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[MEDSCAPE]: 筛查住院患者的严重全身性感染应当使用哪个评分?
2017年05月13日 研究点评, 进展交流 暂无评论

Which Score to Use When Screening for Sepsis on the Wards

Aaron B. Holley, MD

April 21, 2017

Quick Sepsis-Related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients Outside the Intensive Care Unit

Churpek MM, Snyder A, Han X, et al

Am J Respir Crit Care Med. 2017;195:906-911

Background 背景

The Sepsis-3 consensus statement recommends replacing the systemic inflammatory response syndrome (SIRS) criteria with the quick Sequential Organ Failure Assessment (qSOFA).[1,2] Several editorials published in response raised concern that sacrificing the sensitivity obtained with SIRS for increased specificity would lead to delayed identification.[3,4] A review published later in the year noted that studies cited in Sepsis-3 enrolled emergency department and intensive care unit (ICU) patients, but not ward patients.[5] The academic debate highlights how little we know about improving clinical outcomes for hospitalized patients who develop sepsis outside of the ICU.

Sepsis-3共识定义推荐采用快速SOFA (qSOFA)评分替代全身炎症反应综合征(SIRS)。此后发表的一些述评担心,牺牲SIRS的敏感性以提高特异性是否会导致临床延迟发现病例。当年晚些时候发表的综述指出,采用sepsis-3定义的研究入选了急诊科与ICU的患者,但不包括普通病房患者。这一学术争论表明,我们对于如何改进ICU以外住院患者发生全身性感染后的临床预后知之甚少。

The Study 研究介绍

A new study by Churpek and colleagues (the authors of the 2016 review[5]) supplies data to drive this debate. They sampled retrospective data from the University of Chicago over an 8-year period. SIRS, qSOFA, Modified Early Warning Score (MEWS),[6] and National Early Warning Score (NEWS)[7] were calculated for patients in the emergency department and on the wards. Intravenous antibiotic administration and culture orders were used to identify suspicion of infection. The primary outcome was hospital mortality, and the secondary outcome was a composite of death or ICU admission any time after suspicion of infection.

Churpek及其同事(2016年综述的作者)发表了一项新的研究,为上述争论提供了新的依据。他们回顾性分析了芝加哥大学8年间的数据,对急诊科与普通病房的患者计算SIRS、qSOFA、修订早期预警评分(MEWS)及全国早期预警评分(NEWS)。根据静脉抗生素及培养医嘱鉴别可疑感染人群。主要预后指标为住院病死率,次要预后指标为可疑感染后死亡或收入ICU的复合终点。

The researchers found the NEWS and MEWS had the best area under the receiver operating characteristic (AUROC) curve for predicting outcomes. qSOFA was next, and SIRS was last. A SIRS score ≥ 2 had a sensitivity of 91% and a specificity of 13%. Most of the patients met these criteria. Patients had ≥ 2 SIRS, ≥ 2 and > 1 qSOFA criteria 17, 5, and 17 hours before the composite, secondary outcome, respectively.

研究者发现,NEWS和MEWS评分预测预后的AUROC最佳,qSOFA次之,SIRS最差。SIRS评分≥ 2敏感性91%,特异性13%。多数患者符合这些标准。在复合终点出现前17、5和17小时患者SIRS ≥ 2,qSOFA ≥ 2 和 > 1。

Viewpoint 观点

As noted in the accompanying editorial,[8] early identification of sepsis is governed by basic mathematical truths. If you want early and sensitive, you must sacrifice specificity and overall accuracy. If you want a higher AUROC, you'll need a more complicated model (the MEWS and NEWS scores contain five and six variables, respectively, and run from 1 to 9 and 1 to 15).

正如述评指出,早期鉴别全身性感染患者的措施遵循基本的数学原则。如果你希望早期发现(敏感性高),则必须牺牲特异性及总体准确性。如果你希望AUROC较大,则需要更加复杂的模型(MEWS和NEWS评分分别包括5项及6项指标,评分分别从1-9分及1-15分)。

The University of Chicago data are hugely helpful because they allow hospitals and health systems to quantify trade-offs. Decisions regarding which score to use should be governed by resources and patient population. Hospitals with advanced electronic health records looking to optimize finite ICU capacity may opt for the MEWS or NEWS. Those with excess capacity or a lower prevalence of sepsis might want to use SIRS. There's no such thing as a free lunch, but these data help explain what we get for our money.

芝加哥大学的数据大有裨益,因为这些数据有助于医院和健康系统定量权衡利弊。应当根据资源配置及患者人群决定采用哪个评分。如果医院配备了先进电子病历系统,且ICU资源有限,则可采用MEWS或NEWS评分。ICU资源充足或全身性感染罹患率较低的医院可能使用SIRS。天下没有免费的午餐,这些资源有助于说明你在投入后的产出是什么。

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