Acil serviste sepsis tanı, mortalite ve morbiditesinin belirlenmesinde hızlı sepsis ilişkili organ yetmezliği değerlendirme, sistemik inflamatuar yanıt sendromu, ulusal erken uyarı skorlarının karşılaştırılması
Yükleniyor...
Dosyalar
Tarih
2019
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Amaç Bu çalışmada acil servise enfeksiyon şüphesiyle başvuran ve/veya acil servis takibi esnasında enfeksiyon şüphesiyle antibiyoterapi başlanan ya da kültür alınan hastaların giriş qSOFA, SIRS, NEWS skorlarının ; altın standart SOFA skoruna göre sepsis/septik şok tanısı , erken ve geç dönem mortalite , morbidite açısından karşılaştırılması amaçlandı. Yöntem Ege Üniversitesi Acil Servisine enfeksiyon şüphesiyle başvuran ve/veya acil servis takibi esnasında enfeksiyon şüphesiyle antibiyoterapi başlanan ya da kültür alınan hastalara altın standart olarak SOFA skoruna göre sepsis tanısı konuldu. Hastaların geliş qSOFA, SIRS, NEWS skorları hesaplandı. Sepsis tanısı alan hastalarda inotrop ihtiyacı ya da laktat yüksekliği varsa septik şok tanısı konuldu. Sepsis ve sepsis şok insidansı hesaplandı ve bu skorlama sistemleri tanı koyma, erken ve geç mortalite , morbidite ve güvenli taburculuk açısından karşılaştırıldı. Çalışmamızda sepsis/septik şok tanısında Ki-Kare , T-Test , Man-Whitney testleri yapıldı. Mortalite için Kaplan-Meier ve Cox Regresyon Analizleri yapıldı. Bulgular Çalışmamıza n=525 hasta alınmış olup bu hastaların %11,8'ı(n=62) çeşitli sebeplerle [Eksik veri(n=43), çalışmadan ayrılmayı isteme (n=3), dışlama kriterleri(n=16)] çalışmadan çıkarılmış olup toplam n=463 hasta değerlendirmeye alındı. Hastaların %59.2'si(n=274) erkek olup yaş ortalaması 63,27 ± 18,06 saptandı. Hastaların %62'si (n=287) sepsis tanısı, %13,8'i (n=64) septik şok tanısı aldı. Iki günlük oranı %2,5 (n=12) yedi günlük mortalite oranı %8,4 (n=39), 30 günlük mortalite oranı %18,1 (n=84) olarak saptandı. Çalışmaya alınan hastaların %16,6'sında (n=77) entübasyon ihtiyacı, %14,25'inde (n=66) inotrop ihtiyacı olduğu ve %0,6'sında(n=3) ölümcül aritmi geliştiği görüldü . Çalışmaya alınan hastaların %17,27'unun (n=80) yoğun bakım yattığı saptandı. En sık görülen hastalık pnömoni [%36,5 (n=182)] olup sırasıyla üriner sistem enfeksiyonu [%23,1 (n=115)] , batın içi enfeksiyon [%16,3 81 (n=81)] yumuşak doku enfeksiyonu [%34 (n=6,8)] tanısı aldıkları saptandı. Hastaların %47,5'i (n=220) acil serviste izlendiği ve %3,2'sinde (n=14) acil serviste mortalite geliştiği gözlendi. Hastaların %52,48'si (n=243) hastaneye yatırıldı. Bu hastaların %17,27' si (n=80) Yoğun Bakıma, %35,20 (n=163) servise yattığı görüldü. Yoğun bakım mortalite oranı %8,7 (n=41) , servis mortalite oranı %4 (n=119) olarak saptandı. Hastaların %72,6'sında (n=336) SIRS pozitif, %14,50'sinde (n= 67) qSOFA pozitif saptandı. NEWS skoru açısından değerlendirildiğinde %24,62'i (n=114) yüksek risk , %24,40'ü (n=113) orta risk 50,97 %,'u (n=236) düşük risk olarak saptandı. Sepsis tanısı açısından NEWS-1 sensitivitesi %35,54 , spesifitesi %93,18 , PPD %89,47 , NPD %46,99 , NEWS-2 sensitivitisi %65,85 , spesifitesi %78,41 , PPD %83,26 , NPD %58,47 , qSOFA sensitivitesi %23,00 , spesifitesi %99,43 , PPD %98,5 , NPD %44,19 , SIRS sensitivitesi %77,35 , spesifitesi %35,23 , PPD %66,0 , NPD %48,82 olarak saptandı. qSOFA, SIRS ve NEWS'in sepsis tanısında AUROC değerleri sırasıyla NEWS=0,731, qSOFA=0,728 ve SIRS= 0,570 olarak saptandı. Şeptik şok tanısında AUROC değerleri sırasıyla NEWS=0,801 , qSOFA=0,795 SIRS=0,573 olarak saptandı. Mortalitede AUROC değerleri NEWS=0,772 , qSOFA=0,758 , SIRS=0,542 olarak saptandı. III