Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness

Baumann, Brigitte M.; Greenwood, John C.; Lewis, Kristin M.; Nuckton, Thomas J.; Darger, Bryan; Shofer, Frances S.; Troeger, Dawn; Jung, Soo Yeon; Kilgannon, J. Hope; Rodriguez, Robert M.

doi:10.1016/j.ajem.2019.07.003

Cited by 24 publications

(27 citation statements)

References 13 publications

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“…Jo et al reported that NEWS + lactate can provide excellent discriminating value in predicting two-day mortality in general ER patients, and it has the best discriminating value regarding the need for critical care and composite outcomes [ 16 ]. Baumann et al reported that the combination of qSOFA criteria with initial lactate levels provides substantially improved sensitivity for the screening of critical illness compared to isolated lactate and qSOFA thresholds [ 6 ]. This study also showed a marked improvement in performance when lactate was combined with each of the four scoring systems.…”

Section: Discussionmentioning

confidence: 99%

“…Scoring systems have been created for their own goal, and emergency room (ER) doctors use scoring systems to assess disease severity and predict prognosis in patients suspected of having infections or septicemia [ 5 ]. ER-based screening should focus not only on mortality but also on the need for an escalation of care so that mortality can be minimized [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

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Prognostic Value of Severity Score Change for Septic Shock in the Emergency Room

Hwang

Park

et al. 2020

Diagnostics

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The vital signs or laboratory test results of sepsis patients may change before clinical deterioration. This study examined the differences in prognostic performance when systemic inflammatory response syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), quick SOFA (qSOFA) scores, National Early Warning Score (NEWS), and lactate levels were repeatedly measured. Scores were obtained at arrival to triage, 1 h after fluid resuscitation, 1 h after vasopressor prescription, and before leaving the emergency room (ER) in 165 patients with septic shock. The relationships between score changes and in-hospital mortality, mechanical ventilation, admission to the intensive care unit, and mortality within seven days were compared using areas under receiver operating characteristic curve (AUROCs). Scores measured before leaving the ER had the highest AUROCs across all variables (SIRS score 0.827 [0.737–0.917], qSOFA score 0.754 [0.627–0.838], NEWS 0.888 [0.826–0.950], SOFA score 0.835 [0.766–0.904], and lactate 0.872 [0.805–0.939]). When combined, SIRS + lactate (0.882 [0.804–0.960]), qSOFA + lactate (0.872 [0.808–0.935]), NEWS + lactate (0.909 [0.855–0.963]), and SOFA + lactate (0.885 [0.832–0.939]) showed improved AUROCs. In patients with septic shock, scoring systems show better predictive performances at the timepoints reflecting changes in vital signs and laboratory test results than at the time of arrival, and combining them with lactate values increases their predictive powers.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Prognostic Value of Severity Score Change for Septic Shock in the Emergency Room

Hwang

Park

et al. 2020

Diagnostics

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“…Large administrative data analyzed by the SEPSIS-3 authors suggested that a qSOFA score of ≥ 2 would rapidly identify non-ICU patients “more likely to have poor outcomes typical of sepsis,” defined as in-hospital mortality > 10%, with an area under the receiver operating characteristic (AUROC) curve of 0.81 (compared to 0.76 for the SIRS criteria; p = 0.01) 1 , 15 . The authors concluded that the new definitions should “facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis 1 .” Since this assertion in 2016, numerous authors have analyzed the usefulness of qSOFA in retrospective and prospective cohorts at different points in the care continuum from pre-hospital 16 , 17 to initial triage 18 – 20 to the period of ED management 20 , 21 to in-patient wards and the ICU 15 ; have looked at it as a screening tool for all patients presenting to the ED 22 or for those with suspected infection 23 , 24 ; have investigated dynamic changes in qSOFA during ED stay 20 , 25 ; have analyzed its accuracy as a predictor of ICU admission, length of stay, and in-hospital mortality 26 ; have tried to improve the performance of qSOFA by add various biomarkers including lactate 27 , 28 , procalcitonin 29 , monocyte distribution width 30 , and CRP combined with mid-regional proadrenomedullin 31 or vital sign measures including heart rate variability 32 , EtCO 2 33 , and shock index 19 ; have examined its utility in high and low resource settings 27 , 29 , 34 ; and have compared it to other scoring systems including SIRS, MEWS, NEWS, and conventional SOFA 35 , 36 . All of these studies provide important clinical information and have various limitations mainly related to the data sets used, the presence or absence of serial qSOFA values, the clinical setting where the studies were performed, and the overall mortality of the cohorts.…”

