Comparison of PIRO, SOFA, and MEDS scores for predicting mortality in emergency department patients with severe sepsis and septic shock

Risk Factors and Outcomes of Community-Acquired Carbapenem-Resistant Klebsiella pneumoniae Infection in Elderly Patients

The increasing prevalence of carbapenem-resistant Klebsiella pneumoniae (CRKP) infections is a global concern. Elderly patients have a diminished immune response and functional reserve, and are thus more vulnerable to bacterial infection. This study aimed to investigate the risk factors and outcomes in elderly patients with community-acquired CRKP infections. We performed a retrospective cohort study in a tertiary medical center between 1 January 2021, and 31 December 2021. All elderly patients who visited the emergency department during this period with culture-positive K. pneumoniae were enrolled, and their baseline demographics, laboratory profiles, management strategies, and outcomes were recorded and analyzed. We identified 528 elderly patients with K. pneumonia infection, and the proportion of patients with CRKP infection was 10.2% (54/528). Recent intensive care unit (ICU) admission and prior carbapenem use are independent risk factors for CRKP infection in elderly patients. Compared to patients with carbapenem-sensitive K. pneumoniae infection, those with CRKP infection had a significantly higher risk of adverse outcomes, including ICU care, respiratory failure, septic shock, and 90-day mortality. CRKP infection was also identified as an independent risk factor for 90-day mortality. Clinicians should be aware of the increasing prevalence of CRKP infections in elderly patients and judiciously choose appropriate antibiotics for these patients.

Prognostic prediction of sepsis patient using transformer with skip connected token for tabular data

Sepsis is known as a common syndrome in intensive care units (ICU), and severe sepsis and septic shock are among the leading causes of death worldwide. The purpose of this study is to develop a deep learning model that supports clinicians in efficiently managing sepsis patients in the ICU by predicting mortality, ICU length of stay (>14 days), and hospital length of stay (>30 days). The proposed model was developed using 591 retrospective data with 16 tabular data related to a sequential organ failure assessment (SOFA) score. To analyze tabular data, we designed the modified architecture of the transformer that has achieved extraordinary success in the field of languages and computer vision tasks in recent years. The main idea of the proposed model is to use a skip-connected token, which combines both local (feature-wise token) and global (classification token) information as the output of a transformer encoder. The proposed model was compared with four machine learning models (ElasticNet, Extreme Gradient Boosting [XGBoost]), and Random Forest) and three deep learning models (Multi-Layer Perceptron [MLP], transformer, and Feature-Tokenizer transformer [FT-Transformer]) and achieved the best performance (mortality, area under the receiver operating characteristic (AUROC) 0.8047; ICU length of stay, AUROC 0.8314; hospital length of stay, AUROC 0.7342). We anticipate that the proposed model architecture will provide a promising approach to predict the various clinical endpoints using tabular data such as electronic health and medical records.

Prognostic accuracy of SOFA, MEWS, and SIRS criteria in predicting the mortality rate of patients with sepsis: A meta-analysis

BACKGROUND

In recent years, some studies classified patients with sepsis and predicted their mortality by using some evaluation scales. Several studies reported significant differences in the predictive values of several tools, and the non-uniformity of the cut-off value.

OBJECTIVE

To determine and compare the prognostic accuracy of Sequential Organ Failure Assessment (SOFA) score, Modified Early Warning Score (MEWS), and Systemic Inflammatory Response Syndrome (SIRS) criteria in predicting the mortality of patients with sepsis.

METHODS

This study comprised of systematic literature review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched PubMed, Embase, Web of Science and Cochrane Library databases from their establishment to July 31, 2022. The research articles published in the index journals provide sufficient data (true positive, false positive, true negative, and false negative results) for patients with sepsis. The combined sensitivity and specificity of the 95% confidence interval (CI) were calculated using the bivariate random effect model (BRM). The hierarchical overall subject working characteristics (HSROC) curve was drawn to evaluate the accuracy of the overall prognosis.

RESULTS

Data of 55 088 patients from 32 studies were included in this meta-analysis. SOFA had an intermediate sensitivity of 0.73 (95% CI: 0.67-0.78) and a specificity of 0.70 (0.63-0.76). SIRS criteria had the highest sensitivity of 0.75 (0.66-0.82) and the lowest specificity of 0.40 (0.29-0.52). MEWS had the lowest sensitivity of 0.49 (0.40-0.59) and the highest specificity of 0.82 (0.78-0.86).

CONCLUSIONS

Among SOFA, MEWS, and SIRS criteria, SOFA showed moderate sensitivity and specificity for predicting mortality in patients with sepsis, the highest sensitivity of SIRS and the strongest specificity of MEWS for predicting mortality in patients with sepsis. The future research direction is to combine the relevant indicators of MEWS and SIRS to develop a measurement tool with high reliability and validity.

RELEVANCE TO CLINICAL PRACTICE

The review provides useful insights into the prognostic accuracy of different assessment tools in predicting mortality in sepsis patients, which will help clinicians choose the most appropriate tool for early identification and treatment of sepsis. The findings may also contribute to the development of more accurate and reliable prognostic models for sepsis.

Four Assessment Tools for Predicting Mortality and Adverse Events in Surgical Patients With Sepsis and Septic Shock: A Comparative Study

BACKGROUND

The mortality rate for sepsis and septic shock in surgical patients is approximately 36%, which is higher than that of other medical patients. Predisposition, infection/injury, response, and organ dysfunction (PIRO) is currently the most widely used tool for assessing patients with surgical sepsis. However, it is not a standardized assessment tool for surgical patients in general.

PURPOSE

The purposes of this study were to (a) create a modified PIRO (mPIRO) that adds a count of platelets and does not include a body temperature reading; (b) test the sensitivity and specificity of the mPIRO for predicting mortality and adverse events among patients with surgical sepsis; and (c) compare the predictive accuracy of the mPIRO, sequential organ failure assessment (SOFA), quick SOFA, and PIRO tools.

METHODS

A retrospective observational cohort study was conducted. Two thousand fifty-five patient medical records were reviewed, with 103 identified as meeting the inclusion criteria.

RESULTS

Compared with the other tools, mPIRO ≥ 4 achieved better sensitivity (90.5%) in predicting mortality and high sensitivity (72%) and specificity (80%) in predicting adverse events. mPIRO was the most accurate predictor of mortality (area under the receiver operating characteristic curve [AUC] = 0.83) among the tools considered. SOFA and mPIRO were the first and second most accurate predictor of adverse events, respectively, with respective AUC values of 0.86 and 0.82.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

mPIRO, which employs an easy-to-use scoring system, is a valid assessment tool with good sensitivity and AUC for predicting both mortality and adverse events in patients with surgical sepsis. We recommend using mPIRO ≥ 3 as an indicator of potential adverse events.

Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score!

How to cite this article: Kannan A, Jindal A. Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score! Indian J Crit Care Med 2023;27(2):150.

Machine Learning Model Development and Validation for Predicting Outcome in Stage 4 Solid Cancer Patients with Septic Shock Visiting the Emergency Department: A Multi-Center, Prospective Cohort Study

A reliable prognostic score for minimizing futile treatments in advanced cancer patients with septic shock is rare. A machine learning (ML) model to classify the risk of advanced cancer patients with septic shock is proposed and compared with the existing scoring systems. A multi-center, retrospective, observational study of the septic shock registry in patients with stage 4 cancer was divided into a training set and a test set in a 7:3 ratio. The primary outcome was 28-day mortality. The best ML model was determined using a stratified 10-fold cross-validation in the training set. A total of 897 patients were included, and the 28-day mortality was 26.4%. The best ML model in the training set was balanced random forest (BRF), with an area under the curve (AUC) of 0.821 to predict 28-day mortality. The AUC of the BRF to predict the 28-day mortality in the test set was 0.859. The AUC of the BRF was significantly higher than those of the Sequential Organ Failure Assessment score and the Acute Physiology and Chronic Health Evaluation II score (both p < 0.001). The ML model outperformed the existing scores for predicting 28-day mortality in stage 4 cancer patients with septic shock. However, further studies are needed to improve the prediction algorithm and to validate it in various countries. This model might support clinicians in real-time to adopt appropriate levels of care.

