilation more frequently.

Conclusion

Neither thrombocytopenia nor thrombocytosis is not associated with 30-day mortality in ED patients with pneumonia. Thrombocytopenia during follow-up was associated with a higher incidence for a complicated clinical course.

Lactate-enhanced-qSOFA (LqSOFA) score is superior to the other four rapid scoring tools in predicting in-hospital mortality rate of the sepsis patients

Background

The rising prevalence of early therapy for sepsis has led to the demand for rapid risk-stratification tools that can estimate the risk of in-hospital mortality for sepsis patients and the need for intensive care unit (ICU) admission. A robust risk-stratification tool is crucial for in-time sepsis treatment. This study aimed to compare the abilities of five rapid scoring systems, i.e., LqSOFA score, qSOFA score, SIRS, MEDS, and MEWS, in predicting the mortality in hospital and ICU admission for sepsis patients.

Methods

A retrospective observational clinical study was conducted in West China Hospital. Our cases included all patients admitted to the hospital with a diagnosis of sepsis (sepsis-3). We calculated five rapid prediction scores for the enrolled cases. We then compared each rapid score’s ability to predict in-hospital mortality and ICU admission.

Results

A total of 821 of mixed sepsis patients by sepsis-3 definition were included. The all-cause hospital mortality rate was 21.1%. The LqSOFA score presented the most significant discrimination with an area under the receiver operating characteristic curve (AUC) of 0.751. The AUC of the LqSOFA score for mortality in the hospital was significantly higher than qSOFA (AUC 0.717), SIRS (AUC 0.704), MEDS (AUC 0.670), and MEWS (AUC 0.685).

Conclusions

LqSOFA is a superior prognostic tool for predicting mortality in the hospital. It may provide more exact information for hospital mortality than the other 4 rapid scores in treating sepsis patients.

Prognostic utilization of models based on the APACHE II, APACHE IV, and SAPS II scores for predicting in-hospital mortality in emergency department

BACKGROUND

This study was designed to evaluate and compare the prognostic value of the APACHE II, APACHE IV, and SAPSII scores for predicting in-hospital mortality in the ED on a large sample of patients. Earlier studies in the ED setting have either used a small sample or focused on specific diagnoses.

METHODS

A prospective study was conducted to include patients with higher risk of mortality from March 2016 to March 2017 in the ED of Emam Reza Hospital, northeast of Iran. Logistic regression was used to develop three models. Evaluation was performed in terms of the overall performance (Brier Score, BS, and Brier Skill Score, BSS), discrimination (Area Under the Curve, AUC), and calibration (calibration graph).

RESULTS

A total of 2205 patients met the study criteria (53% male and median age of 64, IQR: 50-77). In-hospital mortality amounted to 19%. For APACHE II, APACHE IV, and SAPS II the BS was 0.132, 0.125 and 0.133 and the BSS was 0.156, 0.2, and 0.144, respectively. The AUC was 0.755 (0.74 to 0.779) for APACHE II, 0.794 (0.775 to 0.818) for APACHE IV, and 0.751 (0.727 to 0.776) for SAPS II. The APACHE IV showed significantly greater AUC in comparison to the APACHE II and SAPS II. The graphical evaluation revealed good calibration of the APACHE IV model.

CONCLUSION

APACHEIV outperformed APACHEII and SAPSII in terms of discrimination and calibration. More validation is needed for using these models for decision-making about individual patients, although they would perform best at a cohort level.

Performance of the MEDS score in predicting mortality among emergency department patients with a suspected infection: a meta-analysis

OBJECTIVES

To carry out a meta-analysis to examine the prognostic performance of the Mortality in Emergency Department Sepsis (MEDS) score in predicting mortality among emergency department patients with a suspected infection.

METHODS

Electronic databases-PubMed, Embase, Scopus, EBSCO and the Cochrane Library-were searched for eligible articles from their respective inception through February 2019. Sensitivity, specificity, likelihood ratios and receiver operator characteristic area under the curve were calculated. Subgroup analyses were performed to explore the prognostic performance of MEDS in selected populations.

RESULTS

We identified 24 studies involving 21 246 participants. The pooled sensitivity of MEDS to predict mortality was 79% (95% CI 72% to 84%); specificity was 74% (95% CI 68% to 80%); positive likelihood ratio 3.07 (95% CI 2.47 to 3.82); negative likelihood ratio 0.29 (95% CI 0.22 to 0.37) and area under the curve 0.83 (95% CI 0.80 to 0.86). Significant heterogeneity was seen among included studies. Meta-regression analyses showed that the time at which the MEDS score was measured and the cut-off value used were important sources of heterogeneity.

CONCLUSION

The MEDS score has moderate accuracy in predicting mortality among emergency department patients with a suspected infection. A study comparison MEDS and qSOFA in the same population is needed.

Sepsis patient evaluation emergency department (SPEED) score & mortality in emergency department sepsis (MEDS) score in predicting 28-day mortality of emergency sepsis patients

PURPOSE

Sepsis is a common acute life-threatening condition that emergency physicians routinely face. Diagnostic options within the Emergency Department (ED) are limited due to lack of infrastructure, consequently limiting the use of invasive hemodynamic monitoring or imaging tests. The mortality rate due to sepsis can be assessed via multiple scoring systems, for example, mortality in emergency department sepsis (MEDS) score and sepsis patient evaluation in the emergency department (SPEED) score, both of which quantify the variation of mortality rates according to clinical findings, laboratory data, or therapeutic interventions. This study aims to improve the management processes of sepsis patients by comparing SPEED score and MEDS score for predicting the 28-day mortality in cases of emergency sepsis.

