Met Systemic Inflammatory Response Syndrome Criteria Research Articles

Fever and Systemic Inflammatory Response Syndrome After Wide Resection of Pediatric Bone Sarcomas.

While postoperative fever is common and thought to be physiological, data is limited in pediatric patients with bone sarcomas. Understanding the predictive value of postoperative fever and systemic inflammatory response syndrome (SIRS) in this population is essential to guide further workup and avoid delays in adjuvant therapy. The aim of this study is to characterize the prevalence of postoperative fever and SIRS in pediatric patients undergoing wide resection of bone sarcomas and to determine whether these signs are associated with wound or infectious complications. A retrospective chart review of cases performed by a single surgeon between January 2018 and December 2020 was performed. Twenty-two patients were identified. All patients had pathology-confirmed diagnoses of osteosarcoma (77.3%) or Ewing sarcoma (22.7%). Before discharge, 68.2% developed a fever >38°C and 90.9% met SIRS criteria. The rate of wound and infectious complications during the first 6 weeks after surgery was 27.3%. The positive predictive values (PPV) of fever and SIRS were low at 26.7% and 31.0% respectively. No association between complications and fever [dds ratio (OR): 0.91, 95% confidence interval (CI): 0.12-6.72] or SIRS (OR: 2.24, 95% CI: 0.78-46.14) was identified. High fever >39°C had a better PPV of 50.0%. However, the association between high fever and complications did not reach significance (OR: 6.00, 95% CI: 0.78-46.14). Age, tumor size, days from chemo to surgery, duration of surgery, estimated blood loss, number of packed red blood cells units transfused, and length of stay were not associated with the development of postoperative fever or complications. Pediatric patients undergoing wide resection of bone sarcomas frequently mount a robust SIRS response after surgery. However, fever and SIRS are both poor predictors of infection and wound complications. Patients with postoperative fever or SIRS should not undergo an extensive infectious workup unless there are clear signs or symptoms to suggest an infectious etiology. Level II-prognostic retrospective study.

Lung Ultrasound Findings in COVID-19: A Descriptive Retrospective Study.

BackgroundPoint-of-care ultrasound (POCUS) is an indispensable tool in emergency medicine. With the emergence of the coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a need for improved diagnostic capabilities and prognostic indicators for patients who are symptomatic for COVID-19 has become apparent. POCUS has been demonstrated to be a useful diagnostic and prognostic tool in the emergency department (ED) in assessing other lung complications. Still, limited data regarding its utility in assessing COVID-19 are available. This study sought to evaluate whether POCUS findings in the ED were correlated with vital signs or laboratory abnormalities typically seen among patients with COVID-19.MethodsA retrospective study was conducted that included 39 patients who presented with COVID-19 and systemic inflammatory response syndrome (SIRS) to a large, urban tertiary care ED. The study population was limited to adults aged 18 and above who came to the ED with the primary complaint of respiratory symptoms, met SIRS criteria on admission, and had images of at least one anterior and one posterior intercostal space per lung and a minimum of four intercostal spaces. POCUS images were obtained by trained operators in the ED using portable ultrasound machines, recorded in an image database, and reviewed by ultrasound fellowship-trained emergency physicians. Clinical data (e.g., acute phase reactants and vital signs) were obtained through a chart review of patients’ electronic medical records.Results Both the percentage of intercostal spaces with B-lines and the percentage of merging B-lines were correlated with decreased oxygen saturation on presentation. No other statistically significant correlations were observed between these sonographic findings and other vital signs or acute phase reactants, nor between these clinical data and the percentage of intercostal spaces that were positive for the shred sign.ConclusionsWith the emergence of the COVID-19 pandemic, emergency medicine physicians are on the frontline of identifying and caring for patients affected by the virus. This study found that sonographic findings associated with interstitial pneumonitis, notably merging B-lines, and the overall percentage of intercostal spaces with B-lines, were clearly associated with worsening oxygen saturation, now thought to be one of the driving causes of morbidity and mortality in COVID-19. As ultrasound has become a ubiquitous and indispensable tool in the ED, this study demonstrated its utility in assessing and managing patients with COVID-19. Bedside ultrasound is a cheap, fast, and non-invasive tool that healthcare providers can use as an essential adjunct in addition to laboratory markers and other imaging modalities for the diagnosis and prognosis of COVID-19.