Skorların sepsis ve septik şok tanısı açısından rölatif riskleri(RR) hesaplandı. Buna göre NEWS-2'e göre yüksek-orta risk grubunda olan hastalarda düşük risk grubuna göre sepsis görülme riski 5,19 (%95 GA; RR=3,01-8,97) kat artmış bulundu . qSOFA pozitif olan hastalarda negatif olan gruba göre sepsis görülme riski 1,76 (%95 GA; RR=1,60-1,93) kat artmış bulundu. NEWS-1'e göre yüksek risk grubunda bulunan hastalarda orta ve düşük risk grubuna göre sepsis görülme riski 1,68 (%95 GA; RR=1,50-1,89) kat artmış bulundu. SIRS pozitif olan hastalarda negatif olan gruba göre sepsis görülme riski 1,29 (%95 GA; RR=1,07-1,55) kat artmış bulundu. qSOFA pozitif olan hastalarda negatif olan gruba göre septik şok riski 6,69 (%95 GA; RR=1,60-1,93) kat artmış bulundu. NEWS-2'e göre yüksek-orta risk grubunda olan hastalarda düşük risk grubuna göre septik şok riski 6,35 (%95 GA; RR=3,21-12,55) kat artmış bulundu. NEWS-1'e göre yüksek risk grubunda bulunan hastalarda orta ve düşük risk grubuna göre sepsis görülme riski 5,10 (%95 GA; RR=3,22-8,08) kat artmış bulundu. SIRS pozitif olan hastalarda negatif olan gruba göre sepsis görülmes riski 2,31 (%95 GA; RR=1,17-4,53) kat artmış bulundu. Skorların mortalite odds ratioları(OR) hesaplanmış olup buna göre ; NEWS-2'e göre yüksek-orta risk grubunda olan hastalarda görülen mortalite ihtimalinin düşük risk grubunda olanlara oranı 6,08 (%95 GA; OR=3,42-10,79) bulundu. qSOFA pozitif olan hastalarda görülen mortalite ihtimalinin negatif olan gruba oranı 5,26 (%95 GA; OR=3,39-8,17) bulundu. NEWS-1'e göre yüksek risk grubunda bulunan hastaların mortalite ihtimalinin orta ve düşük risk grubunda olanlara oranı 4,83 (%95 GA; RR=3,14-7,44) bulundu. SIRS pozitif olan hastalarda görülen mortalite ihtimalinin negatif olan gruba oranı 1,86 (%95 GA; RR=1,06-3,25)bulundu. İleri yaşta olan , diabetes mellitus , kronik böbrek yetmezliği, malignite tanısı bulunan hastaların olmayanlara göre istatistiki anlamlı oranda daha fazla sepsis tanısı aldığı saptandı. (p<0,005) KBY ve Malignite tanısı olan hastaların mortalite ihtimalinin olmayanlara oranı sırasıyla 1,98 (%95 GA OR=1,07-3,66) ve 3,67 (%95 GA OR=2,38-5,65) saptandı. Çalışmamızda hipotermi, hipotansiyon hem sepsis tanısında hem de mortalitede istatistiki anlamlı oranda daha fazla saptandı. (p<0,001) IV Yoğun bakım yatışını belirleme açısından; qSOFA skoru istatistiki anlamlı oranda daha fazla pozitif olduğu, NEWS-1'e göre yüksek risk grubunda olanların istatistiki anlamlı oranda daha fazla olduğu, NEWS-2'e göre yüksek-orta risk grubunda olanların istatistiki anlamlı oranda daha fazla olduğu saptandı.(p<0,005) SIRS ise yoğun bakım yatışı belirlemede anlamlı herhangi bir özelliğe sahip değildi(p=0,076) SONUÇ NEWS skorlama sistemi acil servis hasta populasyonunda qSOFA ve SIRS skorlama sistemine göre sepsis/septik şok tanısında, mortalite (erken ve geç dönem) ve morbidite saptanmasında üstündür. SIRS skorlama sistemi NEWS ve qSOFA skorlama sistemine göre daha yüksek sensitiviteye sahiptir bu nedenle acil servislerde kullanılabilir. Acil serviste kullanımı önerilen qSOFA ; sepsis tanısı, mortalite ve morbidite sonuçları açısından iyi olmadığı ve güvenli taburculuk konusunda değersiz olduğu için acil serviste kullanılmaya uygun değildir. NEWS skorlama sistemi risk sınıflaması ve tanı koymada acil servislerde kullanılmalıdır.
