Is comorbid status the best predictor of one-year mortality in patients with severe sepsis and sepsis with shock?

Association between early manifestations of infection or sepsis and prognosis in a high complexity hospital in the city of Medellín

OBJECTIVE

To identify the first symptoms and signs of patients with suspected infection or sepsis and their association with the composite outcome of admission to the Intensive Care Unit (ICU) or mortality.

DESIGN

Prospective cohort study between June 2019 and March 2020.

SETTING

Hospital Universitario San Vicente Fundación, Colombia.

PATIENTS

Over 18 years of age with suspicion or confirmation of sepsis, which required hospitalization.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Symptoms and signs associated with infection, with their time of evolution, specified in the study.

RESULTS

From 1005 eligible patients, 261 were included. After multivariable adjustment with a logistic regression model, the main factors for ICU admission or mortality were heart rate (OR 1.04 with 95% CI 1.04-3.7), respiratory rate (OR 1.19 with 95% CI 1.0-1.4) and capillary refill time (OR 3.4 with 95% CI 1.9-6.1).

CONCLUSIONS

Heart rate, respiratory rate, and capillary refill may behave as early predictors of ICU admission and mortality in cases of sepsis.

Role of Procalcitonin in Predicting Mortality and Organ Dysfunction at Intensive Care Admission

Objective

To assess the prognostic utility of procalcitonin (PCT) in high-risk sepsis patients.

Methods

A retrospective cohort study was conducted with the inclusion of all eligible intensive care unit patients with Sequential Organ Failure Assessment (SOFA) score of 2 or more.

Results

A total of 228 patients were acquired from January 2018 to December 2020, with male predominant (58.8%), mean age of 53.61 years old. The overall 28-day mortality was 57.5%. In the group with PCT ≥ 7 ng/mL, 28-day mortality was 68.5% (87 patients out of a total of 127). Cox regression showed that in this group, the risk of mortality occurring within 28 days from the day of ICU admission was 1.55 times higher (95% CI 1.074–2252, p value 0.02). Independent sample t-test showed that in this group, the mean SOFA score was higher by 2.279 (95% CI 1.497–3.060, p value <0.001).

Conclusion

Procalcitonin levels are associated with mortality and SOFA scores in sepsis patients. Further studies need to be carried out to provide more evidence so that it can help reduce the mortality and morbidity of sepsis.

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.

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.

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

Objectives

Scoring systems have been used to risk stratify in intensive care units (ICU), but not routinely used in emergency departments. The aim of this study was to determine accuracy for predicting mortality in emergency medicine with Sequential Organ Failure Assessment (SOFA), Mortality in ED Sepsis (MEDS) score and Simplified Acute Physiology Score (SAPSII).

Methods

This is a prospective observational study. Patients presenting with evidence of sepsis were all included. SAPSII, MEDS, and SOFA scores were calculated. Analysis compared areas under the receiver operator characteristic (ROC) curves for 28-day mortality.

Results

Two hundred patients were included; consisting of 31 (14.3%) septic shock. 138 (69%) severe sepsis and 31 (15.5%) infection without organ dysfunction. 53 (26.5%) patients died within 28 days.

Area under the ROC curve for mortality was 0.76 for MEDS (0.69–0.82), 0.70 for SAPSII (0.62–0.78); and 1.68 for SOFA (0.60–0.76) scores. Pair wise comparison of AUC between MEDS, SAPSII, SOFA and Lactate were not significant.

Conclusion

According to our results; SOFA, SAPSII and MEDS were not sufficient to predict mortality. Also this result, MEDS was better than other scoring system.

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

OBJECTIVES

The Predisposition Insult Response and Organ failure (PIRO) scoring system has been developed for use in the emergency department (ED) to risk stratify sepsis cases, but has not been well studied among high-risk patients with severe sepsis and septic shock. The PIRO score was compared with the Sequential Organ Failure Assessment (SOFA) and Mortality in ED Sepsis (MEDS) scores to predict mortality in ED patients with features suggesting severe sepsis or septic shock in the ED.

METHODS

This was an analysis of sepsis patients enrolled in a prospective observational ED study of patients presenting with evidence of shock, hypoxemia, or other organ failure. PIRO, MEDS, and SOFA scores were calculated from ED data. Analysis compared areas under the receiver operator characteristic (ROC) curves for 30-day mortality.

RESULTS

Of 240 enrolled patients, final diagnoses were septic shock in 128 (53%), severe sepsis without shock in 70 (29%), and infection with no organ dysfunction in 42 (18%). Forty-eight (20%) patients died within 30 days of presentation. Area under the ROC curve (AUC) for mortality was 0.86 (95% confidence interval [CI] = 0.80 to 0.92) for PIRO, 0.81 (95% CI = 0.74 to 0.88) for MEDS, and 0.78 (95% CI = 0.71 to 0.87) for SOFA scores. Pairwise comparisons of the AUC were as follows: PIRO versus SOFA, p = 0.01; PIRO versus MEDS, p = 0.064; and MEDS versus SOFA; p = 0.37. Mortality increased with increasing PIRO scores: PIRO < 5, 0%; PIRO 5 to 9, 5%; PIRO 10 to 14, 5%; PIRO 15 to 19, 37%; and PIRO ≥ 20, 80% (p < 0.001). The MEDS score also showed increasing mortality with higher scores: MEDS < 5, 0%; MEDS 5 to 7, 12%; MEDS 8 to 11, 15%; MEDS 12 to 14, 48%; and MEDS > 15, 65% (p < 0.001).

CONCLUSIONS

The PIRO model, taking into account comorbidities and septic source as well as physiologic status, performed better than the SOFA score and similarly to the MEDS score for predicting mortality in ED patients with severe sepsis and septic shock. These findings have implications for identifying and managing high-risk patients and for the design of clinical trials in sepsis.