Sepsis in Intensive Care Unit: Which Score Predicts Better about Outcome?

How to cite this article: Clerk AM. Sepsis in Intensive Care Unit: Which Score Predicts Better about Outcome? Indian J Crit Care Med 2022;26(10):1072-1073.

Comparison of PIRO, APACHE IV, and SOFA Scores in Predicting Outcome in Patients with Sepsis Admitted to Intensive Care Unit: A Two-year Cross-sectional Study at Rural Teaching Hospital

Introduction

Though many scoring systems for prognostication of sepsis are available in the intensive care set-up, predisposition, insult, response, and organ dysfunction (PIRO) score helps to assess each patient and evaluate response to therapy. There are few studies comparing the efficacy of PIRO score with other sepsis scores. Hence, our study was planned to compare PIRO score with acute physiology and chronic health evaluation IV (APACHE IV) score and sequential (sepsis-related) organ failure assessment (SOFA) score in predicting the mortality of intensive care patients with sepsis.

Materials and methods

This prospective cross-sectional study was done in the medical intensive care unit (MICU) from August 2019 to September 2021 among patients above 18 years of age with the diagnosis of sepsis. Predisposition, insult, response, and organ dysfunction score, SOFA score, and APACHE IV score on admission and at day 3 were calculated and statistically analyzed in the terms of outcome.

Results

A total of 280 patients fulfilling the inclusion criteria were included in the study, the mean age was 59.38 ± 15.9 years. There was a significant association of PIRO score, SOFA score, and APACHE IV score on admission and at day 3 with mortality (p-value <0.05). Among all three parameters, the PIRO score on admission and at day 3 was the best predictor of mortality at cut-off points of >14 and >16 with 92.50% and 96.50% chances of correctly predicting mortality, respectively.

Conclusion

Predisposition, insult, response, and organ dysfunction score can be considered as a strong predictor of prognostication of patients with sepsis admitted to the intensive care unit (ICU) and predict mortality. It should be routinely used as it is a simple and comprehensive score.

How to cite this article

Dronamraju S, Agrawal S, Kumar S, Acharya S, Gaidhane S, Wanjari A, et al. Comparison of PIRO, APACHE IV, and SOFA Scores in Predicting Outcome in Patients with Sepsis Admitted to Intensive Care Unit: A Two-year Cross-sectional Study at Rural Teaching Hospital. Indian J Crit Care Med 2022;26(10):1099-1105.

Using Machine Learning to Develop and Validate an In-Hospital Mortality Prediction Model for Patients with Suspected Sepsis

Background: Early recognition of sepsis and the prediction of mortality in patients with infection are important. This multi-center, ED-based study aimed to develop and validate a 28-day mortality prediction model for patients with infection using various machine learning (ML) algorithms. Methods: Patients with acute infection requiring intravenous antibiotic treatment during the first 24 h of admission were prospectively recruited. Patient demographics, comorbidities, clinical signs and symptoms, laboratory test data, selected sepsis-related novel biomarkers, and 28-day mortality were collected and divided into training (70%) and testing (30%) datasets. Logistic regression and seven ML algorithms were used to develop the prediction models. The area under the receiver operating characteristic curve (AUROC) was used to compare different models. Results: A total of 555 patients were recruited with a full panel of biomarker tests. Among them, 18% fulfilled Sepsis-3 criteria, with a 28-day mortality rate of 8%. The wrapper algorithm selected 30 features, including disease severity scores, biochemical parameters, and conventional and few sepsis-related biomarkers. Random forest outperformed other ML models (AUROC: 0.96; 95% confidence interval: 0.93–0.98) and SOFA and early warning scores (AUROC: 0.64–0.84) in the prediction of 28-day mortality in patients with infection. Additionally, random forest remained the best-performing model, with an AUROC of 0.95 (95% CI: 0.91–0.98, p = 0.725) after removing five sepsis-related novel biomarkers. Conclusions: Our results demonstrated that ML models provide a more accurate prediction of 28-day mortality with an enhanced ability in dealing with multi-dimensional data than the logistic regression model.

Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients

Background

Stratifying patients with sepsis was the basis of the predisposition, infection, response and organ dysfunction (PIRO) concept, an attempt to resolve the heterogeneity in treatment response. The purpose of this study is to perform an independent validation of the PIRO staging system in an international cohort and explore its utility in the identification of patients in whom time to antibiotic treatment is particularly important.

Methods

Prospective international cohort study, conducted over a 6-month period in five Portuguese hospitals and one Australian institution. All consecutive adult patients admitted to selected wards or the intensive care, with infections that met the CDC criteria for lower respiratory tract, urinary, intra-abdominal and bloodstream infections were included.

Results

There were 1638 patients included in the study. Patients who died in hospital presented with a higher PIRO score (10 ± 3 vs 8 ± 4, p < 0.001). The observed mortality was 3%, 15%, 24% and 34% in stage I, II, III and IV, respectively, which was within the predicted intervals of the original model, except for stage IV patients that presented a lower mortality. The hospital survival rate was 84%. The application of the PIRO staging system to the validation cohort resulted in a positive predictive value of 97% for stage I, 91% for stage II, 85% for stage III and 66% for stage IV. The area under the receiver operating characteristics curve (AUROC) was 0.75 for the all cohort and 0.70 if only patients with bacteremia were considered. Patients in stage III and IV who did not have antibiotic therapy administered within the desired time frame had higher mortality rate than those who have timely administration of antibiotic.

Conclusions

To our knowledge, this is the first external validation of this PIRO staging system and it performed well on different patient wards within the hospital and in different types of hospitals. Future studies could apply the PIRO system to decision-making about specific therapeutic interventions and enrollment in clinical trials based on disease stage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00966-7.

Prognostic scores and early management of septic patients in the emergency department of a secondary hospital: results of a retrospective study

BACKGROUND

Sequential Organ Failure Assessment (SOFA) and other illness prognostic scores predict adverse outcomes in critical patients. Their validation as a decision-making tool in the emergency department (ED) of secondary hospitals is not well established. The aim of this study was to compare SOFA, NEWS2, APACHE II, and SAPS II scores as predictors of adverse outcomes and decision-making tool in ED.

METHODS

Data of 121 patients (age 73 ± 10 years, 58% males, Charlson Comorbidity Index 5.7 ± 2.1) with a confirmed sepsis were included in a retrospective study between January 2017 and February 2020. Scores were computed within the first 24 h after admission. Primary outcome was the occurrence of either in-hospital death or mechanical ventilation within 7 days. Secondary outcome was 30-day all-cause mortality.

