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Kannan A, Jindal A. Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score! Indian J Crit Care Med 2023; 27:150. [PMID: 36865520 PMCID: PMC9973053 DOI: 10.5005/jp-journals-10071-24401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Abinaya Kannan
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Atul Jindal
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India,Atul Jindal, Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India, Phone: +91 8224014667, e-mail:
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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. J Clin Med 2022; 11:jcm11237231. [PMID: 36498805 PMCID: PMC9737041 DOI: 10.3390/jcm11237231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/12/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
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.
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Yang L, Lin Y, Zhang X, Wei B, Wang J, Liu B. Predictive Value of Combination of Procalcitonin and Predisposition, Infection, Response, and Organ Dysfunction (PIRO) System in Septic Patients with Positive Blood Cultures in the Emergency Department. Infect Drug Resist 2022; 15:6189-6202. [PMID: 36312440 PMCID: PMC9597669 DOI: 10.2147/idr.s384689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/13/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Procalcitonin and predisposition, infection, response, and organ dysfunction (PIRO) system have high predictive value for the prognosis of critically ill patients. There are few studies on the predictive value of patients with positive blood cultures. The aim of the study was to evaluate risk stratification and sepsis-related mortality in patients with positive blood cultures via procalcitonin (PCT) combined with the PIRO system in emergency departments (ED). Methods A total of 1074 patients with positive blood cultures were admitted to Beijing Chao-Yang Hospital ED from December 2017 to October 2020. Their serum PCT was recorded, along with a Sequential Organ Failure Assessment (SOFA) score, Mortality in Emergency Department Sepsis (MEDS) score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and PIRO score to predict the prognosis of septic patients with positive blood culture in terms of ICU (intensive care unit) admission, multiple organ dysfunction syndrome (MODS) development, and 28-day mortality. Receiver operating characteristic (ROC) curves and logistic regression analysis were used to assess the prognostic value of the scoring systems. Results A total of 978 patients met the inclusion criteria. PCT, MEDS, APACHE II, and PIRO scores were found to independently predict ICU-admission, MODS development, and 28-day mortality (P<0.05), whereas SOFA did not. The AUC values of the PCT, MEDS, APACHE II, and PIRO scores for ICU-admission were 0.620, 0.740, 0.780, and 0.751, respectively. In the prediction of 28-day mortality, the AUC values of PCT, MEDS, APACHE II, and PIRO were 0.782, 0.745, 0.805, and 0.831, respectively. The AUC values combined PCT and PIRO system in predicting MODS and 28-day mortality were better than when predicting ICU-admission. Conclusion This study indicates that PCT combined with the PIRO scoring system has a higher predictive value and is superior in predicting MODS and 28-day mortality in septic patients with positive blood cultures.
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Affiliation(s)
- Long Yang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, 100020, People’s Republic of China
| | - Yue Lin
- Department of Radiology, China-Japan Friendship Hospital, Beijing, 100029, People’s Republic of China
| | - Xiangqun Zhang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, 100020, People’s Republic of China
| | - Bing Wei
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, 100020, People’s Republic of China
| | - Junyu Wang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, 100020, People’s Republic of China
| | - Bo Liu
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, 100020, People’s Republic of China, Correspondence: Bo Liu; Junyu Wang, Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, 100020, People’s Republic of China, Tel/Fax +86 10-51718171, Email ;
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Cardoso T, Rodrigues PP, Nunes C, Almeida M, Cancela J, Rosa F, Rocha-Pereira N, Ferreira I, Seabra-Pereira F, Vaz P, Carneiro L, Andrade C, Davis J, Marçal A, Friedman ND. Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients. Ann Intensive Care 2021; 11:180. [PMID: 34950977 PMCID: PMC8702585 DOI: 10.1186/s13613-021-00966-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/04/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- T Cardoso
- Intensive Care Unit (UCIP) and Hospital Infection Control Committee, Hospital de Santo António, Oporto University Hospital Center, University of Porto, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal.
