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[JAMA读者来信]:急诊科使用qSOFA评分
2017年05月21日 研究点评, 进展交流 暂无评论

Comment & Response

May 9, 2017

Use of the qSOFA Score in the Emergency Department

Christian S. Scheer, Sven-Olaf Kuhn, Sebastian Rehberg

JAMA. 2017;317(18):1909-1910. doi:10.1001/jama.2017.3504

To the Editor

The quick Sequential Organ Failure Assessment (qSOFA) score is much simpler and faster to accomplish than other screening tools and does not require results from laboratory analyses or invasive monitoring. It represents a useful score for the emergency department and ward. The study by Dr Freund and colleagues1 concluded that “qSOFA resulted in greater prognostic accuracy for in-hospital mortality than did either SIRS [systemic inflammatory response syndrome] or severe sepsis.”

与其他筛查工具相比,快速SOFA评分(qSOFA)更加简单,可以更快速地完成,而且无需实验室检查或有创监测结果。qSOFA评分是急诊科及普通病房非常有用的评分。Freund医生及其同事的研究得出结论,“与SIRS或严重全身性感染相比,qSOFA评分对于住院病死率的预测准确性更高。”

Unfortunately, these conclusions are based on inconsistent methods, questionable definitions, and a data set with a substantial amount of missing values. Why were 149 patients excluded because of missing data for qSOFA, whereas 260 patients with at least 1 missing component for SOFA were included? This inconsistency could result in lower SOFA scores and an underestimation of disease severity with SOFA. It also gives an important methodical advantage to the qSOFA score.

遗憾的是,这些结论基于前后矛盾的研究方法,存在疑问的定义,以及有大量数据缺失的数据集。为什么研究因为qSOFA评分数据缺失的原因排除了149名患者,而SOFA评分至少一项指标缺失的260名患者却被纳入研究?这一矛盾的作用可能导致SOFA评分较低,从而导致根据SOFA评分评估的疾病严重程度较低。这还可能从方法学上有利于qSOFA评分。

In addition, severe sepsis was defined as SIRS combined with elevated lactate levels. All the other types of organ dysfunction that were mentioned in the original guidelines by Bone and colleagues2 and earlier international sepsis definitions3 (ie, arterial hypotension, encephalopathy, thrombocytopenia, renal dysfunction, hypoxia) were not considered. As a consequence of this arbitrary definition, the presented comparison between qSOFA and severe sepsis is only valid for this subgroup of severe sepsis but not for severe sepsis in general.

另外,严重全身性感染定义为SIRS合并乳酸水平升高。研究者没有考虑Bone及其同事制定的最初指南以及早期国际全身性感染定义中有关其他类型的器官功能障碍(及动脉低血压,脑病,血小板减少,肾功能异常,缺氧)。基于这一武断的定义,qSOFA与严重全身性感染之间的比较仅对严重全身性感染的某个亚组而非所有严重全身性感染患者有效。

Despite these limitations, severe sepsis performed as well as qSOFA (positive predictive value 20% for severe sepsis vs 24% for qSOFA; negative predictive value 94% for severe sepsis vs 97% for qSOFA). In addition, the proportion of in-hospital deaths among patients with a qSOFA score of 2 or more points (24%) was similar to that of patients with severe sepsis (20%).

尽管存在这些局限性,严重全身性感染的预后预测价值与qSOFA相同(阳性预期值,严重全身性感染20%,qSOFA 24%;阴性预期值,严重全身性感染94%,qSOFA 97%)。另外,qSOFA评分≥2分的患者中住院死亡的比例(24%)与严重全身性感染患者相似(20%)。

We are aware of the challenges of score calculation in clinical practice. Data are often incomplete because the required laboratory values may not be available for all patients. Against the background of the discussed limitations, however, such a strong conclusion about the superiority of qSOFA over severe sepsis does not seem to be appropriate.

我们理解临床实践中计算评分所面临的挑战。由于并非所有患者都有所需的实验室检查结果,因此数据通常并不完整。然而,基于上述讨论的局限性,有关qSOFA优于严重全身性感染的结论似乎并不恰当。

References

1. Freund  Y, Lemachatti  N, Krastinova  E,  et al.  Prognostic accuracy of Sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department.  JAMA. 2017;317(3):301-308.PubMedArticle

2. Bone  RC, Balk  RA, Cerra  FB,  et al.  Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.  Chest. 1992;101(6):1644-1655.PubMedArticle

3. Levy  MM, Fink  MP, Marshall  JC,  et al.  2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.  Intensive Care Med. 2003;29(4):530-538.PubMedArticle

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