RESULTS

Patients older than 64 years (elderly) represent 82% of sample. Primary and secondary outcomes occurred in 40 and 44%, respectively. Median 30-day survival time of dead patients was 4 days (interquartile range 1-11). The best predictive score based on the area under the receiver operating curve (AUROC) was SAPS II (0.823, 95% confidence interval, CI, 0.744-0.902), followed by APACHE II (0.762, 95% CI 0.673-0.850), NEWS2 (0.708, 95% CI 0.616-0.800), and SOFA (0.650, 95% CI 0.548-0.751). SAPS II cut-off of 49 showed the lowest false-positive rate (12, 95% CI 5-20) and the highest positive predictive value (80, 95% CI 68-92), whereas NEWS2 cut-off of 7 showed the lowest false-negative rate (10, 95% CI 2-19) and the highest negative predictive value (86, 95% CI 74-97). By combining NEWS2 and SAPS II cut-offs, we accurately classified 64% of patients. In survival analysis, SAPS II cut-off showed the highest difference in 30-day mortality (Hazards Ratio, HR, 5.24, 95% CI 2.99-9.21, P < 0.001). Best independent negative predictors of 30-day mortality were body temperature, mean arterial pressure, arterial oxygen saturation, and hematocrit levels. Positive predictors were male sex, heart rate and serum sodium concentration.

CONCLUSIONS

SAPS II is a good prognostic tool for discriminating high-risk patient suitable for sub-intensive/intensive care units, whereas NEWS2 for discriminating low-risk patients for low-intensive units. Our results should be limited to cohorts with a high prevalence of elderly or comorbidities.

Urine Output Is Associated With In-hospital Mortality in Intensive Care Patients With Septic Shock: A Propensity Score Matching Analysis

Background: The relationship between urine output (UO) and in-hospital mortality in intensive care patients with septic shock is currently inconclusive. Methods: The baseline data, UO, and in-hospital prognosis of intensive care patients with septic shock were retrieved from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. By drawing receiver operating characteristic (ROC) curves and comparing the areas under the ROC curves (AUC) to determine the predictive value of UO for in-hospital mortality, and by drawing the Kaplan-Meier curves to compare the difference in in-hospital mortality between different groups of UO. Results: Before and after the propensity score matching (PSM) analysis, UO was always a risk factor for in-hospital mortality in patients with septic shock. The AUC of UO was comparable to the Sequential Organ Failure Assessment (SOFA) scoring system, while the AUC of combining UO and SOFA was greater than that of SOFA. The median survival time of the high-UO group (UO > 0.39 ml/kg/h, before PSM; UO > 0.38 ml/kg/h, after PSM) was longer than that of the low-UO group. Compared with the high-UO group, the hazard ratios (HR) of the low-UO group were 2.6857 (before PSM) and 1.7879 (after PSM). Conclusions: UO is an independent risk factor for septic shock. Low levels of UO significantly increase the in-hospital mortality of intensive care patients with septic shock. The predictive value of UO is comparable to the SOFA scoring system, and the combined predictive value of the two surpasses SOFA alone.

COVID-PIRO (Predisposition, Insult, Response, Organ Dysfunction) Score: A Reliable Predictor of Outcomes in COVID-19 Patients Admitted in Intensive Care Unit

Introduction

To measure the severity of sepsis and pneumonia in adult patients with coronavirus disease 2019 (COVID-19), the PIRO model (predisposition, insult, response, organ dysfunction) was adopted as a scoring system. In this study, the PIRO model was modified to classify the severity of pneumonia in adults and predict mortality risk infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), admitted to a tertiary intensive care unit (ICU) in central rural India.

Method

This prospective, observational study was conducted in the Department of Medicine, in rural medical college at Wardha, Maharashtra, India from May 2020 to May 2021. Patients with reverse transcription-polymerase chain reaction (RT-PCR) positive for COVID-19 and whose age was more than 18 years admitted in the intensive care unit were included in the study.

Results

A total of 240 patients were included in the analysis having mean age of 60.27 ± 15.3 years. Number of deaths were 115 out of 240 (48.3%). Mean ICU stay was 9.09 ± 6.34 days. PIRO score ≤14.5 had a mortality rate of 1.25% as compared to the group having PIRO>14.5 which had mortality of 27.5%, with a cure rate of 26.25% and 5% respectively in both groups (p = 0.0001).

Conclusion

COVID-PIRO modified PIRO score was a highly sensitive and specific model in predicting in-hospital mortality but it is moderately sensitive in predicting ICU stay.

Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department

OBJECTIVE

There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital.

DESIGN, SETTING AND PARTICIPANTS

We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA.

RESULTS

Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716-0.824) vs. AUC 0.699 (0.64-0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715-0.819) vs AUC 0.709 (0.656-0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71-0.82) at 30 d, AUC 0.754 (0.701-0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA.

CONCLUSIONS

We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.

Heart rate n-variability (HRnV) measures for prediction of mortality in sepsis patients presenting at the emergency department

Sepsis is a potentially life-threatening condition that requires prompt recognition and treatment. Recently, heart rate variability (HRV), a measure of the cardiac autonomic regulation derived from short electrocardiogram tracings, has been found to correlate with sepsis mortality. This paper presents using novel heart rate n-variability (HRnV) measures for sepsis mortality risk prediction and comparing against current mortality prediction scores. This study was a retrospective cohort study on patients presenting to the emergency department of a tertiary hospital in Singapore between September 2014 to April 2017. Patients were included if they were above 21 years old and were suspected of having sepsis by their attending physician. The primary outcome was 30-day in-hospital mortality. Stepwise multivariable logistic regression model was built to predict the outcome, and the results based on 10-fold cross-validation were presented using receiver operating curve analysis. The final predictive model comprised 21 variables, including four vital signs, two HRV parameters, and 15 HRnV parameters. The area under the curve of the model was 0.77 (95% confidence interval 0.70–0.84), outperforming several established clinical scores. The HRnV measures may have the potential to allow for a rapid, objective, and accurate means of patient risk stratification for sepsis severity and mortality. Our exploration of the use of wealthy inherent information obtained from novel HRnV measures could also create a new perspective for data scientists to develop innovative approaches for ECG analysis and risk monitoring.

Prediction of Sepsis Related Mortality: An Optimization Approach

Sepsis is a condition that progresses quickly and is a major cause of mortality in hospitalized patients. Data-driven diagnostic and therapeutic interventions are essential to ensure early diagnosis and appropriate care. The Sequential Organ Failure Assessment (SOFA) score is widely utilized in clinical practice to assess septic patients for organ dysfunction. The SOFA score uses points between 0 and 4 to quantify the level of dysfunction in six organ systems. These points are determined based on expert opinion and not informed by data, thus their usefulness can vary among different medical institutions depending on the targeted use. In this study, we propose multiple strategies to adjust the SOFA score using mixed-integer programming to improve the in-hospital mortality prediction of septic patients based on Electronic Health Records (EHRs). We use the same variables and threshold values of the original SOFA score in each strategy. Thus, the proposed approach takes advantage of optimization and data analysis while taking into account the medical expertise. Our results demonstrate a statistically significant improvement (p<0.001) in the prediction of in-hospital mortality among patients susceptible to sepsis when implementing our proposed strategies. Area under the receiver operator curve (AUC) and accuracy values of 0.8928 and 0.8904 are achieved by optimizing the point values of the SOFA score.

Mortality benefit of crystalloids administered in 1-6 hours in septic adults in the ED: systematic review with narrative synthesis

BACKGROUND

Based on the 2018 update of the Surviving Sepsis Campaign, the Committee for Quality Improvement of the NHSs of England recommended the instigation of the elements of the 'Sepsis-6 bundle' within 1 hour to adult patients screened positive for sepsis. This bundle includes a bolus infusion of 30 mL/kg crystalloids in the ED. Besides the UK, both in the USA and Australia, compliance with similar 1-hour targets became an important quality indicator. However, the supporting evidence may neither be contemporaneous nor necessarily valid for emergency medicine settings.

METHOD

A systematic review was designed and registered at PROSPERO to assess available emergency medicine/prehospital evidence published between 2012 and 2020, investigating the clinical benefits associated with a bolus infusion of a minimum 30 mL/kg crystalloids within 1 hour to adult patients screened positive for sepsis. Due to the small number of papers that addressed this volume of fluids in 1 hour, we expanded the search to include studies looking at 1-6 hours.

