开发一种新的儿科脓毒性休克筛查工具。

Development of a New Screening Tool for Pediatric Septic Shock.

机构信息

Division of Emergency Medicine, Boston Children's Hospital, Boston MA.

Division of Emergency Medicine, Lurie Children's Hospital, Chicago IL.

出版信息

Ann Emerg Med. 2024 Dec;84(6):642-650. doi: 10.1016/j.annemergmed.2024.06.026. Epub 2024 Aug 1.

DOI:10.1016/j.annemergmed.2024.06.026

PMID:39093249

Abstract

STUDY OBJECTIVE

Existing screening tools for sepsis in children are limited by suboptimal sensitivity. Our objective was to develop a new, more sensitive screening tool for pediatric septic shock by enhancing 2 aspects of the 4-point Liverpool quick Sequential Organ Failure Assessment (LqSOFA) tool.

METHODS

We performed a secondary analysis of a cohort of children (1 month to 18 years) who presented to a pediatric emergency department (ED) with suspected infection over a 10-year period. Septic shock was defined as intravenous vasoactive infusion within 24-hours of arrival for children with suspected infection and intravenous antibiotics administered. We developed the 4-point quick Pediatric Septic Shock Screening Score (qPS4) by making 2 changes to the 4-point LqSOFA: (1) the pulse rate parameter was replaced with the recently derived Temperature and Age-adjusted Mean Shock Index and (2) standard respiratory rate cutoffs for tachypnea were replaced by cutoffs derived empirically from the study cohort. The other 2 LqSOFA criteria were unchanged (abnormal mentation and capillary refill ≥3 seconds). We defined a positive qPS4 as ≥2 criteria (consistent with LqSOFA). We used the training cohort from the parent study to derive cutoffs for respiratory rate and the validation cohort to compare the qPS4 with LqSOFA and qSOFA.

RESULTS

Among the 47,231 encounters in the validation cohort from the parent study, with median age of 4.5 years, qPS4 had an area under the receiver operating characteristic curve for septic shock of 0.94 (95% confidence interval [CI] 0.92 to 0.96). qPS4 ≥2 had a sensitivity of 89.7% (95% CI 84.9% to 94.5%), and a specificity of 92.2% (95% CI 92.0% to 92.5%) for septic shock. In comparison, the LqSOFA achieved an area under the receiver operating characteristic curve of 0.86 (95% CI 0.82 to 0.89), a sensitivity of 56.1% (95% CI 48.3% to 63.9%), and a specificity of 96.8% (95% CI 96.6% to 96.9%). The median time from first positive qPS4 to initiation of an intravenous vasoactive infusion was 2.5 hours (IQR 0.9 to 6.1) compared to 0.7 hours (IQR 0.0 to 4.5) for LqSOFA.

CONCLUSION

The qPS4, with 2 enhancements to the LqSOFA, demonstrated overall improved sensitivity and specificity for pediatric septic shock.

摘要

研究目的

现有的儿童脓毒症筛查工具存在敏感性不佳的局限性。我们的目标是通过增强利物浦快速序贯器官衰竭评估（LqSOFA）工具的两个方面来开发一种新的、更敏感的儿科感染性休克筛查工具。

方法

我们对在 10 年期间因疑似感染就诊于儿科急诊室的儿童（1 个月至 18 岁）队列进行了二次分析。感染性休克的定义为疑似感染患儿入院后 24 小时内静脉使用血管活性药物和静脉使用抗生素。我们通过对 4 点 LqSOFA 进行两项更改来开发 4 点快速儿科感染性休克筛查评分（qPS4）：（1）用最近推导的体温和年龄校正平均休克指数替代脉搏率参数，（2）用从研究队列中推导出来的临界值替代标准呼吸频率的呼吸过速临界值。其他 2 个 LqSOFA 标准保持不变（意识状态异常和毛细血管再充盈时间≥3 秒）。我们将 qPS4 阳性定义为≥2 个标准（与 LqSOFA 一致）。我们使用来自母研究的训练队列来确定呼吸率的临界值，并使用验证队列来比较 qPS4 与 LqSOFA 和 qSOFA。

结果

在母研究的验证队列中，共有 47231 次就诊，中位年龄为 4.5 岁，qPS4 对感染性休克的受试者工作特征曲线下面积为 0.94（95%置信区间 0.92 至 0.96）。qPS4≥2 对感染性休克的敏感性为 89.7%（95%置信区间 84.9%至 94.5%），特异性为 92.2%（95%置信区间 92.0%至 92.5%）。相比之下，LqSOFA 的受试者工作特征曲线下面积为 0.86（95%置信区间 0.82 至 0.89），敏感性为 56.1%（95%置信区间 48.3%至 63.9%），特异性为 96.8%（95%置信区间 96.6%至 96.9%）。首次 qPS4 阳性至静脉使用血管活性药物的中位时间为 2.5 小时（IQR 0.9 至 6.1），而 LqSOFA 为 0.7 小时（IQR 0.0 至 4.5）。