Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Crit Care Med. 2018 Dec;46(12):1906-1913. doi: 10.1097/CCM.0000000000003360.
Among patients with suspected infection, a single measurement of the quick Sepsis-related Organ Failure Assessment has good predictive validity for sepsis, yet the increase in validity from repeated measurements is unknown. We sought to determine the incremental predictive validity for sepsis of repeated quick Sepsis-related Organ Failure Assessment measurements over 48 hours compared with the initial measurement.
Retrospective cohort study.
Twelve hospitals in southwestern Pennsylvania in 2012.
All adult medical and surgical encounters in the emergency department, hospital ward, postanesthesia care unit, and ICU.
None.
Among 1.3 million adult encounters, we identified those with a first episode of suspected infection. Using the maximum quick Sepsis-related Organ Failure Assessment score in each 6-hour epoch from onset of suspected infection until 48 hours later, we characterized repeated quick Sepsis-related Organ Failure Assessment with: 1) summary measures (e.g., mean over 48 hr), 2) crude trajectory groups, and 3) group-based trajectory modeling. We measured the predictive validity of repeated quick Sepsis-related Organ Failure Assessment using incremental changes in the area under the receiver operating characteristic curve for in-hospital mortality beyond that of baseline risk (age, sex, race/ethnicity, and comorbidity). Of 37,591 encounters with suspected infection, 1,769 (4.7%) died before discharge. Both the mean quick Sepsis-related Organ Failure Assessment at 48 hours (area under the receiver operating characteristic, 0.86 [95% CI, 0.85-0.86]) and crude trajectory groups (area under the receiver operating characteristic, 0.83 [95% CI, 0.83-0.83]) improved predictive validity compared with initial quick Sepsis-related Organ Failure Assessment (area under the receiver operating characteristic, 0.79 [95% CI, 0.78-0.80]) (p < 0.001 for both). Group-based trajectory modeling found five trajectories (quick Sepsis-related Organ Failure Assessment always low, increasing, decreasing, moderate, and always high) with greater predictive validity than the initial measurement (area under the receiver operating characteristic, 0.85 [95% CI, 0.84-0.85]; p < 0.001).
Repeated measurements of quick Sepsis-related Organ Failure Assessment improve predictive validity for sepsis using in-hospital mortality compared with a single measurement of quick Sepsis-related Organ Failure Assessment at the time a clinician suspects infection.
在疑似感染患者中，快速全身性感染相关器官衰竭评估（quick Sepsis-related Organ Failure Assessment，qSOFA）单次测量对脓毒症具有良好的预测价值，但重复测量的有效性增加尚不清楚。我们旨在确定与初始测量相比，在 48 小时内重复快速全身性感染相关器官衰竭评估测量对脓毒症的预测价值是否具有增量预测价值。
回顾性队列研究。
2012 年宾夕法尼亚州西南部的 12 家医院。
急诊科、病房、麻醉后护理单位和 ICU 的所有成年医疗和外科就诊患者。
无。
在 130 万成年患者就诊中，我们确定了首次疑似感染的患者。使用从疑似感染开始到 48 小时后每个 6 小时时相的最大快速全身性感染相关器官衰竭评估评分，我们使用以下方法描述了重复快速全身性感染相关器官衰竭评估：1）总结测量值（例如，48 小时的平均值），2）原始轨迹组，和 3）基于群组的轨迹建模。我们使用医院死亡率的接受者操作特征曲线下面积的增量变化来测量重复快速全身性感染相关器官衰竭评估的预测价值，该变化超过了基线风险（年龄、性别、种族/民族和合并症）。在 37591 例疑似感染患者中，有 1769 例（4.7%）在出院前死亡。48 小时时的平均快速全身性感染相关器官衰竭评估（接受者操作特征曲线下面积，0.86 [95%置信区间，0.85-0.86]）和原始轨迹组（接受者操作特征曲线下面积，0.83 [95%置信区间，0.83-0.83]）均优于初始快速全身性感染相关器官衰竭评估（接受者操作特征曲线下面积，0.79 [95%置信区间，0.78-0.80]）（均 p<0.001）。基于群组的轨迹建模发现了五个轨迹（快速全身性感染相关器官衰竭评估始终较低、增加、减少、中等和始终较高），其预测价值优于初始测量（接受者操作特征曲线下面积，0.85 [95%置信区间，0.84-0.85]；p<0.001）。
与临床医生怀疑感染时的单次快速全身性感染相关器官衰竭评估相比，使用住院死亡率对疑似感染患者进行重复快速全身性感染相关器官衰竭评估可提高脓毒症的预测价值。