RESULTS

Seven full-text articles were identified, which investigated various aspects of the fluid resuscitation in adult sepsis. However, none answered completely to the original research question aimed to determine either the effect of time-to-crystalloids or the optimal fluid volume of resuscitation. Our findings demonstrated that in the USA/UK/Australia/Canada, adult ED septic patients receive 23-43 mL/kg of crystalloids during the first 6 hours of resuscitation without significant differences either in mortality or in adverse effects.

CONCLUSION

This systematic review did not find high-quality evidence supporting the administration of 30 mL/kg crystalloid bolus to adult septic patients within 1 hour of presentation in the ED. Future research must investigate both the benefits and the potential harms of the recommended intervention.

Comparison of qSOFA, SIRS, and NEWS scoring systems for diagnosis, mortality, and morbidity of sepsis in emergency department

PURPOSE

This study was aimed to compare the quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS), and National Early Warning Score (NEWS) scoring systems for diagnosing sepsis and predicting mortality and morbidity.

PATIENTS AND METHODS

A prospective study was designed. qSOFA, SIRS, and NEWS scores were calculated at the admission. The diagnosis of sepsis was made with SOFA scoring initially. The morbidity and mortality of the patients were identified during follow-up. Also, the sensitivity, specificity, negative predictive value, and positive predictive value of three scoring systems were calculated. The scoring systems were compared with ROC analysis.

RESULTS

A total of 463 patients were evaluated. There were 287 (62.0%) patients diagnosed with sepsis, and septic shock occurred in 64 (13.8%) of patients. Seven-day mortality rate was 8.4% (n = 39), 30-day mortality rate was 18.1% (n = 84). The sensitivity for qSOFA, SIRS, and NEWS for diagnosis of sepsis was 23%, 77%, 58%, and specificity was 99%, 35%, 81% respectively. The sensitivity of the qSOFA, SIRS and NEWS scoring systems for mortality was 39%, 82%, 77% and specificity 91%, 29%, and 64%, respectively. AUROC values for mortality detected as NEWS = 0.772, qSOFA = 0.758, SIRS = 0.542. According to the ROC analysis, the SIRS system was significantly less useful than the qSOFA and NEWS system in the diagnosis of sepsis and mortality (p < 0.0001).

CONCLUSION

NEWS and qSOFA scoring systems have similar prognosis in both diagnosing sepsis and predicting mortality and both are superior to SIRS.

Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study

Introduction

This study was proposed to compare the ability and accuracy of modified sequential organ failure assessment (mSOFA), quick SOFA (qSOFA), and qSOFA-65 in predicting the status of nontraumatic patients referred to hospital emergency departments (EDs).

Materials and methods

This study was a prospective design that performed on the 746 nontraumatic patients referred to the ED. Each patient data was collected using a demographic questionnaire, mSOFA, qSOFA, and qSOFA-65 scales. Related variables of each scale were recorded based on patients’ medical records. Then, the outcome of each patient in the ED was followed up and recorded. The severity and specificity of each scale were estimated by the area under receiver operating characteristic (AUROC) curve at 99% confidence interval (CI).

Results

The mean and standard deviation of scores were as follows: mSOFA = 4.40 ± 2.58, qSOFA = 0.50 ± 0.70, and qSOFA-65 = 0.92 ± 0.96. Patients requiring admission to the intensive care unit (ICU) were identified with AUROC curve as follows: mSOFA = 0.882 (99% CI = 0.778–0.865); qSOFA = 0.717 (99% CI = 0.662–0.773); and qSOFA-65 = 0.771 (99% CI = 0.721–0.820), which showed that mSOFA has higher sensitivity and specificity than the other two scales in identifying patients requiring admission to the ICU.

Conclusion

All three scales were found to be reliable for identifying nontraumatic patients at risk of death and patients requiring admission to the ICU. However, since the time and data required to complete qSOFA and qSOFA-65 are much less than those of mSOFA, it is recommended that qSOFA and especially qSOFA-65 be used in ED to identify critically ill nontraumatic patients.

How to cite this article

Ebrahimian A, Shahcheragh SMT, Fakhr-Movahedi A. Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study. Indian J Crit Care Med 2020;24(11):1045–1050.

Effect of age and comorbidity on the ability of quick-Sequential Organ Failure Assessment score to predict outcome in emergency department patients with suspected infection

OBJECTIVE

To determine if a combination of the Charlson Comorbidity Index (CCI) and quick-Sequential Organ Failure Assessment (qSOFA) score is superior to qSOFA alone for predicting the outcome of ED patients with suspected infection.

METHODS

A prospective, observational single-centre study recruited consecutive adult patients who underwent blood culture collection in the ED and were admitted to hospital. The primary outcome was 28-day in-hospital mortality, and the secondary outcome a composite of mortality and/or ICU admission ≥72 h duration. The qSOFA and CCI were combined using logistic regression models, and the resulting area under the receiver operating characteristic curve (AUROC) compared to that for qSOFA alone.

RESULTS

Of 551 patients recruited, 18 (3%) died and 27 (5%) attained the composite outcome. The AUROC for qSOFA/CCI versus qSOFA for the primary outcome is 0.79 versus 0.72 (95% confidence interval 0.71-0.88 vs 0.62-0.82, P = 0.055) and 0.80 versus 0.76 (95% confidence interval 0.73-0.86 vs 0.68-0.84, P = 0.048). Deaths among patients not admitted to ICU (12/495) accounted for most of the overall differences in AUROC.

CONCLUSIONS

This generates the hypothesis that age and comorbid disease status augment the qSOFA score for predicting adverse outcome among patients with suspected infection in the ED. The results may reflect the predominance of these factors in determining suitability for admission to ICU. Reported limitations of qSOFA to detect the risk of adverse outcome may reflect the influence of unmeasured patient factors.

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.

Predictive value of the sequential organ failure assessment (SOFA) score for prognosis in patients with severe acute ischemic stroke: a retrospective study

OBJECTIVE

To identify the risk factors for early death and determine the predictive value of the sequential organ failure assessment (SOFA) score for prognosis of severe acute ischemic stroke (AIS).

METHODS

A total of 110 patients with severe AIS were enrolled and divided into the non-survivor (n = 34) and survivor groups (n = 76). Logistic regression analysis was conducted to identify risk factors for early death, while the receiver operator characteristic (ROC) curve was used to determine the predictive effect of the SOFA score on prognosis.

RESULTS

Logistic regression analysis showed that urinary tract infection (odds ratio [OR] = 17.364, 95% confidence interval [CI]: 1.903-158.427), mechanical ventilation (OR = 1.754, 95% CI: 1.648-2.219), and osmotic therapy (OR = 2.835, 95% CI: 1.871-5.102) were significantly correlated with early death of severe AIS. ROC curve analysis of the area under the curve after hospitalization showed that the maximum SOFA and ΔSOFA scores exceeded 0.7.

CONCLUSION

Our study shows that urinary tract infection, mechanical ventilation, and osmotic therapy are risk factors for early death of severe AIS. The SOFA score has good predictive value for prognosis of severe AIS. These findings may provide a guideline for improving clinical outcome.

Antibiotic treatment with one single dose of gentamicin at admittance in addition to a β-lactam antibiotic in the treatment of community-acquired bloodstream infection with sepsis

Background

Combination therapy in the treatment of sepsis, especially the value of combining a β-Lactam antibiotic with an aminoglycoside, has been discussed. This retrospective cohort study including patients with sepsis or septic shock aimed to investigate whether one single dose of gentamicin at admittance (SGA) added to β-Lactam antibiotic could result in a lower risk of mortality than β-Lactam monotherapy, without exposing the patient to the risk of nephrotoxicity.

