头对头比较 qSOFA 和 SIRS 标准在预测急诊科感染患者死亡率中的作用：一项荟萃分析。

BACKGROUND: Recently, the concept of sepsis was redefined by an international task force. This international task force of experts recommended using the quick Sequential Organ Failure Assessment (qSOFA) criteria instead of the systemic inflammatory response syndrome (SIRS) criteria to classify patients at high risk for death. However, the added value of these new criteria in the emergency department (ED) remains unclear. Thus, we performed this meta-analysis to determine the diagnostic accuracy of the qSOFA criteria in predicting mortality in ED patients with infections and compared the performance with that of the SIRS criteria. METHODS: PubMed, EMBASE and Google Scholar (up to April 2018) were searched for related articles. A 2 × 2 contingency table was constructed according to mortality and qSOFA score (< 2 and ≥ 2) or SIRS score (< 2 and ≥ 2) in ED patients with infections. Two investigators independently assessed study eligibility and extracted data. We used a bivariate meta-analysis model to determine the prognostic value of qSOFA and SIRS in predicting mortality. We used the I index to test heterogeneity. The bivariate random-effects regression model was used to pool the individual sensitivity, specificity, diagnostic odds ratio (DOR), positive likelihood ratio (PLR), and negative likelihood ratio (NLR). The summary receiver operating characteristic curve (SROC) was constructed to assess the overall diagnostic accuracy. RESULTS: Eight studies with a total of 52,849 patients were included. A qSOFA score ≥ 2 was associated with a higher risk of mortality in ED patients with infections, with a pooled risk ratio (RR) of 4.55 (95% CI, 3.38-6.14) using a random-effects model (I = 91.1%). A SIRS score ≥ 2 was a prognostic marker of mortality in ED patients with infections, with a pooled RR of 2.75 (95% CI, 1.96-3.86) using a random-effects model (I = 89%). When comparing the performance of qSOFA and SIRS in predicting mortality, a qSOFA score ≥ 2 was more specific; however a SIRS score ≥ 2 was more sensitive. The initial qSOFA values were of limited prognostic value in ED patients with infections. CONCLUSIONS: A qSOFA score ≥ 2 and SIRS score ≥ 2 are strongly associated with mortality in ED patients with infections. However, it is also clear that qSOFA and SIRS have limitations as risk stratification tools for ED patients with infections.

背景：最近，一个国际专家组重新定义了脓毒症的概念。该国际专家组建议使用快速序贯器官衰竭评估（qSOFA）标准代替全身炎症反应综合征（SIRS）标准来对高死亡风险的患者进行分类。然而，这些新标准在急诊室（ED）中的附加值尚不清楚。因此，我们进行了这项荟萃分析，以确定 qSOFA 标准在预测 ED 感染患者死亡率方面的诊断准确性，并将其与 SIRS 标准的性能进行比较。

方法：检索了 PubMed、EMBASE 和 Google Scholar（截至 2018 年 4 月）中与感染性 ED 患者 qSOFA 评分（<2 分和≥2 分）或 SIRS 评分（<2 分和≥2 分）与死亡率相关的文章。根据 ED 感染患者的死亡率和 qSOFA 评分（<2 分和≥2 分）或 SIRS 评分（<2 分和≥2 分）构建 2×2 四格表。两位研究者独立评估研究纳入标准并提取数据。我们使用双变量荟萃分析模型来确定 qSOFA 和 SIRS 在预测死亡率方面的预后价值。我们使用 I 指数来检验异质性。采用双变量随机效应回归模型汇总个体的灵敏度、特异度、诊断比值比（DOR）、阳性似然比（PLR）和阴性似然比（NLR）。绘制汇总受试者工作特征曲线（SROC）以评估总体诊断准确性。

结果：共纳入 8 项研究，总计 52849 例患者。qSOFA 评分≥2 与 ED 感染患者的死亡风险增加相关，使用随机效应模型时汇总风险比（RR）为 4.55（95%CI，3.38-6.14）（I=91.1%）。SIRS 评分≥2 是 ED 感染患者死亡的预后标志物，使用随机效应模型时 RR 为 2.75（95%CI，1.96-3.86）（I=89%）。比较 qSOFA 和 SIRS 在预测死亡率方面的性能时，qSOFA 评分≥2 具有更高的特异性，而 SIRS 评分≥2 具有更高的敏感性。在 ED 感染患者中，初始 qSOFA 值的预后价值有限。

结论：qSOFA 评分≥2 和 SIRS 评分≥2 与 ED 感染患者的死亡率密切相关。然而，也很明显，qSOFA 和 SIRS 在作为 ED 感染患者的风险分层工具方面存在局限性。