qSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock

Objectives: Sepsis is a common and deadly disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sequential [Sepsis-related] Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Methods: We retrospectively evaluated the sensitivity and specificity of a prehospital qSOFA score ≥ 2 for prehospital identification of patients with severe sepsis or septic shock. Emergency Department (ED) patients with confirmed or suspected infection were classified as having infection without sepsis (n = 71), sepsis (n = 38), or severe sepsis/septic shock (n = 43), where designation of severe sepsis/septic shock required evidence of end-organ dysfunction, hypoperfusion (lactate > 2), or vasopressor requirement. Results: We found that a prehospital qSOFA score ≥ 2 was 16.3% sensitive (95% CI 6.8–30.7%) and 97.3% specific (95% CI 92.1–99.4%) for patients ultimately confirmed to have severe sepsis/septic shock in the ED. Adding an additional point to the prehospital qSOFA score for a pulse > 100, nursing home residence, age > 50, or reported fever increased the sensitivity to 58.1% (95% CI 42.1–73.0%) and decreased the specificity to 78.0% (95% CI 69.0–85.4%). During their ED stay, approximately two-thirds of patients meeting severe sepsis/septic shock criteria eventually met qSOFA criteria with a sensitivity of 67.4% (95% CI 51.5–80.9) and specificity of 86.2% (95% CI 78.3–92). Failure to meet qSOFA criteria prehospital was predominantly due to a systolic blood pressure and respiratory rate that did not yet meet predetermined thresholds. Conclusions: These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.     

集束化治疗对严重脓毒症患者循环灌注和乳酸清除率的影响

目的:研究集束化治疗对综合ICU严重脓毒症患者循环灌注和乳酸清除率的影响.方法:将2007年10月至2009年12月我科收治的18岁以上严重脓毒症患者63例随机分配入集束化治疗组和对照组,观察两组患者心率(HR)、血压(BP)、中心静脉压(CVP)、中心静脉血氧饱和度(ScvO2)、动脉血乳酸(LAC)及乳酸清除率的变化.结果:集束化治疗组HR、SBP和DBP与对照组同期比较差异无统计学意义,但集束化治疗组入选后6 h CVP和ScvO2明显高于对照组同期,LAC明显低于对照组同期(P＜0.05),入选后24 h CVP和ScvO2仍高于对照组同期,LAC仍低于对照组同期,但仅LAC的变化差异具有统计学意义(P ＜ 0.05),集束化治疗组6 h和24 h乳酸清除率均明显高于对照组同期,差异具有统计学意义(P＜0.01).结论:集束化治疗可以明显改善严重脓毒症患者早期的循环灌注.     

血乳酸清除率指导脓毒症患者早期液体复苏的临床效果研究

目的：比较中心静脉血氧饱和度（ScvO2）与乳酸清除率指导脓毒症患者早期液体复苏的临床价值。方法选择2012年6月-2013年12月苏州大学附属第一医院重症医学科收治的60例脓毒症患者,将其随机分为乳酸清除组（A组）和ScvO2组（B组）,每组30例。观察和比较2组患者的复苏成功率、住ICU的时间、总住院时间及28 d病死率,并检测和比较死亡及存活的脓毒症患者入院时及入院后6、24、72 h的血清乳酸浓度。结果2组患者的复苏成功率、住ICU时间、住院时间和28 d病死率比较差异均无统计学意义（P＞0.05）。死亡的脓毒症患者入院时及入院后6、24、72 h的血乳酸浓度均显著高于存活的脓毒症患者,差异有统计学意义（P＜0.05）。结论血乳酸浓度可能用于预测脓毒症患者的预后,而血乳酸清除率用于指导脓毒症患者早期液体复苏的临床价值可堪比ScvO2。     

Limitations in Prehospital Communication Between Trauma Helicopter,Ambulance Services,and Dispatch Centers

Background

Prehospital communication with Emergency Medical Services (EMS) is carried out in hectic situations. Proper communication among all medical personal is required to enhance collaboration, to provide the best care and enable shared situational awareness.