Section: Introductionmentioning

confidence: 99%

The sensitivity of qSOFA calculated at triage and during emergency department treatment to rapidly identify sepsis patients

Perman

Mikkelsen

Goyal

et al. 2020

Sci Rep

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The quick sequential organ failure assessment (qSOFA) score has been proposed as a means to rapidly identify adult patients with suspected infection, in pre-hospital, Emergency Department (ED), or general hospital ward locations, who are in a high-risk category with increased likelihood of “poor outcomes:” a greater than 10% chance of dying or an increased likelihood of spending 3 or more days in the ICU. This score is intended to replace the use of systemic inflammatory response syndrome (SIRS) criteria as a screening tool; however, its role in ED screening and identification has yet to be fully elucidated. In this retrospective observational study, we explored the performance of triage qSOFA (tqSOFA), maximum qSOFA, and first initial serum lactate (> 3 mmol/L) at predicting in-hospital mortality and compared these results to those for the initial SIRS criteria obtained in triage. A total of 2859 sepsis cases were included and the in-hospital mortality rate was 14.4%. The sensitivity of tqSOFA ≥ 2 and maximum qSOFA ≥ 2 to predict in-hospital mortality were 33% and 69%, respectively. For comparison, the triage SIRS criteria and the initial lactate > 3 mmol/L had sensitivities of 82% and 65%, respectively. These results demonstrate that in a large ED sepsis database the earliest measurement of end organ impairment, tqSOFA, performed poorly at identifying patients at increased risk of mortality and maximum qSOFA did not significantly outperform initial serum lactate levels.

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“…However, the qSOFA is not suitable as a screening tool as it lacks sensitivity [11,12]. C-reactive protein (CRP), lactate, and procalcitonin (PCT) have all been shown to increase the sensitivity and overall diagnostic performance of the qSOFA [13][14][15]. To our knowledge, no study has assessed the contribution to the accurate early detection of sepsis in primary care of factors such as symptoms, signs, and biomarkers potentially available as point-ofcare tests (POCT) such as CRP, lactate, and PCT.…”

Section: Introductionmentioning

confidence: 99%

Development of a clinical prediction rule for sepsis in primary care: protocol for the TeSD-IT study

et al. 2020

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Background: Early recognition and treatment of sepsis is crucial to prevent detrimental outcomes. General practitioners (GPs) are often the first healthcare providers to encounter seriously ill patients. The aim of this study is to assess the value of clinical information and additional tests to develop a clinical prediction rule to support early diagnosis and management of sepsis by GPs. Methods: We will perform a diagnostic study in the setting of out-of-hours home visits in four GP cooperatives in the Netherlands. Acutely ill adult patients suspected of a serious infection will be screened for eligibility by the GP. The following candidate predictors will be prospectively recorded: (1) age, (2) body temperature, (3) systolic blood pressure, (4) heart rate, (5) respiratory rate, (6) peripheral oxygen saturation, (7) mental status, (8) history of rigors, and (9) rate of progression. After clinical assessment by the GP, blood samples will be collected in all patients to measure C-reactive protein, lactate, and procalcitonin. All patients will receive care as usual. The primary outcome is the presence or absence of sepsis within 72 h after inclusion, according to an expert panel. The need for hospital treatment for any indication will be assessed by the expert panel as a secondary outcome. Multivariable logistic regression will be used to design an optimal prediction model first and subsequently derive a simplified clinical prediction rule that enhances feasibility of using the model in daily clinical practice. Bootstrapping will be performed for internal validation of both the optimal model and simplified prediction rule. Performance of both models will be compared to existing clinical prediction rules for sepsis. Discussion: This study will enable us to develop a clinical prediction rule for the recognition of sepsis in a high-risk primary care setting to aid in the decision which patients have to be immediately referred to a hospital and who can be safely treated at home. As clinical signs and blood samples will be obtained prospectively, near-complete data will be available for analyses. External validation will be needed before implementation in routine care and to determine in which pre-hospital settings care can be improved using the prediction rule. Trial registration: The study is registered in the Netherlands Trial Registry (registration number NTR7026).

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Combining qSOFA criteria with initial lactate levels: Improved screening of septic patients for critical illness

Cited by 24 publications

References 13 publications

Prognostic Value of Severity Score Change for Septic Shock in the Emergency Room

Prognostic Value of Severity Score Change for Septic Shock in the Emergency Room

The sensitivity of qSOFA calculated at triage and during emergency department treatment to rapidly identify sepsis patients

Development of a clinical prediction rule for sepsis in primary care: protocol for the TeSD-IT study

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