| | - P P Rodrigues
- Department of Community Medicine, Information and Health Decision Sciences & CINTESIS, Faculty of Medicine, University of Porto, Rua Dr. Plácido Costa, s/n, 4200-450, Porto, Portugal
| | - C Nunes
- Intensive Care Unit and Hospital Infection Control Committee, Hospital de Bragança, Northeastern Local Health Unit, Av. Abade Baçal, 5301-852, Bragança, Portugal
| | - M Almeida
- Neurocritical Care Unit and Hospital Infection Control Committee, Hospital de São Marcos, Sete Fontes - São Vitor, 4710-243, Braga, Portugal.,Intensive Care Unit (UCIP), Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - J Cancela
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - F Rosa
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - N Rocha-Pereira
- Infectious Diseases Department, São João Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - I Ferreira
- Internal Medicine Department, Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - F Seabra-Pereira
- Intensive Care Unit (UCIP), Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal.,Intensive Care Unit and Internal Medicine Department, Hospital da Prelada, Rua de Sarmento de Beires, 4250-449, Porto, Portugal
| | - P Vaz
- Internal Medicine Department and Hospital Infection Control Committee, Hospital de Bragança, Northeastern Local Health Unit, Av. Abade Baçal, 5301-852, Bragança, Portugal
| | - L Carneiro
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - C Andrade
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal.,Internal Medicine Department, Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - J Davis
- Department of Renal Medicine, Barwon Health, Geelong, VIC, 3220, Australia
| | - A Marçal
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal.,Internal Medicine Department, Hospital de Santo António, Oporto University Hospital Center, Largo Prof. Abel Salazar, 4099-001, Porto, Portugal
| | - N D Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, VIC, 3220, Australia
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Agor JK, Paramita NLPSP, Ozaltn OY. Prediction of Sepsis Related Mortality: An Optimization Approach. IEEE J Biomed Health Inform 2021; 25:4207-4216. [PMID: 34255639 DOI: 10.1109/jbhi.2021.3096470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Boier Tygesen G, Kirkegaard H, Raaber N, Trøllund Rask M, Lisby M. Consensus on predictors of clinical deterioration in emergency departments: A Delphi process study. Acta Anaesthesiol Scand 2021; 65:266-275. [PMID: 32941660 DOI: 10.1111/aas.13709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/03/2020] [Accepted: 09/09/2020] [Indexed: 12/21/2022]
Abstract
AIM The study aim was to determine relevance and applicability of generic predictors of clinical deterioration in emergency departments based on consensus among clinicians. METHODS Thirty-three predictors of clinical deterioration identified from literature were assessed in a modified two-stage Delphi-process. Sixty-eight clinicians (physicians and nurses) participated in the first round and 48 in the second round; all treating hospitalized patients in Danish emergency departments, some with pre-hospital experience. The panel rated the predictors for relevance (relevant marker of clinical deterioration) and applicability (change in clinical presentation over time, generic in nature and possible to detect bedside). They rated their level of agreement on a 9-point Likert scale and were also invited to propose additional generic predictors between the rounds. New predictors suggested by more than one clinician were included in the second round along with non-consensus predictors from the first round. Final decisions of non-consensus predictors after second round were made by a research group and an impartial physician. RESULTS The Delphi-process resulted in 19 clinically relevant and applicable predictors based on vital signs and parameters (respiratory rate, saturation, dyspnoea, systolic blood pressure, pulse rate, abnormal electrocardiogram, altered mental state and temperature), biochemical tests (serum c-reactive protein, serum bicarbonate, serum lactate, serum pH, serum potassium, glucose, leucocyte counts and serum haemoglobin), objective clinical observations (skin conditions) and subjective clinical observations (pain reported as new or escalating, and relatives' concerns). CONCLUSION The Delphi-process led to consensus of 19 potential predictors of clinical deterioration widely accepted as relevant and applicable in emergency departments.
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Affiliation(s)
- Gitte Boier Tygesen
- Department of Emergency Medicine Horsens Regional Hospital Horsens Denmark
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
| | - Nikolaj Raaber
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Mette Trøllund Rask
- The Research Clinic for Functional Disorders and Psychosomatics Aarhus University Hospital Aarhus Denmark
| | - Marianne Lisby
- Research Centre for Emergency Medicine Aarhus University Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
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Yan S, Zhang G. Predictive performance of critical illness scores and procalcitonin in sepsis caused by different gram-stain bacteria. Clinics (Sao Paulo) 2021; 76:e2610. [PMID: 34133658 PMCID: PMC8158675 DOI: 10.6061/clinics/2021/e2610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/15/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To compare the early and late predictive values of several critical illness scores (CISs) and biomarkers in sepsis-3 patients with bloodstream infections (BSIs) and to identify the prognostic value of procalcitonin (PCT) for different gram-stain bacteria infections. METHODS Patients with at least one positive blood culture within 24h of emergency department admission and with a final diagnosis of sepsis/septic shock were enrolled. CISs were calculated based on the first parameters on the day of admission. The receiver operating characteristics curve was used to analyze the predictive value of CISs and biomarkers for early and late mortality. RESULTS Of 834 enrolled patients with sepsis-3, death occurred in 214 patients within 28 days and in 273 patients within 60 days. Compared with biomarkers, CISs showed a significantly higher area under the curve (AUC) in the prediction of early and late mortality (p<0.01), especially for patients with GNB infection. The Sequential Organ Failure Assessment score showed a higher AUC for predicting early mortality than the Mortality in Emergency Department Sepsis score (p=0.036). Compared with GNB infections, the AUC values of the PCT for gram-positive bacteria (GPB) infections were higher for predicting early or late mortality; PCT showed higher AUC than high-sensitivity C-reactive protein and white blood cells for predicting early mortality (p<0.05). CONCLUSIONS CISs were more advantageous in the assessment of early and late prognosis, especially for patients with GNB infections; however, for sepsis with GPB infection, PCT can be used for the prediction of early mortality.
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Williams A, Griffies T, Damianopoulos S, Fatovich D, Macdonald S. 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. Emerg Med Australas 2020; 33:679-684. [PMID: 33346938 DOI: 10.1111/1742-6723.13703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/01/2020] [Accepted: 12/04/2020] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Alex Williams
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Thomas Griffies
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Sophie Damianopoulos
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Daniel Fatovich
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Stephen Macdonald
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, Perth, Western Australia, Australia
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Asim M, Amin F, El-Menyar A. Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum. Qatar Med J 2020; 2020:22. [PMID: 33628712 PMCID: PMC7884906 DOI: 10.5339/qmj.2020.22] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/03/2020] [Indexed: 12/27/2022] Open
Abstract
Multiorgan dysfunction syndrome (MODS) remains a major complication and challenge to treat patients with critical illness in different intensive care unit settings. The exact mechanism and pathophysiology of MODS is complex and remains unexplored. We reviewed the literature from January 2011 to August 2019 to analyze the underlying mechanisms, prognostic factors, MODS scoring systems, organ systems dysfunctions, and the management of MODS. We used the search engines PubMed, MEDLINE, Scopus, and Google Scholar with the keywords "multiple organ dysfunction syndrome," "intensive care units," "multiorgan failure," "MODS scoring system," and "MODS management." The initial search yielded 3550 abstracts, of which 91 articles were relevant to the scope of the present article. A better understanding of a disease course will help differentiate the signs of an intense inflammatory response from the early onset of sepsis and minimize the inappropriate use of medications. This, in turn, will promote organtargeted therapy and prevent occurrence and progression of MODS.