Purpose In this study, it was aimed to compare the qSOFA, SIRS and NEWS scores of the patients, who were admitted to the emergency department with suspicion of infection and / or were given antibiotherapy or taken culture for suspicion of infection during the emergency service follow-up, in terms of sepsis / septic shock diagnosis, early and late period mortality, morbidity according to the gold standard SOFA score. Method The patients, who were admitted to the Emergency Department of Ege University with the suspicion of infection and / or who were given antibiotherapy or taken culture with the suspicion of infection during the emergency service follow-up, were diagnosed with sepsis according to the SOFA score as the gold standard. The arrival qSOFA, SIRS and NEWS scores of the patients were calculated. Septic shock were diagnosed if there is an inotropic need or lactate elevation in patients with the diagnosis of sepsis. The incidence of sepsis and sepsis shock was calculated and these scoring systems were compared in terms of diagnosis, early and late mortality, morbidity and safe discharge. In our study, Chi-Square, T-Test, Man-Whitney tests were performed in the diagnosis of sepsis / septic shock. Kaplan-Meier and Cox Regression Analyzes were performed for mortality. Results n = 525 patients were included in our study and 11.8% (n = 62) of these patients were excluded from the study for a variety of reasons and a total of n = 463 patients were included in the study. 59.2% (n = 274) of the patients were male and the mean age was 63.27 ± 18.06. 62% (n = 287) of the patients were diagnosed with sepsis and 13,8% (n = 64) with septic shock. It was determined that the 2-day rate was 2.5% (n = 12), the 7-day mortality rate was 8.4% (n = 39) and the 30-day mortality rate was 18.1% (n = 84). It was observed that 16.6% of the patients included in the study(n = 77), needed intubation, 14.25% (n = 66) needed inotropic requirement and 0.6% (n = 3) developed fatal arrhythmia . 17.27% (n = 80) of the patients in the study were admitted to the intensive care unit. It was determined that the most common disease was pneumonia [36.5% (n = 182)], respectively followed by urinary tract infection [23.1% (n = 115)], intraabdominal infection [16.3% (n = 81)] soft tissue infection [34% (n = 6.8)]. It was observed that 47.5% (n = 220) of the patients were monitored in the emergency service and 3.2% (n = 14) of them developed mortality in the emergency department. 52.48% (n = 243) of the patients were hospitalized. 17,27% (n = 80) of these patients were admitted to the intensive care unit, 35,20% (n = 163) were hospitalized in service. It was determined that the mortality rate of intensive care was 8,7% (n = 41) and the mortality rate of service was 4% (n = 119). 72.6% of the patients (n = 336) were positive for SIRS and 14.50% (n = 67) were positive for qSOFA. When evaluated according to the NEWS score, 24.62% (n = 114) had a high risk, and 24.40% (n = 113) had a moderate risk and 50.97% (n = 236) had a low risk. In terms of the diagnosis of sepsis, the sensitivity of NEWS-1 was 35,54%, specificity 93,18%, PPD 89,47%, NPD 46,99; the sensivity of NEWS-2 was 65,85%, specificity 78,41%, PPD 83,26% , NPD 58.47%; the sensivity of qSOFA was 23.00%, specificity 99.43%, PPD 98.5%, NPD 44.19%; the sensivity of SIRS was 77.35%, specificity 35.23%, PPD 66.0% , NPD 48,82%. AUROC values of qSOFA, SIRS and NEWS in the diagnosis of sepsis were determined as NEWS = 0.731, qSOFa = 0.728 and SIRS = 0.570, respectively. AUROC values in the diagnosis of septic shock were determined as NEWS = 0,801, qSOFA = 0,795 SIRS = 0,573, respectively. AUROC values in mortality were found as NEWS = 0.772, qSOFA = 0.775, SIRS = 0.542. Relative risks (RR) were calculated in terms of the diagnosis of sepsis and septic shock. Accordingly, the