Methods and findings

All patients with positive blood cultures were evaluated for participation (n = 1318). After retrospective medical chart review, a group of patients with community-acquired sepsis with positive blood cultures who received β-Lactam antibiotic with or without the addition of SGA (n = 399) were included for the analysis. Mean age was 74.6 yrs. (range 19–98) with 216 (54%) males. Sequential Organ Failure Assessment score (SOFA score) median was 3 (interquartile range [IQR] 2–5) and the median Charlson Comorbidity Index for the whole group was 2 (IQR 1–3). Sixty-seven (67) patients (17%) had septic shock. The 28-day mortality in the combination therapy group was 10% (20 of 197) and in the monotherapy group 22% (45 of 202), adjusted HR 3.5 (95% CI (1.9–6.2), p = < 0.001. No significant difference in incidence of acute kidney injury (AKI) was detected.

Conclusion

This retrospective observational study including patients with community-acquired sepsis or septic shock and positive blood cultures, who meet Sepsis-3 criteria, shows that the addition of one single dose of gentamicin to β-lactam treatment at admittance was associated with a decreased risk of mortality and was not associated with AKI. This antibiotic regime may be an alternative to broad-spectrum antibiotic treatment of community-acquired sepsis. Further prospective studies are warranted to confirm these results.

Validation of the Predisposition Infection Response Organ (PIRO) dysfunction score for the prognostic stratification of patients with sepsis in the Emergency Department

OBJECTIVE

There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital.

DESIGN, SETTING AND PARTICIPANTS

We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA.

RESULTS

Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716-0.824) vs. AUC 0.699 (0.64-0.758) (p=0.03) and similarly at 60 d (AUC 0.767 (0.715-0.819) vs AUC 0.709 (0.656-0.763)(p=0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71-0.82) at 30 d, AUC 0.754 (0.701-0.806) at 60 d, p=ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p=ns). For high level of care admission, PIRO proved inferior to SOFA.

CONCLUSIONS

We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.

Epidemiology of septic shock in prehospital medical services in five Colombian cities

Objective

To explore the association between demographic and clinical factors and the presentation of septic shock in patients treated by prehospital emergency services in five Colombian cities between 2015 and 2016.

Methods

This was a cross-sectional study with retrospective data collection. Clinical and demographic data were collected from the medical records of patients diagnosed with sepsis who received prehospital care in five Colombian cities in 2015 and 2016. The diagnosis of septic shock was checked in 20% of the cases, generating two analyzed scenarios: observed and verified. Data were analyzed using the chi-square test, Student’s t test and an adjusted logistic regression model. Covariates with p < 0.05 were considered significant.

Results

There was a higher frequency of septic shock in women (62.6%) and in individuals older than 80 years (64.5%), but these were not differentiating factors for septic shock. The most common source of infection was the urinary tract. In the observed scenario, age over 60 (prevalence ratio (PR): 3.22; 95% confidence interval (CI): 1.45 - 35.01) and history of cancer (PR: 1.20; 95%CI: 1.2 - 12.87) were the characteristics associated with septic shock, whereas in the verified scenario, chronic obstructive pulmonary disease (PR: 1.99; 95%CI: 1.26 - 7.14), history of cancer (PR: 1.15; 95%CI: 1.11 - 6.62) and presence of hypovolemia (PR: 1.41; 95%CI: 1.02 - 5.50) were observed.

Conclusion

The most important risk factors for septic shock in prehospital care patients in five Colombian cities were oncological and pulmonary diseases and hypovolemia.

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.

Central Venous Access Capability and Critical Care Telemedicine Decreases Inter-Hospital Transfer Among Severe Sepsis Patients: A Mixed Methods Design

OBJECTIVES

Severe sepsis is a complex, resource intensive, and potentially lethal condition and rural patients have worse outcomes than urban patients. Early identification and treatment are important to improving outcomes. The objective of this study was to identify hospital-specific factors associated with inter-hospital transfer.

DESIGN

Mixed method study integrating data from a telephone survey and retrospective cohort study of state administrative claims.

SETTING AND SUBJECTS

Survey of Iowa emergency department administrators between May 2017 and June 2017 and cohort of adults seen in Iowa emergency departments for severe sepsis and septic shock between January 2005 and December 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multivariable logistic regression was used to identify independent predictors of inter-hospital transfer. We included 114 institutions that provided data (response rate = 99%), and responses were linked to a total of 150,845 visits for severe sepsis/septic shock. In our adjusted model, having the capability to place central venous catheters or having a subscription to a tele-ICU service was independently associated with lower odds of inter-hospital transfer (adjusted odds ratio, 0.69; 95% CI, 0.54-0.86 and adjusted odds ratio, 0.69; 95% CI, 0.54-0.88, respectively). A facility's participation in a sepsis-specific quality improvement initiative was associated with 62% higher odds of transfer (adjusted odds ratio, 1.62; 95% CI, 1.10-2.39).

CONCLUSIONS

The insertion of central venous catheters and access to a critical care physician during sepsis treatment are important capabilities in hospitals that transfer fewer sepsis patients. In the future, hospital-specific capabilities may be used to identify institutions as regional sepsis centers.

Mortality Prediction of Septic Patients in the Emergency Department Based on Machine Learning

In emergency departments, the most common cause of death associated with suspected infected patients is sepsis. In this study, deep learning algorithms were used to predict the mortality of suspected infected patients in a hospital emergency department. During January 2007 and December 2013, 42,220 patients considered in this study were admitted to the emergency department due to suspected infection. In the present study, a deep learning structure for mortality prediction of septic patients was developed and compared with several machine learning methods as well as two sepsis screening tools: the systemic inflammatory response syndrome (SIRS) and quick sepsis-related organ failure assessment (qSOFA). The mortality predictions were explored for septic patients who died within 72 h and 28 days. Results demonstrated that the accuracy rate of deep learning methods, especially Convolutional Neural Network plus SoftMax (87.01% in 72 h and 81.59% in 28 d), exceeds that of the other machine learning methods, SIRS, and qSOFA. We expect that deep learning can effectively assist medical staff in early identification of critical patients.

Prevalence of organ failure and mortality among patients in the emergency department: a population-based cohort study

OBJECTIVES

The aim was to describe population-based incidence and emergency department-based prevalence and 1-year all-cause mortality of patients with new organ failure present at arrival.

DESIGN

This was a population-based cohort study of all citizens in four municipalities (population of 230 000 adults).

SETTING

Emergency department at Odense University Hospital, Denmark.

PARTICIPANTS

We included all adult patients who arrived from 1 April 2012 to 31 March 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Organ failure was defined as a modified Sequential Organ Failure Assessment score≥2 within six possible organ systems: cerebral, circulatory, renal, respiratory, hepatic and coagulation.The primary outcome was prevalence of organ failure, and secondary outcomes were 0-7 days, 8-30 days and 31-365 days all-cause mortality.

RESULTS

We identified in total 175 278 contacts, of which 70 399 contacts were further evaluated for organ failure. Fifty-two per cent of these were women, median age 62 (IQR 42-77) years. The incidence of new organ failure was 1342/100 000 person-years, corresponding to 5.2% of all emergency department contacts.The 0-7-day, 8-30-day and 31-365-day mortality was 11.0% (95% CI: 10.2% to 11.8%), 5.6% (95% CI: 5.1% to 6.2%) and 13.2% (95% CI: 12.3% to 14.1%), respectively, if the patient had one or more new organ failures at first contact in the observation period, compared with 1.4% (95% CI: 1.3% to 1.6%), 1.2% (95% CI: 1.1% to 1.3%) and 5.2% (95% CI: 5.0% to 5.4%) for patients without. Seven-day mortality ranged from hepatic failure, 6.5% (95% CI: 4.9% to 8.6%), to cerebral failure, 33.8% (95% CI: 31.0% to 36.8%), the 8-30-day mortality ranged from cerebral failure, 3.9% (95% CI: 2.8% to 5.3%), to hepatic failure, 8.6% (95% CI: 6.6% to 10.8%) and 31-365-day mortality ranged from cerebral failure, 9.3% (95% CI: 7.6% to 11.2%), to renal failure, 18.2% (95% CI: 15.5% to 21.1%).