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Affiliation(s)
- Mohammad Asim
- Department of Surgery, Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Farhana Amin
- Sri Ramaswamy Memorial Medical College Hospital & Research Center, Tamil Nadu, India
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Salzberger B, Hitzenbichler F, Hanses F. [Treatment of infections in the critically ill under immunosuppression : What must be considered?]. Z Rheumatol 2019; 78:940-946. [PMID: 31538231 DOI: 10.1007/s00393-019-00706-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Patients under immunosuppressive treatment have a much higher risk for severe infections and sepsis. The morbidity and mortality of severe infections in critically ill patients are high but the prognosis is not different from immunocompetent patients if diagnosed early and treated adequately, especially in high volume centers. A high level of clinical alertness for infectious complications is essential for rapid and adequate diagnosis and treatment. The established principles for treatment of sepsis are also valid for immunocompromized patients, i.e. rapid initiation of antibiotic treatment, focal control and rapid supportive treatment according to the current guidelines on sepsis. In patients with the corresponding clinical signs and not responding to initial empirical treatment, opportunistic infections as rare causes of sepsis have to be taken into account. To prevent development or selection of resistance due to broad spectrum treatment, the empirical treatment should always focus on the specific pathogen detected.
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Affiliation(s)
- Bernd Salzberger
- Abt. Krankenhaushygiene und Infektiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Florian Hitzenbichler
- Abt. Krankenhaushygiene und Infektiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Frank Hanses
- Abt. Krankenhaushygiene und Infektiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.,Interdisziplinäre Notaufnahme, Universitätsklinikum Regensburg, Regensburg, Deutschland
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11
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Pedersen PB, Henriksen DP, Brabrand M, Lassen AT. Prevalence of organ failure and mortality among patients in the emergency department: a population-based cohort study. BMJ Open 2019; 9:e032692. [PMID: 31666275 PMCID: PMC6830583 DOI: 10.1136/bmjopen-2019-032692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | | | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital & Hospital of South West Jutland, Odense & Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
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Vafaei A, Heydari K, Hashemi-Nazari SS, Izadi N, Hassan Zadeh H. PIRO, SOFA and MEDS Scores in Predicting One-Month Mortality of Sepsis Patients; a Diagnostic Accuracy Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2019; 7:e59. [PMID: 31875213 PMCID: PMC6905425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Different scoring systems based on clinical and laboratory findings are designed for prediction of short-term mortality of patients with severe sepsis and septic shock. This study aimed to compare the screening performance characteristics of PIRO, SOFA and MEDS Scores in predicting one-month mortality of sepsis patients. METHODS This diagnostic accuracy study was performed on septic shock and severe sepsis patients referring to emergency department of Loghmane Hakim Hospital, Tehran, Iran, from 2017 to 2018. The performance of MEDS, SOFA, and PIRO models in predicting 30-day mortality of patients was evaluated using discrimination and calibration indices. RESULTS 200 patients with the mean age of 71.03±15.59 years were studied (61% male). During the 30 days, 66 patients died (mortality rate=33%). The area under the ROC curve of PIRO, MEDS, and SOFA scores were 0.83 (95% CI=0.78-0.89), 0.94 (95% CI=0.91-0.97) and 0.87 (95% CI=0.81-0.92), respectively. Based on Brier, BrierScaled and Nagelkerke's R2 of the models, the best performance in predicting one-month mortality belonged to MEDS score. C-statistic showed that MEDS score had the highest value in the differentiation between the survived and non-survived cases. CONCLUSION This study showed that MEDS score performs better than PIRO and SOFA scores in predicting one-month mortality of patients with severe sepsis and septic shock.
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Affiliation(s)
- Ali Vafaei
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Kamran Heydari
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Seyed-Saeed Hashemi-Nazari
- Prevention of Cardiovascular Disease Research Center, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Neda Izadi
- Student Research Committee, Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hassan Hassan Zadeh
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding Author: Hassan Hassan Zadeh; Loghmane-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail:
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Agor J, Özaltın OY, Ivy JS, Capan M, Arnold R, Romero S. The value of missing information in severity of illness score development. J Biomed Inform 2019; 97:103255. [PMID: 31349049 DOI: 10.1016/j.jbi.2019.103255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 07/10/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Joseph Agor
- School of Mechanical, Industrial and Manufacturing Engineering, Oregon State University, Corvallis, OR 97331-6001, United States
| | - Osman Y Özaltın
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, 400 Daniels Hall, Raleigh, NC 27695-7906, United States.
