Gadrey Shrirang M, Clay Russ, Zimmet Alex N, Lawson Alexander S, Oliver Samuel F, Richardson Emily D, Forrester Vernon J, Andris Robert T, Rhodes Garret T, Voss John D, Moore Christopher C, Moorman J Randall
Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA.
Center for Advanced Medical Analytics, University of Virginia, Charlottesville, VA.
Crit Care Explor. 2020 Sep 25;2(10):e0199. doi: 10.1097/CCE.0000000000000199. eCollection 2020 Oct.
The Sepsis-3 taskforce defined sepsis as suspicion of infection and an acute rise in the Sequential Organ Failure Assessment score by 2 points over the preinfection baseline. Sepsis-3 studies, though, have not distinguished between acute and chronic organ failure, and may not accurately reflect the epidemiology, natural history, or impact of sepsis. Our objective was to determine the extent to which the predictive validity of Sepsis-3 is attributable to chronic rather than acute organ failure.
Retrospective cohort study.
General medicine inpatient service at a tertiary teaching hospital.
A total of 3,755 adult medical acute-care encounters (1,864 confirmed acute infections) over 1 year.
None.
We measured the total Sequential Organ Failure Assessment score at the onset of infection and separated its components (baseline and acute rise) using case-by-case chart reviews. We compared the predictive validities of acuity-focused (acute rise in Sequential Organ Failure Assessment ≥ 2) and conventional (total Sequential Organ Failure Assessment ≥ 2) implementations of Sepsis-3 criteria. Measures of predictive validity were change in the rate of outcomes and change in the area under receiver operating characteristic curves after adding sepsis criteria to multivariate logistic regression models of baseline risk (age, sex, race, and Charlson comorbidity index). Outcomes were inhospital mortality (primary) and ICU transfer or inhospital mortality (secondary). Acuity-focused implementations of Sepsis-3 were associated with neither a change in mortality (2.2% vs 1.2%; = 0.18) nor a rise in area under receiver operating characteristic curves compared with baseline models (0.67 vs 0.66; = 0.75). In contrast, conventional implementations were associated with a six-fold change in mortality (2.4% vs 0.4%; = 0.01) and a rise in area under receiver operating characteristic curves compared with baseline models (0.70 vs 0.66; = 0.04). Results were similar for the secondary outcome.
The evaluation of the validity of organ dysfunction-based clinical sepsis criteria is prone to bias, because acute organ dysfunction consequent to infection is difficult to separate from preexisting organ failure in large retrospective cohorts.
脓毒症-3工作组将脓毒症定义为怀疑感染且序贯器官衰竭评估（SOFA）评分较感染前基线水平急性升高2分。然而，脓毒症-3的研究并未区分急性和慢性器官衰竭，可能无法准确反映脓毒症的流行病学、自然史或影响。我们的目的是确定脓毒症-3的预测效度在多大程度上归因于慢性而非急性器官衰竭。
回顾性队列研究。
一家三级教学医院的普通内科住院服务。
1年内共3755例成人内科急性护理病例（1864例确诊急性感染）。
无。
我们在感染发作时测量了SOFA总分，并通过逐例查阅病历将其组成部分（基线和急性升高）分开。我们比较了以急性程度为重点（SOFA急性升高≥2）和传统（SOFA总分≥2）的脓毒症-3标准实施方式的预测效度。预测效度的衡量指标是在将脓毒症标准添加到基线风险（年龄、性别、种族和查尔森合并症指数）的多变量逻辑回归模型后，结局发生率的变化和受试者工作特征曲线下面积的变化。结局指标为住院死亡率（主要）和ICU转入或住院死亡率（次要）。与基线模型相比，以急性程度为重点的脓毒症-3实施方式与死亡率变化无关（2.2%对1.2%；P=0.18），受试者工作特征曲线下面积也未增加（0.67对0.66；P=0.75）。相比之下，传统实施方式与死亡率变化六倍相关（2.4%对0.4%；P=0.01），受试者工作特征曲线下面积较基线模型增加（0.70对0.66；P=0.04）。次要结局的结果相似。
基于器官功能障碍的临床脓毒症标准的效度评估容易产生偏差,因为在大型回顾性队列中，感染导致的急性器官功能障碍难以与既往存在的器官衰竭区分开来。