Microbiological findings in emergency department patients with sepsis identified by the Sepsis-3 criteria: a single-center prospective population-based cohort study

BackgroundStudies comparing the microbiological profiles among sepsis patients identified with either Sequential Organ Failure Assessment (SOFA) score or systemic inflammatory response syndrome (SIRS) criteria are limited. The aim was to examine if there are differences in the microbiological findings among septic patients identified by Sepsis-3 criteria compared to patients identified by the previous sepsis criteria, SIRS, and without organ failure. A secondary purpose was to examine if we could identify microbiological characteristics with increased risk of 28-day mortality.MethodsProspective cohort study of all adult (≥ 18 years) patients admitted with sepsis to the Emergency Department of Slagelse Hospital, Denmark from 1st October 2017 to 31st March 2018. Information regarding microbiological findings was obtained via linkage between a sepsis database and the local microbiological laboratory data system. Data regarding 28-day mortality were obtained from the Danish Civil Registration System. We used logistic regression to estimate the association between specific microbiological characteristics and 28-day mortality.ResultsA total of 1616 patients were included; 466 (28.8%; 95% CI 26.6%-31.1%) met SOFA criteria, 398 (24.6%; 95% CI 22.5–26.8%) met SIRS criteria. A total of 127 patients (14.7%; 95% CI 12.4–17.2%) had at least one positive blood culture. SOFA patients had more often positive blood cultures compared to SIRS (13.9% vs. 9.5%; 95 CI on difference 0.1–8.7%). Likewise, Gram-positive bacteria (8.6% vs. 2.8%; 95 CI on difference 2.8–8.8%), infections of respiratory origin (64.8% vs. 57.3%; 95 CI on difference 1.0–14%), Streptococcus pneumoniae (3.2% vs. 1.0%; 95% CI on difference 0.3–4.1) and polymicrobial infections (2.6% vs. 0.3% 95 CI on difference 0.8–3.8%) were more common among SOFA patients. Polymicrobial infections (OR 3.70; 95% CI 1.02–13.40), Staphylococcus aureus (OR 6.30; 95% CI 1.33–29.80) and a pool of “other” microorganisms (OR 3.88; 95% CI 1.34–9.79) in blood cultures were independently associated with mortality.ConclusionPatients identified with sepsis by SOFA score were more often blood culture-positive. Gram-positive pathogens, pulmonary tract infections, Streptococcus pneumoniae, and polymicrobial infections were also more common among SOFA patients. Polymicrobial infection, Staphylococcus aureus, and a group of other organisms were independently associated with an increased risk of death.

Comparison of SIRS criteria and qSOFA score for identifying culture-positive sepsis in the emergency department: a prospective cross-sectional multicentre study

ObjectiveTo compare the daily practice of two emergency departments (ED) in the Netherlands, where systemic inflammatory response syndrome (SIRS) criteria and quick Sequential Organ Failure Assessment (qSOFA) score are used...

Performance of Pediatric Systemic Inflammatory Response Syndrome and Organ Dysfunction Criteria in Late-Onset Sepsis in a Quaternary Neonatal Intensive Care Unit: A Case-Control Study

To evaluate accuracy of systemic inflammatory response syndrome (SIRS) criteria in identifying culture-proven late-onset neonatal sepsis and to assess prevalence of organ dysfunction and its relationship with SIRS criteria. This was a retrospective case-control study of patients in the Children's Hospital of Philadelphia level IV neonatal intensive care unit undergoing sepsis evaluations (concurrent blood culture and antibiotics). During calendar years 2016-2017, 77 case and 77 control sepsis evaluations were identified. Cases included infants who had sepsis evaluations with positive blood cultures and antibiotic duration ≥7days. Controls were matched by gestational and postmenstrual age, and had sepsis evaluations with negative blood cultures and antibiotic duration ≤48hours. SIRS criteria were determined at time of sepsis evaluation, and organ dysfunction evaluated in the 72hours following sepsis evaluation. Statistical analysis included descriptive statistics, Mann-Whitney tests, and χ2 (Fisher exact) tests. At time of sepsis evaluation, 42% of cases and 26% of controls met SIRS criteria. Among infants of ≤37weeks postmenstrual age, SIRS criteria were met in only 17% of sepsis evaluations (4 of 23 in both cases and controls). Test characteristics for SIRS at diagnosis of culture-proven sepsis included sensitivity 42% and specificity 74%. Cases had higher rates of new organ dysfunction within 72hours (40% vs 21%); however, 58% of cases developing organ dysfunction did not meet SIRS criteria at time of sepsis evaluation. Of 6 deaths (all cases with organ dysfunction), 2 did not meet SIRS criteria at sepsis evaluation. SIRS criteria did not accurately identify culture-proven late-onset sepsis, with poorest accuracy in preterm infants. SIRS criteria did not predict later organ dysfunction or mortality.

