Sorbonne Universités, UPMC Paris Univ-06, Paris, France2Emergency Department, Hôpital Pitie-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
Emergency Department, Hôpital Pitie-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
JAMA. 2017 Jan 17;317(3):301-308. doi: 10.1001/jama.2016.20329.
IMPORTANCE: An international task force recently redefined the concept of sepsis. This task force recommended the use of the quick Sequential Organ Failure Assessment (qSOFA) score instead of systemic inflammatory response syndrome (SIRS) criteria to identify patients at high risk of mortality. However, these new criteria have not been prospectively validated in some settings, and their added value in the emergency department remains unknown. OBJECTIVE: To prospectively validate qSOFA as a mortality predictor and compare the performances of the new sepsis criteria to the previous ones. DESIGN, SETTINGS, AND PARTICIPANTS: International prospective cohort study, conducted in France, Spain, Belgium, and Switzerland between May and June 2016. In the 30 participating emergency departments, for a 4-week period, consecutive patients who visited the emergency departments with suspected infection were included. All variables from previous and new definitions of sepsis were collected. Patients were followed up until hospital discharge or death. EXPOSURES: Measurement of qSOFA, SOFA, and SIRS. MAIN OUTCOMES AND MEASURES: In-hospital mortality. RESULTS: Of 1088 patients screened, 879 were included in the analysis. Median age was 67 years (interquartile range, 47-81 years), 414 (47%) were women, and 379 (43%) had respiratory tract infection. Overall in-hospital mortality was 8%: 3% for patients with a qSOFA score lower than 2 vs 24% for those with qSOFA score of 2 or higher (absolute difference, 21%; 95% CI, 15%-26%). The qSOFA performed better than both SIRS and severe sepsis in predicting in-hospital mortality, with an area under the receiver operating curve (AUROC) of 0.80 (95% CI, 0.74-0.85) vs 0.65 (95% CI, 0.59-0.70) for both SIRS and severe sepsis (P < .001; incremental AUROC, 0.15; 95% CI, 0.09-0.22). The hazard ratio of qSOFA score for death was 6.2 (95% CI, 3.8-10.3) vs 3.5 (95% CI, 2.2-5.5) for severe sepsis. CONCLUSIONS AND RELEVANCE: Among patients presenting to the emergency department with suspected infection, the use of qSOFA resulted in greater prognostic accuracy for in-hospital mortality than did either SIRS or severe sepsis. These findings provide support for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria in the emergency department setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02738164.
重要性：最近，一个国际专家组重新定义了脓毒症的概念。该专家组建议使用快速序贯器官衰竭评估（qSOFA）评分代替全身炎症反应综合征（SIRS）标准来识别高死亡率风险的患者。然而，这些新的标准在某些环境中尚未得到前瞻性验证，其在急诊科的附加价值尚不清楚。 目的：前瞻性验证 qSOFA 作为死亡率预测指标，并比较新的脓毒症标准与之前标准的表现。 设计、地点和参与者：这是一项在法国、西班牙、比利时和瑞士进行的国际前瞻性队列研究，于 2016 年 5 月至 6 月在 30 家参与的急诊科进行。在这 30 家参与的急诊科中，对连续就诊的疑似感染患者进行了为期 4 周的前瞻性研究。收集了之前和新的脓毒症定义的所有变量。对患者进行了随访，直到出院或死亡。 暴露：qSOFA、SOFA 和 SIRS 的测量。 主要结果和措施：住院死亡率。 结果：在筛选出的 1088 名患者中，有 879 名患者纳入分析。中位年龄为 67 岁（四分位距，47-81 岁），414 名（47%）为女性，379 名（43%）患有呼吸道感染。总的住院死亡率为 8%：qSOFA 评分低于 2 分的患者死亡率为 3%，而 qSOFA 评分等于或高于 2 分的患者死亡率为 24%（绝对差异，21%；95%CI，15%-26%）。qSOFA 预测住院死亡率的表现优于 SIRS 和严重脓毒症，其接受者操作特征曲线（AUROC）下面积为 0.80（95%CI，0.74-0.85），而 SIRS 和严重脓毒症的 AUROC 分别为 0.65（95%CI，0.59-0.70）（P<0.001；增量 AUROC，0.15；95%CI，0.09-0.22）。qSOFA 评分与死亡的风险比为 6.2（95%CI，3.8-10.3），而严重脓毒症的风险比为 3.5（95%CI，2.2-5.5）。 结论和相关性：在急诊科就诊的疑似感染患者中，qSOFA 用于预测住院死亡率的预后准确性优于 SIRS 或严重脓毒症。这些发现为脓毒症和脓毒性休克第三次国际共识定义（Sepsis-3）在急诊科的应用提供了支持。 试验注册：clinicaltrials.gov 标识符：NCT02738164。
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