Prehospital Electrocardiographic Manifestations of Acute Myocardial Ischemia Independently Predict Adverse Hospital Outcomes

Background

Prehospital electrocardiography (PH ECG) is becoming the standard of care for patients activating Emergency Medical Services for symptoms of acute coronary syndrome (ACS). Little is known about the prognostic value of ischemia found on PH ECG.

Objective

The purpose of this study was to determine whether manifestations of acute myocardial ischemia on PH ECG are predictive of adverse hospital outcomes.

Methods

This study was a retrospective analysis of all PH ECGs recorded in 630 patients who called 911 for symptoms of ACS and were enrolled in a prospective clinical trial. ST-segment monitoring software was added to the PH ECG device with automatic storage and transmission of ECGs to the destination Emergency Department. Patient medical records were reviewed for adverse hospital outcomes.

Results

In 630 patients who called 911 for ACS symptoms, 270 (42.9%) had PH ECG evidence of ischemia. Overall, 37% of patients with PH ECG ischemia had adverse hospital outcomes compared with 27% of patients without PH ECG ischemia (p < 0.05). Those with PH ECG ischemia were 1.55 times more likely to have adverse hospital outcomes than those without PH ECG ischemia (95% CI 1.09–2.21; p < 0.05), after controlling for other predictors of adverse hospital outcomes (i.e., age, sex, and medical history).

Conclusions

Evidence of ischemia on PH ECG is an independent predictor of adverse hospital outcomes. ST-segment monitoring in the prehospital setting can identify high-risk patients with symptoms of ACS and provide important prognostic information at presentation to the Emergency Department.     

早期动脉血乳酸清除率评估严重脓毒症患者预后的临床价值

目的：探讨早期动脉血乳酸清除率评估严重脓毒症患者预后的临床价值。方法：回顾性分析中山大学附属第一医院急诊科和河源市人民医院重症监护病房（ICU）68例严重脓毒症患者的临床资料,根据患者的预后情况将其分为存活组及死亡组,比较两组治疗6h后的血乳酸清除率。结果：存活组治疗6h后的血乳酸清除率显著高于死亡组,P〈0．05。结论：治疗6h后的动脉血乳酸清除率可有效地预测严重脓毒症患者的预后。     

院前急救对重型颅脑损伤病人预后的影响

目的:评价院前急救对重型颅脑损伤病人预后的影响。方法:回顾性分析我科2001年7月～2006年10月诊治的190例重型颅脑损伤病人的临床资料,其中102例经过院前急救入院(院前急救组),88例未经任何处理由家属直接送入医院(对照组)。对比两组病人伤后至入院的时间和伤后6个月的GOS评分、预后。结果:院前急救组病人伤后至入院时间平均时间为(20.2±10.3)min,预后为良好28例(27.5%),中残34例(33.3%),重残22例(21.6%),植物状态4例(3.9%),死亡14例(13.7%);而对照组伤后至入院时间平均时间为(60.4±14.5)min,预后为良好12例(13.6%),中残19例(21.6%),重残28例(31.8%),植物状态7例(8.0%),死亡22例(25.0%),两组治疗效果比较有显著性差异(P<0.05)。结论:院前急救为重型颅脑病人患者抢救赢得了时间,对于提高生存率与生存质量,改善预后具有重大意义。     

Prehospital response to respiratory distress by the public ambulance system in a Ukrainian city

BACKGROUND: The capability of the public ambulance system in Ukraine to address urgent medical complaints in a prehospital environment is unknown. Evaluation using reliable sources of patient data is needed to provide insight into current treatments and outcomes. METHODS: We obtained access to de-identified computer records from the emergency medical services (EMS) dispatch center in Poltava, a medium-sized city in central Ukraine. Covering a five-month period, we retrieved data for urgent calls with a patient complaint of respiratory distress. We evaluated ambulance response and treatment times, field diagnoses, and patient disposition, and analyzed factors related to fatal outcomes. RESULTS: Over the five-month period of the study, 2,029 urgent calls for respiratory distress were made to the Poltava EMS dispatch center. A physician-led ambulance typically responded within 10 minutes. Seventy-seven percent of patients were treated and released, twenty percent were taken to hospital, and three percent died in the prehospital phase. On univariate analysis, age over 60 and altered mental status at the time of the call were strongly associated with a fatal outcome. CONCLUSION: The EMS dispatch center in a medium-sized city in Ukraine has adequate organizational infrastructure to ensure that a physician-led public ambulance responds rapidly to complaints of respiratory distress. That EMS system was able to manage most patients without requiring hospital admission. However, a prehospital fatality rate of three percent suggests that further research is warranted to determine training, equipment, or procedural needs of the public ambulance system to manage urgent medical conditions.     