630-P: Systemic Inflammatory Response Syndrome (SIRS) Criteria as a Predictor of Clinical Outcomes in Diabetic Foot Infections

Aim: Previous investigations have identified presence of systemic inflammatory response syndrome (SIRS) as an indicator of severe foot infection in patients with diabetes mellitus (DM). The aim of this study was to assess whether SIRS is correlated with outcomes in patients with diabetic foot infections (DFI). Methods: We retrospective reviewed 173 diabetic patients admitted to hospital with moderate and severe DFI according to Infectious Diseases Society of America (IDSA) guidelines confined to skin and soft tissue infection. We used SIRS criteria to define severe infection based on the presence of at least two of the following: heart rate >90 beats per minute, temperature >38°C or <36°C, respiratory rate >20 breaths per minute and white blood cell count >12,000/mm3 or <4,000/mm3. Results: Of the 173 subjects, 50 (36.5%) met SIRS criteria. Patients with severe infections based on SIRS criteria were significantly younger (49.0±10.4 vs. 54.2±10.8 years, p=0.014), more often had type 1 DM (10.0% vs. 1.1%, p=0.032), less often had a history of a previous foot ulcer (48.0% vs. 66.7%, p=0.040) and had longer hospital stay (8.0±6.1 vs. 11.7±11.3 days, p=0.024). There was not a significant difference in the number of surgical procedures (1.1±1.4 vs. 1.2±1.4, p=0.40), amputation procedures (24% vs. 27.6%, (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.33, 1.720), duration of antibiotic treatment (30.1±42.5 vs. 31.6±48.5 days, p=0.47), proportion of healed wounds (74.0% vs. 66.7%, p=0.304), time to healing (142.6±102.8 vs. 131.9±103.1 days, p=0.67). reinfection (34.0% vs. 42.5%, p=0.29), hospital readmission (30.0% vs. 47.1%, p=0.072) or mortality (4.0% vs. 5.7%, p=1.0). Conclusion: SIRS criteria for severe infections in diabetic patients with skin and soft tissue infections were not associated with worse outcomes other than longer hospital stay. Further investigation is needed to identify factors that portend worse outcome in those with foot STI in the setting of DM. Disclosure J. Ahn: None. E.C. Ryan: None. D. Wukich: Consultant; Self; Orthofix. Other Relationship; Self; Arthrex. J. La Fontaine: None. P.A. Crisologo: None. L.A. Lavery: Consultant; Self; Bayer US, Boehringer Ingelheim Pharmaceuticals, Inc., Medline Industries, Inc. Research Support; Self; Cardinal Health, EO2 Concepts, Integra LifeSciences, MedImmune, Osiris Therapeutics, Inc.

Outcomes of Endourologic Interventions in Patients with Preoperative Funguria

Introduction: Funguria is encountered in 1% to 5% of cultured urine specimens and may be a result of specimen contamination, colonization, or invasive infection. The characteristics and outcomes of patients with funguria undergoing endourologic intervention have not been evaluated. Materials and Methods: Patients with preoperative funguria undergoing endourologic intervention were retrospectively identified. Preoperative funguria was defined as a urine culture containing >10,000 colony forming units of fungus within 30 days of the operative intervention. Univariable and multivariable regression was performed to identify predictors of postoperative systemic inflammatory response syndrome (SIRS). Results: A total of 65 patients with preoperative funguria were identified, of whom 49 (75.4%) underwent ureteroscopy and 16 (24.6%) underwent percutaneous nephrolithotomy. Average patient age was 55.1 ± 18.3 years, body mass index was 31.8 ± 11.0, and Charlson comorbidity index was 2.52 ± 2.0. Twenty-three patients (35.4%) carried a diagnosis of neurogenic bladder, of whom 18 (27.7%) required indwelling or intermittent catheterization. In total 57 patients (87.7%) had been exposed to antibiotics in the 3 months before intervention. Eighteen (27.7%) patients met SIRS criteria postoperatively, of whom 11 (16.9%) required intensive care unit (ICU) admission. Three (4.6%) and two (3.1%) patients developed postoperative fungemia and bacteremia, respectively. All cases of fungemia were caused by Candida glabrata. On univariable analysis, presence of an indwelling catheter (p = 0.009), presence of a known neurological diagnosis (p = 0.02), presence of C. glabrata on preoperative culture (p = 0.04), and longer operative time (p = 0.04) were predictive of development of postoperative SIRS. No significant predictors were identified on multivariable analysis. Conclusions: Patients with preoperative funguria have high rates of comorbid illness, urinary catheterization, and recent exposure to antibiotics. This patient population is at high risk of perioperative infectious complications after endourologic intervention.