CONCLUSIONS

The study revealed an incidence of new organ failure at 1342/100 000 person-years and a prevalence of 5.2% of all emergency department contacts. One-year all-cause mortality was 29.8% among organ failure patients.

Biomarkers in Shock Patients and Their Value as A Prognostic Tool; A Prospective Multi-Center Cohort Study

Objective

To investigate the prognostic value of clinical and laboratory tests in prediction of outcome in patients at day 30 post presentation to hospital with shock and to determine the prognostic value of mid regional pro-adrenomedullin (MR-proADM) on mortality prediction at 30 days in the same patient cohort.

Method

This prospective multicenter cohort study analyzed data from patients who had presenting with shock to the emergency departments of eleven urban, tertiary-care University hospitals in Spain between March, 2011 and May, 2011. Recruitment of patients was via convenience sampling. Inclusion criteria included age between 14 and 100 years with clinical diagnostic criteria of shock on admission. Various patient parameters were analysed, such as age, sex, past medical history. Other clinical variables were measured on arrival to hospital, including sequential organ failure assessment score (score SOFA), blood pressure, oxygen saturations, capillary refill time and shock index (SI). Laboratory variables investigated included base excess, MR-proADM, lactate, C-Reactive Protein (CRP) and procalcitonin (PCT).

Results

There were 212 patients included in the study from the eleven hospitals involved. The mean age was 72.2 years old and 60.4% of the patients were men. In the discriminant analysis only age, MR-proADM and PCT remained in the final discriminant equation. The separate analysis of MR-proADM showed that, in the non-survivors group, MR-proADM levels are significantly higher than those found in the group of survivors (p<0.001).

Conclusion

Age, PCT and MR-proADM were useful to predict short-term mortality in patients presenting to the emergency department shock. This suggests that PCT and MR-proADM in combination with the most common prediction models will improve prognostic value.

Validation of the mortality in emergency department sepsis (MEDS) score in a Singaporean cohort

The emergency department (ED) serves as the first point of hospital contact for most septic patients. Early mortality risk stratification using a quick and accurate triage tool would have great value in guiding management. The mortality in emergency department sepsis (MEDS) score was developed to risk stratify patients presenting to the ED with suspected sepsis, and its performance in the literature has been promising. We report in this study the first utilization of the MEDS score in a Singaporean cohort.In this retrospective observational cohort study, adult patients presenting to the ED with suspected sepsis and fulfilling systemic inflammatory response syndrome (SIRS) criteria were recruited. Primary outcome was 30-day in-hospital mortality (IHM) and secondary outcome was 72-hour mortality. MEDS, acute physiology and chronic health evaluation II (APACHE II), and sequential organ failure assessment (SOFA) scores were compared for prediction of primary and secondary outcomes. Receiver operating characteristic (ROC) analysis was conducted to compare predictive performance.Of the 249 patients included in the study, 46 patients (18.5%) met 30-day IHM. MEDS score achieved an area under the ROC curve (AUC) of 0.87 (95% confidence interval [CI], 0.82-0.93), outperforming the APACHE II score (0.77, 95% CI 0.69-0.85) and SOFA score (0.78, 95% CI 0.71-0.85). On secondary analysis, MEDS score was superior to both APACHE II and SOFA scores in predicting 72-hour mortality, with AUC of 0.88 (95% CI 0.82-0.95), 0.81 (95% CI 0.72-0.89), and 0.79 (95% CI 0.71-0.87), respectively. In predicting 30-day IHM, MEDS score ≥12, APACHE II score ≥23, and SOFA score ≥5 performed at sensitivities of 76.1%, 67.4%, and 76.1%, and specificities of 83.3%, 73.9%, and 65.0%, respectively.The MEDS score performed well in its ability for mortality risk stratification in a Singaporean ED cohort.

The value of missing information in severity of illness score development

OBJECTIVE

We aim to investigate the hypothesis that using information about which variables are missing along with appropriate imputation improves the performance of severity of illness scoring systems used to predict critical patient outcomes.

STUDY DESIGN AND SETTING

We quantify the impact of missing and imputed variables on the performance of prediction models used in the development of a sepsis-related severity of illness scoring system. Electronic health records (EHR) data were compiled from Christiana Care Health System (CCHS) on 119,968 adult patients hospitalized between July 2013 and December 2015. Two outcomes of interest were considered for prediction: (1) first transfer to intensive care unit (ICU) and (2) in-hospital mortality. Five different prediction models were employed. Indicators were utilized in these prediction models to identify when variables were missing and imputed.

RESULTS

We observed statistically significant gains in prediction performance when moving from models that did not indicate missing information to those that did. Moreover, this increase was higher in models that use summary variables as predictors compared to those that use all variables.

CONCLUSION

When developing prediction models using longitudinal EHR data, researchers should explore the incorporation of indicators for missing variables along with appropriate imputation.

Combining Heart Rate Variability with Disease Severity Score Variables for Mortality Risk Stratification in Septic Patients Presenting at the Emergency Department

The emergency department (ED) serves as the first point of hospital contact for many septic patients, where risk-stratification would be invaluable. We devised a combination model incorporating demographic, clinical, and heart rate variability (HRV) parameters, alongside individual variables of the Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation II (APACHE II), and Mortality in Emergency Department Sepsis (MEDS) scores for mortality risk-stratification. ED patients fulfilling systemic inflammatory response syndrome criteria were recruited. National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), quick SOFA (qSOFA), SOFA, APACHE II, and MEDS scores were calculated. For the prediction of 30-day in-hospital mortality, combination model performed with an area under the receiver operating characteristic curve of 0.91 (95% confidence interval (CI): 0.88–0.95), outperforming NEWS (0.70, 95% CI: 0.63–0.77), MEWS (0.61, 95% CI 0.53–0.69), qSOFA (0.70, 95% CI 0.63–0.77), SOFA (0.74, 95% CI: 0.67–0.80), APACHE II (0.76, 95% CI: 0.69–0.82), and MEDS scores (0.86, 95% CI: 0.81–0.90). The combination model had an optimal sensitivity and specificity of 91.4% (95% CI: 81.6–96.5%) and 77.9% (95% CI: 72.6–82.4%), respectively. A combination model incorporating clinical, HRV, and disease severity score variables showed superior predictive ability for the mortality risk-stratification of septic patients presenting at the ED.

Application of dynamic pulse pressure and vasopressor tools for predicting outcomes in patients with sepsis in intensive care units

PURPOSE

We aimed to determine whether the combination of dynamic pulse pressure and vasopressor (DPV) use is applicable for mortality risk stratification in patients with severe sepsis. We proposed the use of the DPV tool and compared it with traditional sepsis severity indices.

MATERIALS AND METHODS

All adult patients who met the sepsis criteria of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) between August 2013 and January 2017 were eligible for the study. Patients who expired within 3 days of admission to the intensive care unit (ICU) were excluded. The primary outcomes were 7-day and 28-day mortality.