risk of sepsis was found to be increased by 5.19 (95% CI; RR = 3.01-8.97) in patients with high-moderate risk compared to the low-risk group according to NEWS-2. The risk of sepsis was found to be increased by 1.76 (95% CI; RR = 1.60-1.93) in patients with qSOFA-positive patients compared to qSOFA negatives. .The risk of sepsis was found to be increased by 1.68 (95% CI; RR = 1.50-1.89) in the high-risk group compared to the middle and low-risk group according to NEWS-1. The risk of sepsis was found to be increased by 1,29 (95% CI; RR = 1,07-1,55) in patients with SIRS positive compared to the negative group. The risk of septic shock was found to be increased by 6.69 (95% CI; RR = 1.60-1.93) in patients with qSOFA positive compared to the negatives. The risk of septic shock was found to be increased by 6.35 (95% CI; RR = 3.21-12.55) in patients in high-moderate risk group compared to the low-risk group according to NEWS-2. The risk of sepsis was found to be increased by 5,10 (95% CI; RR = 3,22-8,08) in the patients in high risk group compared to the moderate-low risk group according to NEWS-1. The risk of sepsis was found to be increased by 2.31 (95% CI; RR = 1.17-4.53) in patients with SIRS positive compared to the negative group. Mortality odds ratios (OR) of the scores were calculated and accordingly the rate of mortality possibility in patients in the high-moderate risk group was 6.08 (95% CI; OR = 3.42-10.79) compared to the patients in the low-risk group.The rate of mortality possibility was found to be 5.26 (95% CI; OR = 3.39-8.17) in patients with qSOFA positive compared to the negative group. The rate of mortality possibility was 4.83 (95% CI; RR = 3.14-7.44) in the high-risk group compared to moderate-low risk group according to NEWS-1. The rate of mortality possibility was found to be 1.86 (95% CI; RR = 1.06-3.25) in patients with SIRS positive compared to negatives. It was determined that elderly patients, patients with diabetes mellitus, chronic renal failure, and malignancy were found to be diagnosed with a significantly higher incidence of sepsis than those without. (p <0.005) The ratio of mortality possibility in the patients with CRF and Malignancy was 1.98 (95% CI OR = 1.07-3.66) and 3.67 (95% CI OR = 2.38-5.65) respectively compared to those without diagnosis. In our study, hypothermia and hypotension were found to be significantly higher in both sepsis and mortality (p <0.001). In terms of determining the hospitalization of intensive care unit; it was determined that qSOFA score was statistically and significantly more positive, patients in the high-risk group according to NEWS-1 were found to be statistically significiantly higher, and those with high-moderate risk according to NEWS-2 were found to be statistically significantly higher (p <0.005). SIRS did not have any significant features in determining intensive care unit stay (p = 0.076) Conclusions In the emergency service patient population, the NEWS scoring system is superior in the diagnosis of sepsis / septic shock, mortality (early and late period) and morbidity compared to qSOFA and SIRS scoring systems. The SIRS scoring system has higher sensitivity than the NEWS and QSOFA scoring systems, thus, it can be used in emergency services. Since qSOFA, recommended for use in the emergency department, is not good at diagnosis of sepsis, mortality and morbidity results and it is worthless about safe discharge, it is not suitable for use in emergency departments. NEWS scoring system should be used in emergency services in risk classification and diagnosis.