| | - Julie S Ivy
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, 400 Daniels Hall, Raleigh, NC 27695-7906, United States
| | - Muge Capan
- Decision Sciences & MIS Department, LeBow College of Business, Drexel University, Philadelphia, PA 19104, United States
| | - Ryan Arnold
- Department of Emergency Medicine and School of Medicine, Drexel University, Philadelphia, PA 19102, United States
| | - Santiago Romero
- Mayo Clinic Rochester, Center for Innovation, Rochester, MN 55905, United States
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Jang HN, Park HJ, Cho HS, Bae E, Lee TW, Chang SH, Park DJ. The logistic organ dysfunction system score predicts the prognosis of patients with alcoholic ketoacidosis. Ren Fail 2019; 40:693-699. [PMID: 30741615 PMCID: PMC7011874 DOI: 10.1080/0886022x.2018.1491405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Alcoholic ketoacidosis (AKA) is occasionally associated with multiple complications leading to death. However, no study has yet evaluated prognostic factors in patients with AKA. It is known that the logistic organ dysfunction system (LODS) score is an objective and useful index to predict the prognosis. We used LODS score to predict prognosis of AKA. We retrospectively reviewed the medical records of 46 patients who were diagnosed as AKA in our hospital. The mean LODS score was 6.3. The probability of mortality based on the LODS score was 36.6%, and 16 patients (34.5%) did, in fact, die. The total LODS score and lactate dehydrogenase (LDH) were significantly higher in the non-survival group. Prothrombin activity, serum platelet number, and the serum albumin levels were significantly higher in the survival group. We found significant correlations between the LODS score and arterial pH, the albumin level, and the LDH concentration. Multivariate analysis showed that the serum albumin and LDH levels were independently associated with survival in AKA patients. AKA patients suffered high-level mortality and the LODS score was an accurate predictor of prognosis. Clinicians may use the LODS score to this end.
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Affiliation(s)
- Ha Nee Jang
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , South Korea
| | - Hee Jung Park
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , South Korea
| | - Hyun Seop Cho
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , South Korea
| | - Eunjin Bae
- b Department of Internal Medicine , Changwon Gyeongsang National University Hospital , Changwon , South Korea
| | - Tae Won Lee
- b Department of Internal Medicine , Changwon Gyeongsang National University Hospital , Changwon , South Korea
| | - Se-Ho Chang
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , South Korea.,c Department of Internal Medicine, College of Medicine , Gyeongsang National University , Jinju , South Korea.,d Institute of Health Science , Gyeongsang National University , Jinju , South Korea
| | - Dong Jun Park
- b Department of Internal Medicine , Changwon Gyeongsang National University Hospital , Changwon , South Korea.,c Department of Internal Medicine, College of Medicine , Gyeongsang National University , Jinju , South Korea.,d Institute of Health Science , Gyeongsang National University , Jinju , South Korea
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Pedersen PB, Hrobjartsson A, Nielsen DL, Henriksen DP, Brabrand M, Lassen AT. Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: A systematic review. PLoS One 2018; 13:e0206610. [PMID: 30383864 PMCID: PMC6211733 DOI: 10.1371/journal.pone.0206610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/16/2018] [Indexed: 01/31/2023] Open
Abstract
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.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- * E-mail:
| | - Asbjørn Hrobjartsson
- Centre for Evidence-Based Medicine, University of Southern Denmark & Odense University Hospital, Odense, Denmark
| | | | - Daniel Pilsgaard Henriksen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Fabbian F, De Giorgi A, Boari B, Misurati E, Gallerani M, Cappadona R, Cultrera R, Manfredini R, Rodrìguez Borrego MA, Lopez-Soto PJ. Infections and internal medicine patients: Could a comorbidity score predict in-hospital mortality? Medicine (Baltimore) 2018; 97:e12818. [PMID: 30334978 PMCID: PMC6211916 DOI: 10.1097/md.0000000000012818] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 09/20/2018] [Indexed: 11/25/2022] Open
Abstract
Infectious diseases (ID) are frequently cause of internal medicine wards (IMW) admission. We aimed to evaluate risk factors for in-hospital mortality (IHM) in IMW patients with ID, and to test the usefulness of a comorbidity score (CS).This study included ID hospital admissions between January 2013, and December 2016, recorded in the database of the local hospital. ICD-9-CM codes were selected to identify infections, development of sepsis, and to calculate a CS.We analyzed 12,173 records, (age 64.8 ± 25.1 years, females 66.2%, sepsis 9.3%). Deceased subjects (1545, 12.7%) were older, had higher percentage of sepsis, pulmonary infections, and endocarditis. Mean value of CS was also significantly higher. At multivariate analysis, the odds ratio (OR) for sepsis (OR 5.961), endocarditis (OR 4.247), pulmonary infections (OR 1.905), other sites of infection (OR 1.671), and urinary tracts infections (OR 0.548), were independently associated with IHM. The CS (OR 1.070 per unit of increasing score), was independently associated with IHM as well. The calculated weighted risk, obtained by multiplying 1.070 for the mean score value in deceased patients, was 19.367. Receiver operating characteristic (ROC) analysis showed that CS and development of sepsis were significant predictors for IHM (area under the curve, AUC: 0.724 and 0.670, respectively).Careful evaluation of comorbidity in internal medicine patients is nowadays matter of extreme importance in IMW patients hospitalized for ID, being IHM related to severity of disease, type and site of infection, and also to concomitant comorbidities. In these patients, a careful evaluation of CS should represent a fundamental step in the disease management.