中心静脉导管相关性败血症病原菌的临床分析及处理

目的:探讨中心静脉导管相关性败血症(catheter-relatedsepsis,CRS)病人病原菌的分布特点及耐药情况。方法:对40例CRS病人的静脉导管尖端进行培养和药敏试验。结果:CRS常见的致病菌依次为革兰阳性球菌(32/45),真菌(8/45),革兰阴性杆菌(5/45)。革兰阳性球菌以表皮葡萄球菌为主,而且多数对苯唑西林耐药,万古霉素敏感率为100%,白色念珠菌为主要的致病真菌(7/8),革兰阴性杆菌常为耐药菌株。结论:CRS病原菌以革兰阳性球菌为主。CRS的有效处理方法是拔除感染的导管。     

集束化护理干预对严重脓毒症患者早期脱机及睡眠质量的影响

目的:探讨严重脓毒症患者予以集束化护理干预对早期脱机及睡眠质量的影响.方法:选取2016 年12月12日至2018年11月19日遵义医科大学第五附属(珠海)医院重症医学科收治的严重脓毒症患者63 例作为研究对象,按照抓阄法分为对照组(n=31)和观察组(n=32).对照组采用常规护理,观察组在常规护理的基础上联合集束化护理.比较2组的护理效果.结果:1)对照组的脱机失败率为19.35%,比观察组的3.43%高,差异有统计学意义(P<0.05);2)对照组的机械通气时间和ICU入住时间,均较观察组长,差异有统计学意义(P<0.05);3)观察组的睡眠质量评分比对照组低,差异有统计学意义(P<0.05).结论:严重脓毒症患者予以集束化护理干预,有助于其尽早脱机,改善睡眠质量.     

Prehospital Emergency Care in Shanghai: Present and Future

Background

In Shanghai, prehospital emergency medical services are provided by the public Ambulance Services. The 60th anniversary of the local Ambulance Services is a good opportunity to provide an overview of the current trends in prehospital emergency medical care in Shanghai.

Objectives

In this report, the features of Shanghai prehospital emergency medical care are described, as well as the Shanghai model of purely prehospital emergency medical care, including the communications and dispatch system, ambulance depots and ambulances, and prehospital rescue teams. Responses to major incidents including public health emergencies and natural disasters are also discussed, with the intention of highlighting future directions in emergency medical services, as well as the influence of international trends in emergency patient care.

Discussion

Although Shanghai has the most advanced dispatch system in China (equipped with a Global Positioning System, Global Information System, and more) and can be expanded quickly in case of mass casualty incidents, there is, as yet, no uniform Emergency Medical Service (EMS) dispatching for the entire city. Nor are there certifications, degrees, or special continuing education programs available for EMS dispatchers. Although there are more and more ambulance depots spread all over Shanghai, the city struggles with inadequate prehospital emergency caregivers, because every ambulance has to be staffed with a qualified Emergency Physician, and there are also recruitment problems for ambulance physicians.

Conclusions

Although faced with many challenges, substantial progress is expected in Shanghai prehospital emergency care.     

Lights and Siren Transport and the Need for Hospital Intervention in Trauma Patients

