3 papers from ED. counting sepsis sepsis 3 wet or dry?

Transcription

1 3 papers from ED counting sepsis sepsis 3 wet or dry?

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3 5 million deaths/yr globally 24 billion USD annually in US system causes or contributes to half of US hospital deaths

4 BP GCS RR

5 From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8): doi: /jama Figure Legend: Operationalization of Clinical Criteria Identifying Patients With Sepsis and Septic ShockThe baseline Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score should be assumed to be zero unless the patient is known to have preexisting (acute or chronic) organ dysfunction before the onset of infection. qsofa indicates quick SOFA; MAP, mean arterial pressure. Date of download: 9/27/2017 Copyright 2016 American Medical Association. All rights reserved.

6 SIRS criteria sepsis definition (1992): Suspected infection + SIRS criteria 2 o Core temperature > 38 C or < 36 C. o Heart rate > 90 beats per minute. o Respiratory rate > 20 breaths per minute or a PaCO2 < 32 mmhg or mechanical ventilation for an acute process. o White blood cell (WBC) count of > 12 x 10 9 /L or < 4 x 10 9 /L, or > 10% immature neutrophils. SOFA criteria sepsis definition (2016): Suspected infection + SOFA 2 qsofa bedside clinical score criteria (2016): Abnormal mentation (GCS <15) Respiratory rate 22 / minute Systolic blood pressure 100 mmhg SOFA GCS PaO2/FiO2; IPV MAP; pressors Bilirubin Coags Creat/ UO

7 Mortality among Patients with Severe Sepsis, According to Number of SIRS Criteria Met. 14 year look back study of ANZICS database. 1.2 million ICU admissions 109 thousand severe sepsis + organ failure; 12% SIRS-negative The need for two or more SIRS criteria to define severe sepsis excluded one in eight otherwise similar patients with infection, organ failure, and substantial mortality and failed to define a transition point in the risk of death. Kaukonen K et al. N Engl J Med 2015;372:

8 ICU admissions 185,000 admissions to ICU (17% pneumonia) 18% mortality 87% >2 SIRS (AUROC 0.6 for death) 55% >2 qsofa (AUROC 0.75) (Raith et al ANZICS CORE. JAMA 2017;317(3): )

9 Three quarters of SIRS 2+ sepsis in ED (8.5% IHM) would not meet Sepsis 3.0 qsofa criteria. This group has mortality of >1:25 (Shetty et al., EMA 2017.)

10 the caveats Neither qsofa nor SOFA is intended to be a stand-alone definition of sepsis. It is crucial, however, that failure to meet 2 or more qsofa or SOFA criteria should not lead to a deferral of investigation or treatment of infection or to a delay in any other aspect of care deemed necessary by the practitioners. qsofa can be rapidly scored at the bedside without the need for blood tests, and it is hoped that it will facilitate prompt identification of an infection that poses a greater threat to life. If appropriate laboratory tests have not already been undertaken, this may prompt testing to identify biochemical organ dysfunction. These data will primarily aid patient management but will also enable subsequent SOFA scoring. The task force wishes to stress that SIRS criteria may still remain useful for the identification of infection.

11 SIRS vs qsofa Lactate>2; LqSOFA (12389 patients Sepsis Kills program NSW CEC): odds ratios for IHM : 2.93 (95%CI ) for lactate ( ), for lactate ( ), for lactate ( ) for lactate 4.0 or more >10% of patients with suspected sepsis and lactate 2mmol/L experienced a prolonged ICU stay or died in hospital.

12 Lactate cut-off (mmol/l) Systolic BP > 100mm Hg N Died number (%; 95% CI) Total cohort (5.8, ) 1 <1 1 2 <2 2 3 <3 3 4 < (2.4, ) 503 (6.4, ) 170 (3.4, ) 371 (8.4, ) 273 (3.9, ) 268 (11.6, ) 353 (4.3, ) 188 (15.9, ) Systolic BP 100mm Hg OR* N Died (95% number CI) (%; 95% CI) NA (14.7, ) 2.76 ( ) 2.61 ( ) 3.27 ( ) 4.21 ( ) (5.4, ) 419 (15.9, ) 88 (7.4, ) 348 (19.7, ) 166 (9.0, ) 270 (24.3, ) 232 (10.2, ) 204 (30.0, ) NA 3.37 ( ) 3.08 ( ) 3.25 ( ) 3.77 ( ) OR* (95% CI) OR*: odds-ratio and 95% confidence interval calculated at each cut-point conducted on imputed dataset of patients

13 Lactate cut-off (mmol/l) Systolic BP > 100mm Hg N Any AE # number (%, 95% CI) Total cohort (7.6, ) 1 <1 1 2 <2 2 3 <3 3 4 < (3.6, ) 657 (8.4, ) 237 (4.8, ) 476 (10.8, ) 377 (5.3, ) 336 (14.5, ) 476 (5.8, ) 236 (20.1, ) 2.47 ( ) 2.42 ( ) 3.01 ( ) 4.06 ( ) OR* (95% CI) Systolic BP 100mm Hg N Any AE # number (%, 95% CI) NA (18.5, ) (7.0, ) 526 (19.9, ) 112 (9.4, ) 436 (24.7, ) 216 (11.7, ) 332 (29.9, ) 303 (13.3, ) 245 (36.0, ) OR* (95% CI) NA 3.34 ( ) 3.14 ( ) 3.23 ( ) 3.66 ( ) AE # (adverse event): died or intensive care unit stay length of stay (ICU LOS) 72h with no overlap, OR*: odds-ratio and 95% confidence interval calculated at each cut-point conducted on imputed dataset of patients

14 wet or dry?

15 FEAST study: Maitland et al 2011; NEJM 364: mL v 40mL/kg bolus saline/albumin

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