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Affiliation(s)
- Fabio Fabbian
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
- Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba & Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Alfredo De Giorgi
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
| | - Benedetta Boari
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
| | - Elisa Misurati
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
| | - Massimo Gallerani
- First Internal Medicine Unit, Department of Internal Medicine, General Hospital of Ferrara
| | - Rosaria Cappadona
- Obstetrics and Gynecology Unit, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara
| | - Rosario Cultrera
- Infectious Diseases University Unit, Department of Medical Sciences, University of Ferrara, Italy
| | - Roberto Manfredini
- Clinica Medica Unit, Department of Medical Sciences, University of Ferrara
- Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba & Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Maria A. Rodrìguez Borrego
- Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba & Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Pablo J. Lopez-Soto
- Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba & Hospital Universitario Reina Sofía, Córdoba, Spain
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Tolonen M, Coccolini F, Ansaloni L, Sartelli M, Roberts DJ, McKee JL, Leppaniemi A, Doig CJ, Catena F, Fabian T, Jenne CN, Chiara O, Kubes P, Kluger Y, Fraga GP, Pereira BM, Diaz JJ, Sugrue M, Moore EE, Ren J, Ball CG, Coimbra R, Dixon E, Biffl W, MacLean A, McBeth PB, Posadas-Calleja JG, Di Saverio S, Xiao J, Kirkpatrick AW. Getting the invite list right: a discussion of sepsis severity scoring systems in severe complicated intra-abdominal sepsis and randomized trial inclusion criteria. World J Emerg Surg 2018; 13:17. [PMID: 29636790 PMCID: PMC5889572 DOI: 10.1186/s13017-018-0177-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/13/2018] [Indexed: 12/24/2022] Open
Abstract
Background Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an inception cohort sick enough to benefit from the intervention; otherwise, no effect of a potentially beneficial therapy may be apparent. An evaluation of abilities of recognized predictive systems to recognize SCIAS patients was conducted using an existing intra-abdominal sepsis (IAS) database. Methods All consecutive adult patients with a diffuse secondary peritonitis between 2012 and 2013 were collected from a quaternary care hospital in Finland, excluding appendicitis/cholecystitis. From this retrospectively collected database, a target population (93) of those with either ICU admission or mortality were selected. The performance metrics of the Third Consensus Definitions for Sepsis and Septic Shock based on both SOFA and quick SOFA, the World Society of Emergency Surgery Sepsis Severity Score (WSESSSS), the APACHE II score, Manheim Peritonitis Index (MPI), and the Calgary Predisposition, Infection, Response, and Organ dysfunction (CPIRO) score were all tested for their discriminant ability to identify this subgroup with SCIAS and to predict mortality. Results Predictive systems with an area under-the-receiving-operating characteristic (AUC) curve > 0.8 included SOFA, Sepsis-3 definitions, APACHE II, WSESSSS, and CPIRO scores with the overall best for CPIRO. The highest identification rates were SOFA score ≥ 2 (78.4%), followed by the WSESSSS score ≥ 8 (73.1%), SOFA ≥ 3 (75.2%), and APACHE II ≥ 14 (68.8%) identification. Combining the Sepsis-3 septic-shock definition and WSESSS ≥ 8 increased detection to 80%. Including CPIRO score ≥ 3 increased this to 82.8% (Sensitivity-SN; 83% Specificity-SP; 74%. Comparatively, SOFA ≥ 4 and WSESSSS ≥ 8 with or without septic-shock had 83.9% detection (SN; 84%, SP; 75%, 25% mortality). Conclusions No one scoring system behaves perfectly, and all are largely dominated by organ dysfunction. Utilizing combinations of SOFA, CPIRO, and WSESSSS scores in addition to the Sepsis-3 septic shock definition appears to offer the widest "inclusion-criteria" to recognize patients with a high chance of mortality and ICU admission. Trial registration https://clinicaltrials.gov/ct2/show/NCT03163095; Registered on May 22, 2017.
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Affiliation(s)
- Matti Tolonen
- 1Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Federico Coccolini
- 2Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Bufalini Hospital of Cesena, Cesna, Italy
| | | | - Derek J Roberts
- 5Department of Surgery, University of Calgary, Calgary, Alberta Canada
| | - Jessica L McKee
- 6Regional Trauma Services, Foothills Medical Centre, Calgary, Canada
| | - Ari Leppaniemi
- 1Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Christopher J Doig
- 7Departments of Critical Care Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Fausto Catena
- 8Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Timothy Fabian
- 9University of Tennessee Health Sciences Center, Memphis, TN USA
| | - Craig N Jenne
- 10Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
| | - Osvaldo Chiara
- General Surgery and Trauma Team Niguarda Hospital Milano, Milan, Italy
| | - Paul Kubes
- 12Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada.,13Departments of Physiology and Pharmacology Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Gustavo P Fraga
- 15Division of Trauma Surgery, University of Campinas, Campinas, SP Brazil
| | - Bruno M Pereira
- 16Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Jose J Diaz
- 17Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School on Medicine, Baltimore, MD USA
| | - Michael Sugrue
- 18Letterkenny University Hospital, Donegal Clinical Research Academy, Donegal, Ireland
| | - Ernest E Moore
- 19Trauma and Critical Care Research, University of Colorado, Denver, CO USA
| | - Jianan Ren
- 20Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chad G Ball
- 21Acute Care, and Hepatobiliary Surgery, and Regional Trauma Services, University of Calgary, Calgary, Alberta Canada
| | - Raul Coimbra
- 22Riverside University Health System Medical Center, Moreno Valley, USA.,23Loma Linda University School of Medicine, Loma Linda, CA USA
| | - Elijah Dixon
- 24Surgery, Oncology, and Community Health Sciences, City Wide Section of General Surgery, University of Calgary, Calgary, Alberta Canada
| | - Walter Biffl
- 25Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, California USA
| | - Anthony MacLean
- 26Division of General Surgery Foothills Medical Centre, Department of Surgery, University of Calgary, Calgary, Canada