METHODS

The study is a cross-sectional, prospective study including 61 sepsis patients in ED in Suez Canal University Hospital, Egypt, from August 2017 to June 2018. Patients were selected by two steps: (1) suspected septic patients presenting with at least one of the following abnormal clinical findings: (a) body temperature higher than 38 °C or lower than 36 °C, (b) heart rate higher than 90 beats/min, (c) hyperventilation evidenced by respiratory rate higher than 20 breaths/min or PaCO₂ lower than 32 mmHg, and (d) white blood cell count higher than 12,000/μL or lower than 4000/μL; (2) confirmed septic patients with at least a 2-point increase from the baseline total sequential organ failure assessment (SOFA) score following infection. Other inclusion criteria included adult patients with an age ≥18 years regardless of gender and those who had either systemic inflammatory response syndrome or suspected/confirmed infection. Patients were shortly follow-up for the 28-day mortality. Each patient was subject to SPEED score and MEDS score and then the results were compared to detect which of them was more effective in predicting outcome. The receiver operating characteristic curves were also done for MEDS and SPEED scores.

RESULTS

Among the 61 patients, 41 died with the mortality rate of 67.2%. The mortality rate increased with a higher SPEED and MEDS scores. Both SPEED and MEDS scores revealed significant difference between the survivors and nonsurvivors (p = 0.004 and p < 0.001, respectively), indicating that both the two systems are effective in predicting the 28-day mortality of sepsis patients. Thereafter, the receiver operating characteristic curves were plotted, which showed that SPEED was better than the MEDS score when applied to the complete study population with an area under the curve being 0.87 (0.788-0.963) as compared with 0.75 (0.634-0.876) for MEDS. Logistic regression analysis revealed that the best fitting predictor of 28-day mortality for sepsis patients was the SPEED scoring system. For every one unit increase in SPEED score, the odds of 28-day mortality increased by 37%.

CONCLUSION

SPEED score is more useful and accurate than MEDS score in predicting the 28-day mortality among sepsis patients. Therefore SPEED rather than MEDS should be more widely used in the ED for sepsis patients.

Predictive performance of the SOFA and mSOFA scoring systems for predicting in-hospital mortality in the emergency department

BACKGROUND

The Sequential Organ Failure Assessment (SOFA) and modified SOFA (mSOFA) are risk stratification systems which incorporate respiratory, coagulatory, liver, cardiovascular, renal, and neurologic systems to quantify the overall severity of acute disorder in the intensive care unit.

OBJECTIVE

To evaluate the prognostic performance of the SOFA and mSOFA scores at arrival for predicting in-hospital mortality in the emergency department (ED).

METHODS

All adult patients with an Emergency Severity Index (ESI) of 1-3 in the ED of Imam Reza Hospital, northeast of Iran were included from March 2016 to March 2017. The predictive performance of the SOFA or mSOFA scores were expressed in terms of accuracy (Brier Score, BS and Brier Skill Score, BSS), discrimination (Area Under the Receiver Operating Characteristic Curve, AUC), and calibration.

RESULTS

A total of 2205 patients (mean age 61.8 ± 18.5 years, 53% male) were included. The overall in-hospital mortality was 19%. For SOFA and mSOFA the BS was 0.209 and 0.192 and the BSS was 0.11 and 0.09, respectively. The estimated AUCs of SOFA and mSOFA models were 0.751 and 0.739, respectively. No significant difference was observed between the AUCs (P = 0.186). The Hosmer-Lemeshow test did not show that the predictions deviated from the true probabilities. Also, the calibration plots revealed good agreement between the actual and predicted probabilities.

CONCLUSION

The SOFA and mSOFA scores demonstrated fair discrimination and good calibration in predicting in-hospital mortality when applied to ED. However, further external validation studies are needed before their use in routine clinical care.

Hydroxysafflor Yellow A Attenuates the Apoptosis of Peripheral Blood CD4+ T Lymphocytes in a Murine Model of Sepsis

Sepsis is generally considered as a severe condition of inflammation that leads to lymphocyte apoptosis and multiple organ dysfunction. Hydroxysafflor yellow A (HSYA) exerts anti-inflammatory and anti-apoptotic effects in infectious diseases. However, the therapeutic effect of HSYA on polymicrobial sepsis remains unknown. This study was undertaken to investigate the therapeutic effects and the mechanisms of action of HSYA on immunosuppression in a murine model of sepsis induced by cecal ligation and puncture (CLP). NIH mice were randomly divided into four groups: control group, sham group, CLP group, and CLP+HSYA group. HSYA (120 mg/kg) was intravenously injected into experimental mice at 12 h before CLP, concurrent with CLP and 12 h after CLP. The levels of circulating inflammatory cytokines, the apoptosis of CD4⁺ and CD8⁺ T lymphocytes, and protein expression of cytochrome C (Cytc), Bax, Bcl-2, cleaved caspase-9, and cleaved caspase-3 were examined. Plasma levels of IL-6, IL-10 and TNF-alpha as well as the apoptosis of CD4⁺ T lymphocytes were increased compared with sham group. These changes were accompanied by increases of pro-apoptotic proteins including Cytc, Bax, cleaved caspase-9, and cleaved caspase-3 and decreases of anti-apoptotic protein Bcl-2 in CD4⁺ T lymphocytes from mice undergoing CLP. In contrast, we fail to observe significant effect of HSYA on the apoptosis of CD8⁺ T lymphocytes in CLP-treated group. Of note, HSYA treatment reversed all above changes observed in CD4⁺ T lymphocytes, and significantly increased the ratio of CD4⁺:CD8⁺ T lymphocytes in CLP-treated mice. In conclusion, HSYA was an effective therapeutic agent in ameliorating sepsis-induced apoptosis of CD4⁺ T lymphocytes probably through its anti-inflammatory and anti-apoptotic effects.