Henning Daniel J, Puskarich Michael A, Self Wesley H, Howell Michael D, Donnino Michael W, Yealy Donald M, Jones Alan E, Shapiro Nathan I
Division of Emergency Medicine, University of Washington, Seattle, WA.
Department of Emergency Medicine, University of Mississippi, Jackson, MS.
Ann Emerg Med. 2017 Oct;70(4):544-552.e5. doi: 10.1016/j.annemergmed.2017.01.008. Epub 2017 Mar 3.
STUDY OBJECTIVE: The Third International Consensus Definitions Task Force (SEP-3) proposed revised criteria defining sepsis and septic shock. We seek to evaluate the performance of the SEP-3 definitions for prediction of inhospital mortality in an emergency department (ED) population and compare the performance of the SEP-3 definitions to that of the previous definitions. METHODS: This was a secondary analysis of 3 prospectively collected, observational cohorts of infected ED subjects aged 18 years or older. The primary outcome was all-cause inhospital mortality. In accordance with the SEP-3 definitions, we calculated test characteristics of sepsis (quick Sequential Organ Failure Assessment [qSOFA] score ≥2) and septic shock (vasopressor dependence plus lactate level >2.0 mmol/L) for mortality and compared them to the original 1992 consensus definitions. RESULTS: We identified 7,754 ED patients with suspected infection overall; 117 had no documented mental status evaluation, leaving 7,637 patients included in the analysis. The mortality rate for the overall population was 4.4% (95% confidence interval [CI] 3.9% to 4.9%). The mortality rate for patients with qSOFA score greater than or equal to 2 was 14.2% (95% CI 12.2% to 16.2%), with a sensitivity of 52% (95% CI 46% to 57%) and specificity of 86% (95% CI 85% to 87%) to predict mortality. The original systemic inflammatory response syndrome-based 1992 consensus sepsis definition had a 6.8% (95% CI 6.0% to 7.7%) mortality rate, sensitivity of 83% (95% CI 79% to 87%), and specificity of 50% (95% CI 49% to 51%). The SEP-3 septic shock mortality was 23% (95% CI 16% to 30%), with a sensitivity of 12% (95% CI 11% to 13%) and specificity of 98.4% (95% CI 98.1% to 98.7%). The original 1992 septic shock definition had a 22% (95% CI 17% to 27%) mortality rate, sensitivity of 23% (95% CI 18% to 28%), and specificity of 96.6% (95% CI 96.2% to 97.0%). CONCLUSION: Both the new SEP-3 and original sepsis definitions stratify ED patients at risk for mortality, albeit with differing performances. In terms of mortality prediction, the SEP-3 definitions had improved specificity, but at the cost of sensitivity. Use of either approach requires a clearly intended target: more sensitivity versus specificity.
研究目的：第三届国际共识定义特别工作组（SEP - 3）提出了修订后的脓毒症和脓毒性休克定义标准。我们旨在评估SEP - 3定义在急诊科（ED）人群中预测住院死亡率的性能，并将SEP - 3定义的性能与先前定义的性能进行比较。 方法：这是对3个前瞻性收集的、年龄在18岁及以上的感染性ED受试者观察队列的二次分析。主要结局是全因住院死亡率。根据SEP - 3定义，我们计算了脓毒症（快速序贯器官衰竭评估[qSOFA]评分≥2）和脓毒性休克（血管活性药物依赖加乳酸水平>2.0 mmol/L）的死亡率测试特征，并将其与1992年的原始共识定义进行比较。 结果：我们共识别出7754例疑似感染的ED患者；117例未记录精神状态评估，最终纳入分析的患者有7637例。总体人群的死亡率为4.4%（95%置信区间[CI] 3.9%至4.9%）。qSOFA评分大于或等于2的患者死亡率为14.2%（95% CI 12.2%至16.2%），预测死亡率的敏感性为52%（95% CI 46%至57%），特异性为86%（95% CI 85%至87%）。基于1992年原始全身炎症反应综合征的共识性脓毒症定义的死亡率为6.8%（95% CI 6.0%至7.7%），敏感性为83%（95% CI 79%至87%），特异性为50%（95% CI 49%至51%）。SEP - 3脓毒性休克死亡率为23%（95% CI 16%至30%），敏感性为12%（95% CI 11%至13%），特异性为98.4%（95% CI 98.1%至98.7%）。1992年原始脓毒性休克定义的死亡率为22%（95% CI 17%至27%），敏感性为23%（95% CI 18%至28%），特异性为96.6%（95% CI 96.2%至97.0%）。 结论：新的SEP - 3定义和原始脓毒症定义均对有死亡风险的ED患者进行了分层，尽管性能有所不同。在死亡率预测方面，SEP - 3定义提高了特异性，但以敏感性为代价。使用任何一种方法都需要明确的目标：更高的敏感性还是特异性。
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