Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Prahran, Melbourne, Australia2Discipline of Surgery, School of Medicine, University of Adelaide, Adelaide, Australia.
Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Prahran, Melbourne, Australia3Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Prahran, Melbourne, Australia.
JAMA. 2017 Jan 17;317(3):290-300. doi: 10.1001/jama.2016.20328.
IMPORTANCE: The Sepsis-3 Criteria emphasized the value of a change of 2 or more points in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, introduced quick SOFA (qSOFA), and removed the systemic inflammatory response syndrome (SIRS) criteria from the sepsis definition. OBJECTIVE: Externally validate and assess the discriminatory capacities of an increase in SOFA score by 2 or more points, 2 or more SIRS criteria, or a qSOFA score of 2 or more points for outcomes among patients who are critically ill with suspected infection. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort analysis of 184 875 patients with an infection-related primary admission diagnosis in 182 Australian and New Zealand intensive care units (ICUs) from 2000 through 2015. EXPOSURES: SOFA, qSOFA, and SIRS criteria applied to data collected within 24 hours of ICU admission. MAIN OUTCOMES AND MEASURES: The primary outcome was in-hospital mortality. In-hospital mortality or ICU length of stay (LOS) of 3 days or more was a composite secondary outcome. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC). Adjusted analyses were performed using a model of baseline risk determined using variables independent of the scoring systems. RESULTS: Among 184 875 patients (mean age, 62.9 years [SD, 17.4]; women, 82 540 [44.6%]; most common diagnosis bacterial pneumonia, 32 634 [17.7%]), a total of 34 578 patients (18.7%) died in the hospital, and 102 976 patients (55.7%) died or experienced an ICU LOS of 3 days or more. SOFA score increased by 2 or more points in 90.1%; 86.7% manifested 2 or more SIRS criteria, and 54.4% had a qSOFA score of 2 or more points. SOFA demonstrated significantly greater discrimination for in-hospital mortality (crude AUROC, 0.753 [99% CI, 0.750-0.757]) than SIRS criteria (crude AUROC, 0.589 [99% CI, 0.585-0.593]) or qSOFA (crude AUROC, 0.607 [99% CI, 0.603-0.611]). Incremental improvements were 0.164 (99% CI, 0.159-0.169) for SOFA vs SIRS criteria and 0.146 (99% CI, 0.142-0.151) for SOFA vs qSOFA (P <.001). SOFA (AUROC, 0.736 [99% CI, 0.733-0.739]) outperformed the other scores for the secondary end point (SIRS criteria: AUROC, 0.609 [99% CI, 0.606-0.612]; qSOFA: AUROC, 0.606 [99% CI, 0.602-0.609]). Incremental improvements were 0.127 (99% CI, 0.123-0.131) for SOFA vs SIRS criteria and 0.131 (99% CI, 0.127-0.134) for SOFA vs qSOFA (P <.001). Findings were consistent for both outcomes in multiple sensitivity analyses. CONCLUSIONS AND RELEVANCE: Among adults with suspected infection admitted to an ICU, an increase in SOFA score of 2 or more had greater prognostic accuracy for in-hospital mortality than SIRS criteria or the qSOFA score. These findings suggest that SIRS criteria and qSOFA may have limited utility for predicting mortality in an ICU setting.
重要性：Sepsis-3 标准强调了Sequential [Sepsis-related] Organ Failure Assessment（SOFA）评分增加 2 分或以上、引入快速 SOFA（qSOFA）以及从脓毒症定义中删除全身炎症反应综合征（SIRS）标准的价值。 目的：验证和评估在疑似感染的重症监护病房（ICU）中，SOFA 评分增加 2 分或以上、出现 2 个或更多 SIRS 标准或 qSOFA 评分 2 分或以上对患者结局的区分能力。 设计、设置和参与者：对 2000 年至 2015 年期间澳大利亚和新西兰 182 家 ICU 中 184875 名感染相关入院诊断患者的回顾性队列分析。 暴露：SOFA、qSOFA 和 SIRS 标准应用于 ICU 入院后 24 小时内收集的数据。 主要结果和措施：主要结局为院内死亡率。院内死亡或 ICU 住院时间（LOS）超过 3 天为次要复合结局。使用接受者操作特征曲线（AUROC）下面积评估区分度。使用基于与评分系统无关的变量确定基线风险的模型进行调整分析。 结果：在 184875 名患者中（平均年龄 62.9 岁[标准差 17.4]；女性 82540 名[44.6%]；最常见的诊断为细菌性肺炎，32634 名[17.7%]），共有 34578 名患者（18.7%）院内死亡，102976 名患者（55.7%）死亡或 ICU LOS 超过 3 天。SOFA 评分增加 2 分或以上的患者占 90.1%；86.7%的患者出现 2 个或更多 SIRS 标准，54.4%的患者 qSOFA 评分 2 分或以上。SOFA 对院内死亡率的预测能力明显优于 SIRS 标准（粗 AUROC，0.753 [99%CI，0.750-0.757]）和 qSOFA（粗 AUROC，0.607 [99%CI，0.603-0.611]）。SOFA 与 SIRS 标准相比，SOFA 增加了 0.164（99%CI，0.159-0.169），与 qSOFA 相比，SOFA 增加了 0.146（99%CI，0.142-0.151）（P<.001）。SOFA（AUROC，0.736 [99%CI，0.733-0.739]）在次要终点（SIRS 标准：AUROC，0.609 [99%CI，0.606-0.612]；qSOFA：AUROC，0.606 [99%CI，0.602-0.609]）的预测能力优于其他评分。SOFA 与 SIRS 标准相比，SOFA 增加了 0.127（99%CI，0.123-0.131），与 qSOFA 相比，SOFA 增加了 0.131（99%CI，0.127-0.134）（P<.001）。在多个敏感性分析中，这两种结果的发现均一致。 结论和相关性：在疑似感染并入住 ICU 的成年人中，SOFA 评分增加 2 分或以上对院内死亡率的预后准确性优于 SIRS 标准或 qSOFA 评分。这些发现表明，SIRS 标准和 qSOFA 可能对 ICU 环境中死亡率的预测作用有限。
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