The utility of systemic inflammatory response syndrome (SIRS) for diagnosing sepsis in the immediate postpartum period

BackgroundThe systemic inflammatory response syndrome (SIRS) and sepsis definitions were developed to improve the ability for early detection of infection and sepsis. We studied the incidence of immediate postpartum SIRS and sepsis. We further studied immediate postpartum SIRS as a potential predictor for immediate postpartum sepsis. MethodsThis was a retrospective study of 638 immediate postpartum women who delivered either vaginally or by cesarean section. Multivariate logistic regression was used for statistical analysis. Predictor variables included demographic, labor and delivery, and SIRS variables to determine their association with acute immediate postpartum sepsis. ResultsWe found that 72.10% of vital signs of immediate postpartum women met SIRS criteria while only 1.25% had sepsis. Both preterm gestational age of <37 weeks (OR:19.09, 95% CI:4.13, 88.36, p < 0.001) and only one of the four SIRS criteria of abnormal temperature (OR:25.90, 95% CI: 3.17, 211.52, p = 0.002) were each significantly associated with increased odds for sepsis. ConclusionOur findings suggest that immediate postpartum SIRS is not useful for the identification of immediate postpartum sepsis. Furthermore, SIRS does not appear to be a useful screening tool for infection and sepsis in the immediate postpartum period.

Comparison of qSOFA with current emergency department tools for screening of patients with sepsis for critical illness

ObjectiveWe sought to compare the quick sequential organ failure assessment (qSOFA) to systemic inflammatory response syndrome (SIRS), severe sepsis criteria and lactate levels for their ability to identify ED patients...

Pressure Sores and Systemic Inflammatory Response Syndrome: UC Davis Quality Improvement Initiative.

The National Pressure Ulcer Advisory Panel estimates pressure sore care to approach $11 billion annually. It is not uncommon for these patients to present to the emergency department (ED) with a chief concern of a pressure sore, while concurrently carrying an undiagnosed infectious process that is the culprit for the acute presentation, rather than the chronic pressure injury. We aim to identify patients who met systemic inflammatory response syndrome (SIRS) criteria at ED presentation who were referred to plastic and reconstructive surgery for pressure sore debridement prior to a complete medical workup. We hypothesize that a restructuring of the ED triaging system would help conserve hospital resources, reduce costs of pressure sore management, and improve patient care and outcomes by first treating primary, underlying pathologies. This is a retrospective chart review of 36 patients who presented to the University of California, Davis Medical Center Emergency Department with a pressure sore and met SIRS criteria, but obtained a plastic surgery consult prior to a full medical workup. We defined SIRS based on standardized criteria: temperature greater than 100.4°F or less than 96.8°F, pulse rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min or PaCO2 less than 32 mm Hg, white blood cell count greater than 12,000, less than 4000, or greater than 10% bands. Fifty percent of patients (18/36) met SIRS criteria at ED presentation for their pressure sores. Of these SIRS patients, 9 (50%) had a diagnosis of urinary tract infection or urosepsis, 6 (33.3%) had sepsis of undefined origin, and 3 (16.7%) had other diagnoses such as osteomyelitis or acute respiratory distress syndrome. Half of patients consulted while in the University of California, Davis Medical Center Emergency Department with pressure sores met SIRS criteria and received a plastic and reconstructive surgery consult prior to a full medical workup. We propose a new algorithm for triaging pressure sore patients be established in our institution that emphasizes a medical and surgical collaborative approach in order to reduce cost, conserve resources, and improve patient care.

Systemic inflammatory response syndrome, infection, and outcome in intracerebral hemorrhage.