Purpose In this study, it was aimed to compare the qSOFA, SIRS and NEWS scores of the patients, who were admitted to the emergency department with suspicion of infection and / or were given antibiotherapy or taken culture for suspicion of infection during the emergency service follow-up, in terms of sepsis / septic shock diagnosis, early and late period mortality, morbidity according to the gold standard SOFA score. Method The patients, who were admitted to the Emergency Department of Ege University with the suspicion of infection and / or who were given antibiotherapy or taken culture with the suspicion of infection during the emergency service follow-up, were diagnosed with sepsis according to the SOFA score as the gold standard. The arrival qSOFA, SIRS and NEWS scores of the patients were calculated. Septic shock were diagnosed if there is an inotropic need or lactate elevation in patients with the diagnosis of sepsis. The incidence of sepsis and sepsis shock was calculated and these scoring systems were compared in terms of diagnosis, early and late mortality, morbidity and safe discharge. In our study, Chi-Square, T-Test, Man-Whitney tests were performed in the diagnosis of sepsis / septic shock. Kaplan-Meier and Cox Regression Analyzes were performed for mortality. Results n = 525 patients were included in our study and 11.8% (n = 62) of these patients were excluded from the study for a variety of reasons and a total of n = 463 patients were included in the study. 59.2% (n = 274) of the patients were male and the mean age was 63.27 ± 18.06. 62% (n = 287) of the patients were diagnosed with sepsis and 13,8% (n = 64) with septic shock. It was determined that the 2-day rate was 2.5% (n = 12), the 7-day mortality rate was 8.4% (n = 39) and the 30-day mortality rate was 18.1% (n = 84). It was observed that 16.6% of the patients included in the study(n = 77), needed intubation, 14.25% (n = 66) needed inotropic requirement and 0.6% (n = 3) developed fatal arrhythmia . 17.27% (n = 80) of the patients in the study were admitted to the intensive care unit. It was determined that the most common disease was pneumonia [36.5% (n = 182)], respectively followed by urinary tract infection [23.1% (n = 115)], intraabdominal infection [16.3% (n = 81)] soft tissue infection [34% (n = 6.8)]. It was observed that 47.5% (n = 220) of the patients were monitored in the emergency service and 3.2% (n = 14) of them developed mortality in the emergency department. 52.48% (n = 243) of the patients were hospitalized. 17,27% (n = 80) of these patients were admitted to the intensive care unit, 35,20% (n = 163) were hospitalized in service. It was determined that the mortality rate of intensive care was 8,7% (n = 41) and the mortality rate of service was 4% (n = 119). 72.6% of the patients (n = 336) were positive for SIRS and 14.50% (n = 67) were positive for qSOFA. When evaluated according to the NEWS score, 24.62% (n = 114) had a high risk, and 24.40% (n = 113) had a moderate risk and 50.97% (n = 236) had a low risk. In terms of the diagnosis of sepsis, the sensitivity of NEWS-1 was 35,54%, specificity 93,18%, PPD 89,47%, NPD 46,99; the sensivity of NEWS-2 was 65,85%, specificity 78,41%, PPD 83,26% , NPD 58.47%; the sensivity of qSOFA was 23.00%, specificity 99.43%, PPD 98.5%, NPD 44.19%; the sensivity of SIRS was 77.35%, specificity 35.23%, PPD 66.0% , NPD 48,82%. AUROC values of qSOFA, SIRS and NEWS in the diagnosis of sepsis were determined as NEWS = 0.731, qSOFa = 0.728 and SIRS = 0.570, respectively. AUROC values in the diagnosis of septic shock were determined as NEWS = 0,801, qSOFA = 0,795 SIRS = 0,573, respectively. AUROC values in mortality were found as NEWS = 0.772, qSOFA = 0.775, SIRS = 0.542. Relative