SỬ DỤNG THANG ĐIỂM Q SOFA & SIRS TRONG CHẨN ĐOÁN VÀ TIÊN LƯỢNG MỨC ĐỘ NẶNG Ở BỆNH NHÂN NHIỄM KHUẨN

(3) Sepsis criteria better at diagnosing infection; Q Sofa better at prediocting mortality. (4) A combined score may have synergies[r]

Utility of Q SOFA & SIRS Criteria for diagnosis of Sepsis & Prediction of

Mortality

William T McGee, M.D MHA, FCCM, FCCP

Critical Care Medicine Associate Professor of Medicine and Surgery

University of Massachusetts

759 Chestnut Street, Springfield, MA 01199 Tel: 413-794-5439 | Fax: 413-794-3987 william.mcgee@baystatehealth.org

 55 y/o morbidly obese (138 kg) male

 cc: severe abdominal pain for ~2 days

 (+) anorexia, nausea and dysuria

 T 101.5°F, BP 134/68, HR 110, RR 20, 98% on room air (+) dry mucous membranes, tachycardia, diffuse lower abd pain

 Basic labs, an iv line and crystalloid fluids - wide open

 WBC 23K , no bands, lactate of 4 mmol/L

 Urine analysis urinary tract infection

 All other labs are unremarkable

 Appropriate antibiotics are started

 Discharged home on HD 3

Case

Kalantari - West J Emerg Med 2017

National Hospital Discharge Database

Source: CDC.org

Confusion RR≥22 SBP ≤100

qSOFA

qSOFA fails validation

Churpek MM - Am J Respir Crit Care Med 2017

Modified from criteria published in:

Balk, R., Crit Care Clinics 2000; 16:337-351;

Kleinpell, R Crit Care Nurs Clin N Am 2003; 15:27-34.

Cardiovascular: Tachycardia Hypotension Altered CVP & PAOP

Renal:

Oliguria Anuria

Identifying Acute Organ Dysfunction

as a Marker of (Severe) Sepsis

Sepsis Mortality Increases with

the Number of Organ Dysfunctions

Angus DC, et al Crit Care Med 2001;29:1303-1310

A Comparison of the Quick-SOFA and Systemic Inflammatory Response Syndrome Criteria for the Diagnosis of Sepsis and

Prediction of Mortality

Rodrigo Serafim, MD, José Andrade Gomes, MD, Jorge

Salluh, MD, PhD, Pedro Póvoa, MD, PhD

Figure 1

CHEST 2018 153, 646-655DOI: (10.1016/j.chest.2017.12.015)

Copyright © 2017 American College of Chest Physicians Terms and Conditions

Figure 4

CHEST 2018 153, 646-655DOI: (10.1016/j.chest.2017.12.015)

Copyright © 2017 American College of Chest Physicians Terms and Conditions

Figure 5

CHEST 2018 153, 646-655DOI: (10.1016/j.chest.2017.12.015)

Copyright © 2017 American College of Chest Physicians Terms and Conditions

Quick score q Sofa

https://www.mdcalc.com/qsofa-quick-sofa-score-sepsis

Lactate controversy

 55 y/o morbidly obese (138 kg) male

 cc: severe abdominal pain for ~2 days

 (+) anorexia, nausea and dysuria

 T 101.5°F, BP 134/68, HR 110, RR 20, 98% on room air (+) dry mucous membranes, tachycardia, diffuse lower abd pain

 Basic labs, an iv line and crystalloid fluids - wide open

 WBC 23K , no bands, lactate of 4 mmol/L

 Urine analysis urinary tract infection

 All other labs are unremarkable

 Appropriate antibiotics are started

 Discharged home on HD 3

Case

Kalantari - West J Emerg Med 2017

Serum Lactate as a Predictor of Mortality in Emergency

Department Patients with Infection

 Prospective cohort study, urban ED

 1,278 consecutive patients

 Inclusion criteria: ≥18 years, serum lactate level

obtained, admission with infection-related diagnosis

Shapiro, N., Ann of Emer Med 2005; 45:524-528

Lactate (mmol/L)

28-day in-hospital mortality, % 4.9 9.0 28.4

Nguyen HB - Crit Care Med 2004 Aug;32(8):1637-42.

DO2 = SV x HR x (Hb x 1.39 x SaO2 + paO2 x 0.0003)

Oxygen delivery equation

Lactate production

Marik PE, Bellomo R OA Critical Care 2013

Epinephrine and lactate

James JH - Lancet 1999 ;354(9177):505-8.

(1) Elevated lactate in septic shock is not (ALWAYS) due to anaerobic metabolism

(2) Elevated lactate in septic shock is also due to

stimulation of beta-2 adrenergic receptors

(3) Lactate clearance in shock is a good marker of

successful resuscitation and persistence is correlated with Death

using-it-to-our-advantage/

https://emcrit.org/pulmcrit/understanding-lactate-in-sepsis-Lactate can help guide

resuscitation

• We suggest guiding resuscitation to

normalize lactate in patients with elevated lactate levels as a marker of tissue

hypoperfusion

(Weak recommendation; low quality of

evidence)

(1) Elevated lactate needs to be corrected or your patient will die

(2) Systemic organ dysfunction is correlated with Death

ARDS; AKI ( dialysis )

(3) Sepsis criteria better at diagnosing infection; Q Sofa

better at prediocting mortality

(4) A combined score may have synergies!

Key points

using-it-to-our-advantage/