RESULTS

The study participants included 757 consecutive adult patients. A subpopulation of 155 patients underwent immune profiling assays on days 1, 3, and 7 of ICU admission. The DPV tool had a better performance for predicting 7-day mortality (area under curve, AUC: 0.70), followed by the Sequential Organ Failure Assessment (SOFA) (AUC: 0.64), the plus pulse pressure (AUC: 0.64). For predicting 28-day mortality, the DPV tool was not inferior to the SOFA (AUC: 0.61), DPV tool (AUC: 0.59).

CONCLUSIONS

The DPV tool can be applied for 7-day and 28-day mortality risk prediction in patients with sepsis.

Sepsis Surveillance Using Adult Sepsis Events Simplified eSOFA Criteria Versus Sepsis-3 Sequential Organ Failure Assessment Criteria

OBJECTIVES

Sepsis-3 defines organ dysfunction as an increase in the Sequential Organ Failure Assessment score by greater than or equal to 2 points. However, some Sequential Organ Failure Assessment score components are not routinely recorded in all hospitals' electronic health record systems, limiting its utility for wide-scale sepsis surveillance. The Centers for Disease Control and Prevention recently released the Adult Sepsis Event surveillance definition that includes simplified organ dysfunction criteria optimized for electronic health records (eSOFA). We compared eSOFA versus Sequential Organ Failure Assessment with regard to sepsis prevalence, overlap, and outcomes.

DESIGN

Retrospective cohort study.

SETTING

One hundred eleven U.S. hospitals in the Cerner HealthFacts dataset.

PATIENTS

Adults hospitalized in 2013-2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified clinical indicators of presumed infection (blood cultures and antibiotics) concurrent with either: 1) an increase in Sequential Organ Failure Assessment score by 2 or more points (Sepsis-3) or 2) 1 or more eSOFA criteria: vasopressor initiation, mechanical ventilation initiation, lactate greater than or equal to 2.0 mmol/L, doubling in creatinine, doubling in bilirubin to greater than or equal to 2.0 mg/dL, or greater than or equal to 50% decrease in platelet count to less than 100 cells/μL (Centers for Disease Control and Prevention Adult Sepsis Event). We compared area under the receiver operating characteristic curves for discriminating in-hospital mortality, adjusting for baseline characteristics. Of 942,360 patients in the cohort, 57,242 (6.1%) had sepsis by Sequential Organ Failure Assessment versus 41,618 (4.4%) by eSOFA. Agreement between sepsis by Sequential Organ Failure Assessment and eSOFA was good (Cronbach's alpha 0.81). Baseline characteristics and infectious diagnoses were similar, but mortality was higher with eSOFA (17.1%) versus Sequential Organ Failure Assessment (14.4%; p < 0.001) as was discrimination for mortality (area under the receiver operating characteristic curve, 0.774 vs 0.759; p < 0.001). Comparisons were consistent across subgroups of age, infectious diagnoses, and comorbidities.

CONCLUSIONS

The Adult Sepsis Event's eSOFA organ dysfunction criteria identify a smaller, more severely ill sepsis cohort compared with the Sequential Organ Failure Assessment score, but with good overlap and similar clinical characteristics. Adult Sepsis Events may facilitate wide-scale automated sepsis surveillance that tracks closely with the more complex Sepsis-3 criteria.

A Pilot Study of the Association of Amino-Terminal Pro-B-Type Natriuretic Peptide and Severity of Illness in Pediatric Septic Shock

OBJECTIVES

Biomarkers that can measure illness severity and predict the risk of delayed recovery may be useful in guiding pediatric septic shock. Amino-terminal pro-B-type natriuretic peptide has not been assessed in pediatric septic patients at the time of presentation to the emergency department prior to any interventions. The primary aim was to assess if emergency department amino-terminal pro-B-type natriuretic peptide is associated with worse outcomes and severity of illness.

DESIGN

Prospective observational pilot study.

SETTINGS

Tertiary free-standing children's hospital.

PATIENTS

Children 0-17 years old with a diagnosis of septic shock were enrolled. Patients with preexisting cardiac and renal dysfunction were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Amino-terminal pro-B-type natriuretic peptide analysis was performed on samples obtained in the emergency department prior to any intervention. The association between biomarkers and clinical outcomes and illness severity using Pediatric RISk of Mortality 3 were assessed. Eighty-two patients with septic shock underwent analysis. The median (interquartile range) amino-terminal pro-B-type natriuretic peptide levels was 394 pg/mL (102-1,392 pg/mL). Each decile change increase in amino-terminal pro-B-type natriuretic peptide was associated with a change in ICU length of stay by 8.7%, (95% CI, 2.4-15.5), hospital length of stay by 5.7% (95% CI, 0.4-11.2), organ dysfunction by 5.1% (95% CI, 1.8-8.5), a higher inotropic score at 12, 24, and 36 hours, and longer time requiring vasoactive agents. There was a significant correlation between baseline amino-terminal pro-B-type natriuretic peptide and the Pediatric RISk of Mortality 3 score (Spearman rho = 0.247; p = 0.029).

CONCLUSIONS

This pilot study shows an association between emergency department amino-terminal pro-B-type natriuretic peptide on presentation and worse septic shock outcomes and amino-terminal pro-B-type natriuretic peptide levels correlates with an ICU severity score.

Comparison of severity score models based on different sepsis definitions to predict in-hospital mortality among sepsis patients in the Intensive Care Unit

OBJECTIVE

A comparison is made of the accuracy between severity models, based on different sepsis definitions (systemic inflammatory response syndrome (SIRS), predisposition, insult, response, organ dysfunction (PIRO), and sequential organ failure assessment (SOFA) concepts), in predicting outcomes among sepsis patients.

DESIGN

A retrospective study was carried out.

SETTING

The study was conducted in the Intensive Care Unit (ICU) of a university teaching hospital.

PATIENTS

Septic patients admitted to the ICU during 2007-2016.

MAIN VARIABLES OF INTEREST

The primary outcome was in-hospital mortality, with ICU mortality being the secondary outcome.

RESULTS

A total of 2152 septic patient were identified, with ICU and in-hospital mortality rates of 33.3% and 45.9%, respectively. The Moreno PIRO (AUC, 95%CI) (0.835; 0.818-0.852) showed the highest discriminating capacity, followed by SOFA (0.828; 0.811-0.846), qSOFA (0.792; 0.775-0.809), Rubulotta PIRO (0.708; 0.687-0.730), Howell PIRO (0.706; 0.685-0.728) and SIRS (0.578; 0.556-0.600). The AUC of the SOFA score was comparable to that of the Moreno PIRO (p=0.43), though the AUCs of both of these scores were significantly higher than those of the other scores (p<0.001 for all other comparisons). However, the SOFA score showed the best discriminating capacity in predicting ICU mortality (0.838; 0.820-0.855), followed by Moreno PIRO (0.804; 0.785-0.823) and qSOFA (0.787; 0.770-0.805). The accuracy of the qSOFA in predicting ICU mortality was comparable to that of the Moreno PIRO score (p=0.15).

CONCLUSION

The SOFA score and Moreno PIRO score showed the best accuracy in predicting in-hospital mortality among septic patients admitted to the ICU.