| | - Paul B McBeth
- 5Department of Surgery, University of Calgary, Calgary, Alberta Canada.,10Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada.,27The Trauma Program, University of Calgary, Calgary, Alberta Canada
| | | | - Salomone Di Saverio
- 28Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Jimmy Xiao
- 6Regional Trauma Services, Foothills Medical Centre, Calgary, Canada
| | - Andrew W Kirkpatrick
- 5Department of Surgery, University of Calgary, Calgary, Alberta Canada.,10Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada.,27The Trauma Program, University of Calgary, Calgary, Alberta Canada.,29EG23 Foothills Medical Centre, Calgary, Alberta T2N 2T9 Canada
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Pedersen PB, Hrobjartsson A, Nielsen DL, Henriksen DP, Brabrand M, Lassen AT. Prevalence and prognosis of acutely ill patients with organ failure at arrival to hospital: protocol for a systematic review. Syst Rev 2017; 6:227. [PMID: 29141664 PMCID: PMC5688673 DOI: 10.1186/s13643-017-0622-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/07/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acutely ill patients are a heterogeneous group, and some of these suffer from organ failure. As the prognosis of organ failure improves with early treatment, it is important to identify these patients as early as possible. Most studies on organ failure have been performed in intensive care settings, or on selected groups of patients, where a high prevalence and mortality have been reported. Before patients arrive to the intensive care unit, or the general ward, most of them have passed through the emergency department (ED), where diagnosis and treatment has been initiated. The prevalence and prognosis of acutely ill patients, with organ failure, at arrival have been studied in some selected groups, but methods and results differ. This systematic review aims to identify, summarize, and analyze studies of prevalence and prognosis of new onset organ failure in acutely ill undifferentiated patients, at arrival to hospital. The result of the review will assist physicians working in an ED, when assessing patients' risk of organ failure and their associated prognosis. METHODS The information sources used are electronic databases, PubMed, Cochrane Library, EMBASE, and CINAHL; references in included studies and review articles; and authors' personal files. One author will perform the title and abstract screening and exclude obviously ineligible studies. By an independent full-text screening, two authors will decide on the eligibility for the remaining studies. Eligible studies will include an unselected group of acutely ill adult patients at arrival to hospital, with one or more organ failures (respiratory, renal, cerebral, circulatory, hepatic, or coagulation failure). Included studies will have assessed the prevalence or prognosis, defined as mortality or ICU transfer, of new onset organ failure. From included studies, bibliographical and study description data, patient characteristics, and data related to prevalence of organ failure and prognosis will be extracted. We will assess risk of bias in included studies using the Quality in Prognosis Studies tool for prognostic studies and the Newcastle-Ottawa Scale for observational studies. We expect heterogeneity and to conduct a qualitative synthesis of the results. If, however, heterogeneity is low, we will conduct a random effects meta-analysis stratified by basic study design. DISCUSSION This review will summarize and analyze studies of prevalence and prognosis of acutely ill patients, with organ failure at arrival to hospital, assist ED physicians assessing the risk of organ failure in unselected patients, and guide recommendations for further research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017060871.
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Affiliation(s)
- Peter Bank Pedersen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark and Odense University Hospital, DK-5000, Odense C, Denmark.
| | - Asbjorn Hrobjartsson
- Centre for Evidence-Based Medicine, University of Southern Denmark and Odense University Hospital, DK-5000, Odense C, Denmark
| | - Daniel Lykke Nielsen
- Department of Emergency Medicine, Odense University Hospital, DK-5000, Odense C, Denmark
| | - Daniel Pilsgaard Henriksen
- Department of Emergency Medicine and Department of Respiratory Medicine, Odense University Hospital, DK-5000, Odense C, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, DK-5000, Odense C, Denmark.,Hospital of South West Jutland, DK-6700, Esbjerg, Denmark
| | - Annmarie Touborg Lassen
- Department of Emergency Medicine, Institute of Clinical Research, University of Southern Denmark and Odense University Hospital, DK-5000, Odense C, Denmark
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Dreger NM, Degener S, Ahmad-Nejad P, Wöbker G, Roth S. Urosepsis--Etiology, Diagnosis, and Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:837-47; quiz 848. [PMID: 26754121 DOI: 10.3238/arztebl.2015.0837] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 11/02/2015] [Accepted: 11/02/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Sepsis is among the most common causes of death in Germany. Urosepsis accounts for 9-31% of all cases and has a mortality of 20-40%, which is low compared with that of sepsis in general. As the population ages, the incidence of urosepsis is likely to rise. METHODS Review of pertinent articles and guidelines retrieved by a selective search in PubMed. RESULTS Enterobacteria and Gram-positive organisms are the pathogens that most commonly cause urosepsis. The diagnosis can and must be made early on the basis of the typical clinical features, altered vital signs, and laboratory abnormalities, so that timely treatment can be initiated. 80% of cases are due to obstructive uropathy. The diagnostic evaluation includes physical examination, blood cultures, urinalysis, procalcitonin measurement, and ultrasonography. In one study, each additional hour of delay in the treatment of urosepsis with antibiotics was found to lower the survival rate by 7.6%. Antibiotics should be chosen in consideration of local resistance patterns and the expected pathogen spectrum. CONCLUSION Urologists, intensive care specialists, and microbiologists should all be involved in the interdisciplinary treatment of urosepsis. Patients' outcomes have improved recently, probably because of the frequent use of minimally invasive treatments to neutralize foci of infection. New biomarkers and new treatments still need to be validated in multicenter trials.