Emergent ambulance transportation is associated with increased risk of collision, injury, and death for EMS professionals, patients, and the general public. Time saved using lights and siren (L&S) is typically small, and often provides minimal clinical benefit. Our objective was to investigate the frequency of L&S transports, describe the precision of the decision to employ L&S to predict the need for a time critical hospital intervention (TCHI) within 15 minutes of hospital arrival, identify clinical predictors of a TCHI, and compare clinical outcomes in patients transported by Emergency Medical Services (EMS) with and without L&S in a trauma-specific population. EMS patient care reports and trauma registry data were retrospectively reviewed for trauma patients consecutively transported from the field by three EMS agencies to three trauma centers within urban and suburban settings over a two-year period. TCHIs were collaboratively developed by the study team. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were utilized to report the precision of the decision to employ L&S to predict the need of a TCHI. Univariate and multivariate analyses determined predictors of a TCHI and compared clinical outcomes. 2,091 patients were included in the study. Of the 19.8% of patients transported with L&S, 22.9% received a TCHI. The most common TCHI was airway or respiratory procedures (87.2% of all TCHI's). The sensitivity and specificity of L&S to predict the need for a TCHI was 87.2% (95% CI 79.4–92.8) and 84.0% (95% CI 82.2–85.5), respectively. PPV was 23.0% (95% CI 23.53–38.01); NPV was 99.2% (95% CI 98.6–99.6). L&S was predictive for the need for a TCHI (p < 0.001), as was abnormal Glasgow Coma Score (p < 0.001), abnormal systolic blood pressure and age (p < 0.05 for all). Among patients that received a TCHI, over a third that were transported with L&S (36.8%) expired, compared with two of 14 patients (14.3%) not transported L&S. EMS professionals in this study demonstrated a high ability to discern which trauma patients did not require L&S. Nevertheless, L&S transport resulted in a TCHI less than one quarter of the time, suggesting an opportunity for further reduction of L&S transports in trauma patients.     

Severe Sepsis in Do-not-resuscitate Patients: Intervention and Mortality Rates

Background

Severe sepsis is a high-mortality disease, and early resuscitation decreases mortality. Do-not-resuscitate (DNR) status may influence physician decisions beyond cardiopulmonary resuscitation, but this has not been investigated in sepsis.

Objective

Among Emergency Department (ED) severe sepsis patients, define the incidence of DNR status, prevalence of central venous catheter placement, and vasopressor administration (invasive measures), and mortality.

Methods

Retrospective observational cohort of consecutive severe sepsis patients to single ED in 2009–2010. Charts abstracted for DNR status on presentation, demographics, vitals, Sequential Organ Failure Assessment (SOFA) score, inpatient and 60-day mortality, and discharge disposition. Primary outcomes were mortality, discharge to skilled nursing facility (SNF), and invasive measure compliance. Chi-squared test was used for univariate association of DNR status and outcome variables; multivariate logistic regression analyses for outcome variables controlling for age, gender, SOFA score, and DNR status.

Results

In 376 severe sepsis patients, 50 (13.3%) had DNR status. DNR patients were older (79.2 vs 60.3 years, p < 0.001) and trended toward higher SOFA scores (7 vs. 6, p = 0.07). DNR inpatient and 60-day mortalities were higher (50.5% vs. 19.6%, 95% confidence interval [CI] 15.9–44.9%; 64.0% vs. 24.9%, 95% CI 25.1–53.3%, respectively), and remained higher in multivariate logistic regression analysis (odds ratio [OR] 3.01, 95% CI 1.48–6.17; OR 3.80, 95% CI 1.88–7.69, respectively). The groups had similar rates of discharge to SNF, and in persistently hypotensive patients (n = 326) had similar rates of invasive measures in univariate and multivariate analyses (OR 1.19, 95% CI 0.45–3.15).

Conclusion

In this sample, 13.3% of severe sepsis patients had DNR status, and 50% of DNR patients survived to hospital discharge. DNR patients received invasive measures at a rate similar to patients without DNR status.     

腹部重症脓毒症老年患者术后免疫球蛋白及补体的变化

目的术创伤、脓毒症均可通过多种途径影响机体的免疫功能,本文通过对腹部重症脓毒症患者机体免疫指标（免疫球蛋白及补体IgA、IgG、IgM、C3、C4,为重症脓毒症患者免疫治疗及各免疫指标的变化对严重脓毒症患者预后的影响提供参考。方法将20例腹部无明显感染的患者、15例腹部脓毒症患者不伴器官功能障碍、12例腹部严重脓毒症及脓毒性休克患者分为A、B、C组,A、B、C组术后第1、3、7天,各抽取外周静脉血5ml于普通试管,测定免疫球蛋白及补体（IgA、IgG、IgM、C3、CA）。同时记录生命体征的变化和预后转归。结果A组与术前比较,免疫球蛋白在第1天IgA、IgM、IgG,C3、C4均下降,IgA、IgM与术前比较,差异有显著性（P〈0．05）,而补体C3在第1天明显下降,与术前、术后第7天相比差异均具有显著性（P〈0．05）,C4下降不明显,无统计学意义（P〉0．05）,A、B两组术后第1、3、7天IgA、IgG、IgM、C3、CA均无显著统计学差异（P〉0．05）,第1、3、7天C组IgA、IgM、IgG、C3、CA均低,与A、B两组相比较明显降低,具有统计学意义（P〈0．05）。结论手术创伤对免疫球蛋白影响不大。对于术后重症脓毒症及脓毒性休克患者IgA、IgM、IgG,C3、CA明显降低,且随病情恶化,持续在较低水平。     