Systemic Angiopoietin-1/2 Dysregulation in Pediatric Sepsis and Septic Shock

Background: Angiopoietin-1 and -2 are vascular growth factors that exert opposing effects on endothelial activation and dysfunction. The aim of this study was to assess the association of these biomarkers with outcomes in children with sepsis. Methods: Biomarkers were assayed from the blood collected in an emergency department prior to any intervention. Predictor variables were Ang-1 and Ang-2 levels and the Ang-2/Ang-1 ratio. Outcomes included mortality, length of time on vasopressors, and ICU and hospital lengths of stay. The Pediatric RISk of Mortality III Score was calculated. A vasoactive inotrope score was calculated every 12 hours. Results: Forty-five children with sepsis and 49 with septic shock were analyzed. The median Ang-2 was higher in septic shock. The Ang-2/Ang-1 ratio was approximately 2-fold greater in those with septic shock. The Ang-2/Ang-1 ratio was associated with higher doses of vasoactive agents at 12 hours and longer ICU length of stay. In septic shock, for every 0.35 unit increase in the Ang-2/Ang-1 ratio, the PRISM III score increased by 1. Conclusions: The Ang-2/Ang-1 ratio was higher in children with septic shock. Ang-2/Ang-1 was associated with higher vasoactive agents, longer ICU length of stay, and correlated with the severity of illness score.

Comparison of Various Severity Assessment Scoring Systems in Patients with Sepsis in a Tertiary Care Teaching Hospital

BACKGROUND

Sepsis is a complex condition defined by the systemic response to infection. Severity assessment scoring systems are used to aid the physician in deciding whether aggressive treatment is needed or not. In this study, various severity assessment scoring systems, namely Acute Physiology and Chronic Health Evaluation II (APACHE II), Rapid Emergency Medicine Score (REMS), Sequential Organ Failure Assessment (SOFA), Multiple Organ Dysfunction Score (MODS), Predisposition, Infection, Response, and Organ Dysfunction (PIRO), and Mortality in Emergency Department Sepsis (MEDS), were compared to assess their sensitivity and specificity.

MATERIALS AND METHODS

A prospective cohort study was conducted over 6 months. The study was conducted in the intensive care unit (ICU) of a tertiary care teaching hospital. All patients above 18 years of age with confirmed sepsis diagnosis and a well-defined outcome were included in the study.

RESULTS

A total of 193 patients were included in the study. The mean age was 57.2 ± 15.3 (mean ± standard deviation) years. Majority of the patients were male, 125 (64.76%). Overall mortality was 108 (55.9%). The calculated area under the receiver operating characteristic curve was 0.86 (95% confidence interval [CI]: 0.80-0.90) for APACHE II, 0.81 (95% CI: 0.75-0.87) for REMS, 0.80 (95% CI: 0.74-0.86) for SOFA, 0.74 (95% CI: 0.67-0.80) for MODS, 0.78 (95% CI: 0.71-0.84) for PIRO, and 0.77 (95% CI: 0.71-0.83) for MEDS. Sensitivity and specificity for APACHE II were 81.5 and 75.3, respectively.

CONCLUSIONS

In our study, APACHE II score was found to be the most sensitive and specific in predicting the severity of sepsis compared to other scores.

Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the Emergency Department

OBJECTIVES

The increasing use of sepsis screening in the Emergency Department (ED) and the Sepsis-3 recommendation to use the quick Sepsis-related Organ Failure Assessment (qSOFA) necessitates validation. We compared Systemic Inflammatory Response Syndrome (SIRS), qSOFA, and the National Early Warning Score (NEWS) for the identification of severe sepsis and septic shock (SS/SS) during ED triage.

METHODS

This was a retrospective analysis from an urban, tertiary-care academic center that included 130,595 adult visits to the ED, excluding dispositions lacking adequate clinical evaluation (n = 14,861, 11.4%). The SS/SS group (n = 930) was selected using discharge diagnoses and chart review. We measured sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) for the detection of sepsis endpoints.

RESULTS

NEWS was most accurate for triage detection of SS/SS (AUROC = 0.91, 0.88, 0.81), septic shock (AUROC = 0.93, 0.88, 0.84), and sepsis-related mortality (AUROC = 0.95, 0.89, 0.87) for NEWS, SIRS, and qSOFA, respectively (p < 0.01 for NEWS versus SIRS and qSOFA). For the detection of SS/SS (95% CI), sensitivities were 84.2% (81.5-86.5%), 86.1% (83.6-88.2%), and 28.5% (25.6-31.7%) and specificities were 85.0% (84.8-85.3%), 79.1% (78.9-79.3%), and 98.9% (98.8-99.0%) for NEWS ≥ 4, SIRS ≥ 2, and qSOFA ≥ 2, respectively.

CONCLUSIONS

NEWS was the most accurate scoring system for the detection of all sepsis endpoints. Furthermore, NEWS was more specific with similar sensitivity relative to SIRS, improves with disease severity, and is immediately available as it does not require laboratories. However, scoring NEWS is more involved and may be better suited for automated computation. QSOFA had the lowest sensitivity and is a poor tool for ED sepsis screening.

Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: A systematic review

Introduction

Patients in an emergency department are diverse. Some are more seriously ill than others and some even arrive in multi-organ failure. Knowledge of the prevalence of organ failure and its prognosis in unselected patients is important from a diagnostic, hospital planning, and from a quality evaluation point of view, but is not reported systematically.

Objectives

To analyse the prevalence and prognosis of new onset organ failure in unselected acute patients at arrival to hospital.

Methods

A systematic review of studies of prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital. We searched PubMed, Cochrane Library, Embase and Cinahl, and read references in included studies. Two authors decided independently on study eligibility and extracted data. Results were summarised qualitatively.

Results

Four studies were included with a total of 678,960 patients. The number of different organ failures reported in the studies ranged from one to six, and the settings were emergency departments and wards. The definitions of organ failure varied between studies. The prevalence of organ failure was 7%, 14%, 14%, and 23%, and in-hospital mortality was 5%, 11% and 15% respectively. The relative risk of in-hospital mortality for patients with organ failure compared to patients without organ failure varied from 2.58 to 8.65. Numbers of organ failures per 1,000 visits varied from 71 to 256.

Conclusion

The results of this review indicate that clinicians have good reasons to be alert when a patient arrives to the emergency department; as a state of organ failure seems both frequent and highly severe.

However, most studies identified were performed in patients after a diagnosis was established, and only very few studies were performed in unselected patients.

Systematic review registration number

PROSPERO: CRD42017060871.

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.

Lactate ≥2 mmol/L plus qSOFA improves utility over qSOFA alone in emergency department patients presenting with suspected sepsis

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.

Using Statistical and Machine Learning Methods to Evaluate the Prognostic Accuracy of SIRS and qSOFA

Objectives

The objective of this study was to compare the performance of two popularly used early sepsis diagnostic criteria, systemic inflammatory response syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA), using statistical and machine learning approaches.

Methods

This retrospective study examined patient visits in Emergency Department (ED) with sepsis related diagnosis. The outcome was 28-day in-hospital mortality. Using odds ratio (OR) and modeling methods (decision tree [DT], multivariate logistic regression [LR], and naïve Bayes [NB]), the relationships between diagnostic criteria and mortality were examined.

Results

Of 132,704 eligible patient visits, 14% died within 28 days of ED admission. The association of qSOFA ≥2 with mortality (OR = 3.06; 95% confidence interval [CI], 2.96–3.17) greater than the association of SIRS ≥2 with mortality (OR = 1.22; 95% CI, 1.18–1.26). The area under the ROC curve for qSOFA (AUROC = 0.70) was significantly greater than for SIRS (AUROC = 0.63). For qSOFA, the sensitivity and specificity were DT = 0.39, LR = 0.64, NB = 0.62 and DT = 0.89, LR = 0.63, NB = 0.66, respectively. For SIRS, the sensitivity and specificity were DT = 0.46, LR = 0.62, NB = 0.62 and DT = 0.70, LR = 0.59, NB = 0.58, respectively.

Conclusions

The evidences suggest that qSOFA is a better diagnostic criteria than SIRS. The low sensitivity of qSOFA can be improved by carefully selecting the threshold to translate the predicted probabilities into labels. These findings can guide healthcare providers in selecting risk-stratification measures for patients presenting to an ED with sepsis.