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Affiliation(s)
- Nici Markus Dreger
- Department of Adult and Pediatric Urology, Witten/Herdecke University, HELIOS, Klinikum Wuppertal, Center for Research in Clinical Medicine (ZFKM), Institute for Microbiology and Laboratory Medicine, Witten/Herdecke University, Center for Research in Clinical Medicine (ZFKM), HELIOS Klinikum, Wuppertal, Department of Intensive Care Medicine, Witten/Herdecke University, HELIOS, Klinikum Wuppertal
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Zhang Z, Smischney NJ, Zhang H, Van Poucke S, Tsirigotis P, Rello J, Honore PM, Sen Kuan W, Ray JJ, Zhou J, Shang Y, Yu Y, Jung C, Robba C, Taccone FS, Caironi P, Grimaldi D, Hofer S, Dimopoulos G, Leone M, Hong SB, Bahloul M, Argaud L, Kim WY, Spapen HD, Rocco JR. AME evidence series 001-The Society for Translational Medicine: clinical practice guidelines for diagnosis and early identification of sepsis in the hospital. J Thorac Dis 2016; 8:2654-2665. [PMID: 27747021 PMCID: PMC5059246 DOI: 10.21037/jtd.2016.08.03] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 07/27/2016] [Indexed: 02/05/2023]
Abstract
Sepsis is a heterogeneous disease caused by an infection stimulus that triggers several complex local and systemic immuno-inflammatory reactions, which results in multiple organ dysfunction and significant morbidity and mortality. The diagnosis of sepsis is challenging because there is no gold standard for diagnosis. As a result, the clinical diagnosis of sepsis is ever changing to meet the clinical and research requirements. Moreover, although there are many novel biomarkers and screening tools for predicting the risk of sepsis, the diagnostic performance and effectiveness of these measures are less than satisfactory, and there is insufficient evidence to recommend clinical use of these new techniques. As a consequence, diagnostic criteria for sepsis need regular revision to cope with emerging evidence. This review aims to present the most updated information on diagnosis and early recognition of sepsis. Recommendations for clinical use of different diagnostic tools rely on the Grades of Recommendation Assessment, Development and Evaluation (GRADE) framework. Because most of the studies were observational and did not allow a reliable assessment of these tools, a two-step inference approach was employed. Future trials need to confirm or refute a particular index test and should directly explore relevant patient outcome parameters.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
- Department of Critical Care Medicine, Jinhua Hospital of Zhejiang University, Jinhua 321000, China
| | | | - Haibo Zhang
- Keenan Research Center for Biomedical Science of St. Michael’s Hospital, Departments of Anesthesia and Physiology, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Sven Van Poucke
- Departments of Anesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Panagiotis Tsirigotis
- 2nd Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jordi Rello
- CIBERES, Vall d’Hebron Institut of Research, Universitat Autonoma de Barcelona, Spain
| | - Patrick M. Honore
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore and the Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Juliet June Ray
- DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Jiancang Zhou
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical Collegue, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China
| | - Christian Jung
- University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, Düsseldorf, Germany
| | - Chiara Robba
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pietro Caironi
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - David Grimaldi
- Intensive Care Department, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Marc Leone
- Service d’anesthésie et de réanimation, Hôpital Nord, Assistance Publique – Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Herbert D. Spapen
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Jose Rodolfo Rocco
- Department of Internal Medicine and Post-graduated Program, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Severity Scores in Emergency Department Patients With Presumed Infection: A Prospective Validation Study. Crit Care Med 2016; 44:539-47. [PMID: 26901543 DOI: 10.1097/ccm.0000000000001427] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The objectives of this study were to 1) validate a number of severity of illness scores in a large cohort of emergency department patients admitted with presumed infection and 2) compare the performance of scores in patient subgroups with increasing mortality: infection without systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock. DESIGN Prospective, observational study. SETTING Adult emergency department in a metropolitan tertiary, university-affiliated hospital. PATIENTS Emergency department patients admitted with presumed infection. INTERVENTIONS None. METHODS Consecutive emergency department patients admitted with presumed infection were identified over 160 weeks in two periods between 2007 and 2011. Clinical and laboratory data sufficient to calculate Mortality in Emergency Department Sepsis score, Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, and the Severe Sepsis Score were entered into a database. Model discrimination was quantified using area under the receiver operating curve. Calibration was assessed using visual plots, Hosmer-Lemeshow statistics, and linear regressions of observed and predicted values. MEASUREMENTS AND MAIN RESULTS A total of 8,871 patients were enrolled with 30-day mortality of 3.7%. Area under the receiver operating curve values for the entire cohort were: Mortality in Emergency Department Sepsis score of 0.92, Simplified Acute Physiology Score II and Acute Physiology and Chronic Health Evaluation II scores of 0.90, Sequential Organ Failure Assessment score of 0.86, and Severe Sepsis Score of 0.82. Discrimination decreased in subgroups with greater mortality for each score. All scores overestimated mortality, but closest concordance between predicted and observed mortality was seen with Mortality in Emergency Department Sepsis score. CONCLUSIONS The decrease in area under the receiver operating curve seen in subgroups with increasing mortality may explain some variation in results seen in previous validation studies. Scores developed in intensive care settings overestimated mortality in the emergency department. Our results underscore the importance of employing predictive models developed in similar patient populations. The Mortality in Emergency Department Sepsis score outperformed more complex predictive models and would be the most appropriate scoring system for use in similar emergency department populations with a wide spectrum of mortality risk.