Impact of Sepsis Bundle Strategy on Outcomes of Patients Suffering from Severe Sepsis and Septic Shock in China

Background

It is well known that poor sepsis outcomes are related to delays in diagnosis and treatment.

Objectives

The aim of this study was to compare the mortality rate between two groups of patients, one group presenting before and one group presenting after implementation of the Surviving Sepsis Campaign (SSC) sepsis performance improvement bundles in the Emergency Department (ED).

Methods

This was a prospective study. The studied population included severe sepsis and septic shock patients entered in the SSC database who were admitted to the ED between June 2008 and December 2009. Patients were divided into two groups based on when they presented to the ED. Key treatment interventions, admission to the intensive care unit, and in-hospital mortality were compared. In addition, a survey was completed by the treating physicians to identify reasons for failures to comply with indicators.

Results

One hundred ninety-five (195) patients with severe sepsis and septic shock were enrolled in the study. Mortality was significantly higher at 44.8% in the baseline group (Group 1) compared to 31.6% in the group studied after the SSC protocol was instituted (Group 2) (p < 0.05). Compliance with all elements of the sepsis resuscitation bundle was 1% in Group 1 and 9% in Group 2 (p < 0.05). Compliance with all elements of the management bundle was 1% in Group 1 and 12.8% in Group 2. The most frequently reported reasons by physicians for failure to comply with the bundles were: “did not think it was needed” and “unsure of reason.”

Conclusion

The results revealed a significant drop in mortality after implementing the SSC protocol and sepsis performance improvement bundles in the ED. The barriers to implementing sepsis guidelines are knowledge, attitude, and behavioral barriers.     

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma

Background

The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care.

Tissue Oxygenation Does Not Predict Central Venous Oxygenation in Emergency Department Patients With Severe Sepsis and Septic Shock

Objectives: This study sought to determine whether tissue oxygenation (StO₂) could be used as a surrogate for central venous oxygenation (ScVO₂) in early goal‐directed therapy (EGDT). Methods: The study enrolled a prospective convenience sample of patients aged ≥18 years with sepsis and systolic blood pressure <90 mm Hg after 2 L of normal saline or lactate >4 mmol, who received a continuous central venous oximetry catheter. StO₂ and ScVO₂ were measured at 15‐minute intervals. Data were analyzed using a random coefficients model, correlations, and Bland‐Altman plots. Results: There were 284 measurements in 40 patients. While a statistically significant relationship existed between StO₂ and ScVO₂ (F(1,37) = 10.23, p = 0.002), StO₂ appears to systematically overestimate at lower ScVO₂ and underestimate at higher ScVO₂. This was reflected in the fixed effect slope of 0.49 (95% confidence interval [CI] = 0.266 to 0.720) and intercept of 34 (95% CI = 14.681 to 50.830), which were significantly different from 1 and 0, respectively. The initial point correlation (r = 0.5) was fair, but there was poor overall agreement (bias = 4.3, limits of agreement = ?20.8 to 29.4). Conclusions: Correlation between StO₂ and ScVO₂ was fair. The two measures trend in the same direction, but clinical use of StO₂ in lieu of ScVO₂ is unsubstantiated due to large and systematic biases. However, these biases may reflect real physiologic states. Further research may investigate if these measures could be used in concert as prognostic indicators. ACADEMIC EMERGENCY MEDICINE 2010; 17:349–352 © 2010 by the Society for Academic Emergency Medicine