risks (RR) were calculated in terms of the diagnosis of sepsis and septic shock. Accordingly, the risk of sepsis was found to be increased by 5.19 (95% CI; RR = 3.01-8.97) in patients with high-moderate risk compared to the low-risk group according to NEWS-2. The risk of sepsis was found to be increased by 1.76 (95% CI; RR = 1.60-1.93) in patients with qSOFA-positive patients compared to qSOFA negatives. .The risk of sepsis was found to be increased by 1.68 (95% CI; RR = 1.50-1.89) in the high-risk group compared to the middle and low-risk group according to NEWS-1. The risk of sepsis was found to be increased by 1,29 (95% CI; RR = 1,07-1,55) in patients with SIRS positive compared to the negative group. The risk of septic shock was found to be increased by 6.69 (95% CI; RR = 1.60-1.93) in patients with qSOFA positive compared to the negatives. The risk of septic shock was found to be increased by 6.35 (95% CI; RR = 3.21-12.55) in patients in high-moderate risk group compared to the low-risk group according to NEWS-2. The risk of sepsis was found to be increased by 5,10 (95% CI; RR = 3,22-8,08) in the patients in high risk group compared to the moderate-low risk group according to NEWS-1. The risk of sepsis was found to be increased by 2.31 (95% CI; RR = 1.17-4.53) in patients with SIRS positive compared to the negative group. Mortality odds ratios (OR) of the scores were calculated and accordingly the rate of mortality possibility in patients in the high-moderate risk group was 6.08 (95% CI; OR = 3.42-10.79) compared to the patients in the low-risk group.The rate of mortality possibility was found to be 5.26 (95% CI; OR = 3.39-8.17) in patients with qSOFA positive compared to the negative group. The rate of mortality possibility was 4.83 (95% CI; RR = 3.14-7.44) in the high-risk group compared to moderate-low risk group according to NEWS-1. The rate of mortality possibility was found to be 1.86 (95% CI; RR = 1.06-3.25) in patients with SIRS positive compared to negatives. It was determined that elderly patients, patients with diabetes mellitus, chronic renal failure, and malignancy were found to be diagnosed with a significantly higher incidence of sepsis than those without. (p <0.005) The ratio of mortality possibility in the patients with CRF and Malignancy was 1.98 (95% CI OR = 1.07-3.66) and 3.67 (95% CI OR = 2.38-5.65) respectively compared to those without diagnosis. In our study, hypothermia and hypotension were found to be significantly higher in both sepsis and mortality (p <0.001). In terms of determining the hospitalization of intensive care unit; it was determined that qSOFA score was statistically and significantly more positive, patients in the high-risk group according to NEWS-1 were found to be statistically significiantly higher, and those with high-moderate risk according to NEWS-2 were found to be statistically significantly higher (p <0.005). SIRS did not have any significant features in determining intensive care unit stay (p = 0.076) Conclusions In the emergency service patient population, the NEWS scoring system is superior in the diagnosis of sepsis / septic shock, mortality (early and late period) and morbidity compared to qSOFA and SIRS scoring systems. The SIRS scoring system has higher sensitivity than the NEWS and QSOFA scoring systems, thus, it can be used in emergency services. Since qSOFA, recommended for use in the emergency department, is not good at diagnosis of sepsis, mortality and morbidity results and it is worthless about safe discharge, it is not suitable for use in emergency departments. NEWS scoring system should be used in emergency services in risk classification and diagnosis.
Açıklama
Anahtar Kelimeler
Sepsis, SIRS, qSOFA, NEWS