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Sepsis and septic shock in low-income and middle-income countries: need for a different paradigm. Int J Infect Dis 2016; 48:120-2. [PMID: 27117201 DOI: 10.1016/j.ijid.2016.04.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 04/18/2016] [Indexed: 12/29/2022] Open
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Chen JP, Fang XM, Jin XJ, Kang RT, Liu KX, Li JB, Luo Y, Lu ZJ, Miao CH, Ma HX, Mei W, Ou YW, Qi SH, Qin ZS, Tian GG, Wu AS, Wang DX, Yu T, Yu YH, Zhao J, Zuo MZ, Zhang SH. Expert consensus on the perioperative management of patients with sepsis. World J Emerg Med 2015; 6:245-60. [PMID: 26702328 DOI: 10.5847/wjem.j.1920-8642.2015.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Jun-Ping Chen
- Department of Anesthesiology, Ningbo Number 2 Hospital, Ningbo, China
| | - Xiang-Ming Fang
- Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao-Ju Jin
- Department of Anesthesiology and Critical Care Medicine, Yijishan Hospital, Wannan Medical College, Wuhu, China
| | - Rong-Tian Kang
- Department of Anesthesiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ke-Xuan Liu
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin-Bao Li
- Department of Anesthesiology and Intensive Care Medicine, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan Luo
- Department of Anesthesiology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhi-Jie Lu
- Department of Anesthesiology and Intensive Care Medicine, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Chang-Hong Miao
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, China
| | - Han-Xiang Ma
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Wei Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang-Wen Ou
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Si-Hua Qi
- Department of Anesthesiology, Fourth Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Zai-Sheng Qin
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Guo-Gang Tian
- Department of Anesthesiology, People's Hospital of Sanya, Sanya, China
| | - An-Shi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Surgical Intensive Care, Peking University First Hospital, Beijing, China
| | - Tian Yu
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical College, Zunyi, China
| | - Yong-Hao Yu
- Department of Anesthesiology, Tianjin Medical University General Hospital, and Tianjin Research Institute of Anesthesiology, Tianjin, China
| | - Jing Zhao
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Zhang Zuo
- Department of Anesthesiology, Beijing Hospital, Beijing, China
| | - Shi-Hai Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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25
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Blasco-Algora S, Masegosa-Ataz J, Gutiérrez-García ML, Alonso-López S, Fernández-Rodríguez CM. Acute-on-chronic liver failure: Pathogenesis, prognostic factors and management. World J Gastroenterol 2015; 21:12125-12140. [PMID: 26576097 PMCID: PMC4641130 DOI: 10.3748/wjg.v21.i42.12125] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/17/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is increasingly recognized as a complex syndrome that is reversible in many cases. It is characterized by an acute deterioration of liver function in the background of a pre-existing chronic liver disease often associated with a high short-term mortality rate. Organ failure (OF) is always associated, and plays a key role in determining the course, and the outcome of the disease. The definition of ACLF remains controversial due to its overall ambiguity, with several disparate criteria among various associations dedicated to the study of liver diseases. Although the precise pathogenesis needs to be clarified, it appears that an altered host response to injury might be a contributing factor caused by immune dysfunction, ultimately leading to a pro-inflammatory status, and eventually to OF. The PIRO concept (Predisposition, Insult, Response and Organ Failure) has been proposed to better approach the underlying mechanisms. It is accepted that ACLF is a different and specific form of liver failure, where a precipitating event is always involved, even though it cannot always be ascertained. According to several studies, infections and active alcoholism often trigger ACLF. Viral hepatitis, gastrointestinal haemorrhage, or drug induced liver injury, which can also provoke the syndrome. This review mainly focuses on the physiopathology and prognostic aspects. We believe these features are essential to further understanding and providing the rationale for improveddisease management strategies.
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26
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Westphal GA, Lino AS. Systematic screening is essential for early diagnosis of severe sepsis and septic shock. Rev Bras Ter Intensiva 2015; 27:96-101. [PMID: 26340147 PMCID: PMC4489775 DOI: 10.5935/0103-507x.20150018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/10/2015] [Indexed: 01/08/2023] Open
Affiliation(s)
- Glauco Adrieno Westphal
- Centro Hospitalar Unimed - Joinville (SC), Brazil
- Hospital Municipal São José - Joinville (SC),
Brazil
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27
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Macdonald SPJ, Arendts G, Fatovich DM, Brown SGA. Comparison of PIRO, SOFA, and MEDS scores for predicting mortality in emergency department patients with severe sepsis and septic shock. Acad Emerg Med 2014; 21:1257-63. [PMID: 25377403 DOI: 10.1111/acem.12515] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 06/18/2014] [Accepted: 07/02/2014] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Stephen P. J. Macdonald
- The Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth WA
- The Discipline of Emergency Medicine University of Western Australia Perth WA
- The Emergency Department Armadale Health Service Perth WA
| | - Glenn Arendts
- The Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth WA
- The Discipline of Emergency Medicine University of Western Australia Perth WA
- The Emergency Department Royal Perth Hospital Perth WA Australia
| | - Daniel M. Fatovich
- The Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth WA
- The Discipline of Emergency Medicine University of Western Australia Perth WA
- The Emergency Department Royal Perth Hospital Perth WA Australia
| | - Simon G. A. Brown
- The Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth WA
- The Discipline of Emergency Medicine University of Western Australia Perth WA
- The Emergency Department Royal Perth Hospital Perth WA Australia
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