(3) Sepsis criteria better at diagnosing infection; Q Sofa better at prediocting mortality. (4) A combined score may have synergies[r]
(1)Utility of Q SOFA & SIRS Criteria for diagnosis of Sepsis & Prediction of
Mortality
William T McGee, M.D MHA, FCCM, FCCP Critical Care Medicine
Associate Professor of Medicine and Surgery University of Massachusetts
759 Chestnut Street, Springfield, MA 01199 Tel: 413-794-5439 | Fax: 413-794-3987
(2) 55 y/o morbidly obese (138 kg) male
cc: severe abdominal pain for ~2 days
(+) anorexia, nausea and dysuria
T 101.5°F, BP 134/68, HR 110, RR 20, 98% on room air
(+) dry mucous membranes, tachycardia, diffuse lower abd pain
Basic labs, an iv line and crystalloid fluids - wide open
WBC 23K , no bands, lactate of mmol/L
Urine analysis urinary tract infection
All other labs are unremarkable
Appropriate antibiotics are started
Discharged home on HD
Case
(3)National Hospital Discharge Database
(4)qSOFA
(5)(6)(7)qSOFA fails validation
(8)(9)Modified from criteria published in:
Balk, R., Crit Care Clinics 2000; 16:337-351;
Kleinpell, R Crit Care Nurs Clin N Am. 2003; 15:27-34
Cardiovascular: Tachycardia Hypotension Altered CVP &
PAOP Renal: Oliguria Anuria Creatinine Hematologic: Platelets
PT/INR, aPTT
Protein C
D-dimer Hepatic: Jaundice, Liver enzymes Albumin CNS: Altered consciousness Confusion Respiratory: Tachypnea
PaO2
PaO2/FiO2 ratio
Metabolic: Metabolic Acidosis
Lactate level
Lactate Clearance
(10)(11)Sepsis Mortality Increases with the Number of Organ Dysfunctions
Angus DC, et al Crit Care Med. 2001;29:1303-1310
21.2 44.3 64.5 76.2 10 20 30 40 50 60 70 80 90
One Two Three Four or More
(12)A Comparison of the Quick-SOFA and Systemic Inflammatory Response Syndrome Criteria for the Diagnosis of Sepsis and
Prediction of Mortality
Rodrigo Serafim, MD, José Andrade Gomes, MD, Jorge Salluh, MD, PhD, Pedro Póvoa, MD, PhD
CHEST
Volume 153, Issue 3, Pages 646-655 (March 2018) DOI: 10.1016/j.chest.2017.12.015
(13)Figure
CHEST2018 153, 646-655DOI: (10.1016/j.chest.2017.12.015)
(14)(15)Figure
CHEST2018 153, 646-655DOI: (10.1016/j.chest.2017.12.015)
(16)Figure
CHEST2018 153, 646-655DOI: (10.1016/j.chest.2017.12.015)
(17)Quick score q Sofa
(18)(19) 55 y/o morbidly obese (138 kg) male
cc: severe abdominal pain for ~2 days
(+) anorexia, nausea and dysuria
T 101.5°F, BP 134/68, HR 110, RR 20, 98% on room air
(+) dry mucous membranes, tachycardia, diffuse lower abd pain
Basic labs, an iv line and crystalloid fluids - wide open
WBC 23K , no bands, lactate of mmol/L
Urine analysis urinary tract infection
All other labs are unremarkable
Appropriate antibiotics are started
Discharged home on HD
Case
(20)Serum Lactate as a Predictor of Mortality in Emergency Department Patients with Infection
Prospective cohort study, urban ED
1,278 consecutive patients
Inclusion criteria: ≥18 years, serum lactate level
obtained, admission with infection-related diagnosis
Shapiro, N., Ann of Emer Med. 2005; 45:524-528
Lactate (mmol/L)
0-2.4 2.5-3.9 >4.0
28-day in-hospital mortality, % 4.9 9.0 28.4
(21)(22)CaO2 = Hb x 1.39 x SaO2 + paO2 x 0.0003
DO2 = CO x CaO2 ; CO = SV x HR
DO2 = SV x HR x (Hb x 1.39 x SaO2 + paO2 x 0.0003)
(23)(24)Lactate production
(25)Epinephrine and lactate
(26)(1) Elevated lactate in septic shock is not (ALWAYS) due to anaerobic metabolism
(2) Elevated lactate in septic shock is also due to stimulation of beta-2 adrenergic receptors
(3) Lactate clearance in shock is a good marker of
successful resuscitation and persistence is correlated with Death
(27)Lactate can help guide resuscitation
• We suggest guiding resuscitation to
normalize lactate in patients with elevated lactate levels as a marker of tissue
hypoperfusion
(28)(1) Elevated lactate needs to be corrected or your patient will die
(2) Systemic organ dysfunction is correlated with Death ARDS; AKI ( dialysis )
(3) Sepsis criteria better at diagnosing infection; Q Sofa better at prediocting mortality
(4) A combined score may have synergies!
Key points
Terms and Conditions