Objective:Systemic inflammatory response syndrome (SIRS) may be related to poor outcomes after intracerebral hemorrhage (ICH).Methods:The Ethnic/Racial Variations of Intracerebral Hemorrhage study is an observational study of ICH in whites, blacks, and Hispanics throughout the United Sates. SIRS was defined by standard criteria as 2 or more of the following on admission: (1) body temperature <36°C or >38°C, (2) heart rate >90 beats per minute, (3) respiratory rate >20 breaths per minute, or (4) white blood cell count <4,000/mm3 or >12,000/mm3. The relationship among SIRS, infection, and poor outcome (modified Rankin Scale [mRS] 3–6) at discharge and 3 months was assessed.Results:Of 2,441 patients included, 343 (14%) met SIRS criteria at admission. Patients with SIRS were younger (58.2 vs 62.7 years; p < 0.0001) and more likely to have intraventricular hemorrhage (IVH; 53.6% vs 36.7%; p < 0.0001), higher admission hematoma volume (25.4 vs 17.5 mL; p < 0.0001), and lower admission Glasgow Coma Scale (GCS; 10.7 vs 13.1; p < 0.0001). SIRS on admission was significantly related to infections during hospitalization (adjusted odds ratio [OR] 1.36, 95% confidence interval [CI] 1.04–1.78). In unadjusted analyses, SIRS was associated with poor outcomes at discharge (OR 1.96, 95% CI 1.42–2.70) and 3 months (OR 1.75, 95% CI 1.35–2.33) after ICH. In analyses adjusted for infection, age, IVH, hematoma location, admission GCS, and premorbid mRS, SIRS was no longer associated with poor outcomes.Conclusions:SIRS on admission is associated with ICH score on admission and infection, but it was not an independent predictor of poor functional outcomes after ICH.

Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis

ObjectivesThe Quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score has been shown to accurately predict mortality in septic patients and is part of recently proposed diagnostic criteria for sepsis. We sought to ascertain the sensitive of the score in diagnosing sepsis, as well as the diagnostic timeliness of the score when compared to traditional systemic inflammatory response syndrome (SIRS) criteria in a population of emergency department (ED) patients treated in the ED, admitted, and subsequently discharged with a diagnosis of sepsis. MethodsElectronic health records of 200 patients who were treated for suspected sepsis in our ED and ultimately discharged from our hospital with a diagnosis of sepsis were randomly selected for review from a population of adult ED patients (N=1880). Data extracted included the presence of SIRS criteria and the qSOFA score as well as time required to meet said criteria. ResultsIn this cohort, 94.5% met SIRS criteria while in the ED whereas only 58.3% met qSOFA. The mean time from arrival to SIRS documentation was 47.1min (95% CI: 36.5–57.8) compared to 84.0min (95% CI: 62.2–105.8) for qSOFA. The median ED “door” to positive SIRS criteria was 12min and 29min for qSOFA. ConclusionsAlthough qSOFA may be valuable in predicting sepsis-related mortality, it performed poorly as a screening tool for identifying sepsis in the ED. As the time to meet qSOFA criteria was significantly longer than for SIRS, relying on qSOFA alone may delay initiation of evidence-based interventions known to improve sepsis-related outcomes.

Hypoalbuminemia, systemic inflammatory response syndrome, and functional outcome in intracerebral hemorrhage

PurposeHypoalbuminemia and systemic inflammatory response syndrome (SIRS) are reported in critically-ill patients, but their relationship is unclear. We sought to determine the association of admission serum albumin and SIRS with outcomes in patients with intracerebral hemorrhage (ICH). MethodsWe used a multicenter, multinational registry of ICH patients to select patients in whom SIRS parameters and serum albumin levels had been determined on admission. Hypoalbuminemia was defined as the lowest standardized quartile of albumin; SIRS according to standard criteria. Primary outcomes were modified Rankin Scale (mRS) at discharge and in-hospital mortality. Regression models were used to assess for the association of hypoalbuminemia and SIRS with discharge mRS and in-hospital mortality. ResultsOf 761 ICH patients included in the registry 518 met inclusion criteria; 129 (25%) met SIRS criteria on admission. Hypoalbuminemia was more frequent in patients with SIRS (42% versus 19%; p<0.001). SIRS was associated with worse outcomes (OR: 4.68, 95%CI, 2.52–8.76) and in-hospital all-cause mortality (OR: 2.18, 95% CI, 1.60–2.97), while hypoalbuminemia was not associated with all-cause mortality. ConclusionsIn patients with ICH, hypoalbuminemia is strongly associated with SIRS. SIRS, but not hypoalbuminemia, predicts poor outcome at discharge. Recognizing and managing SIRS early may prevent death or disability in ICH patients.

Systemic Inflammatory Response Syndrome (SIRS) Score Independently Predicts Poor Outcome in Isolated Traumatic Brain Injury.

Systemic inflammatory response syndrome (SIRS) is frequently observed after various types of acute cerebral injury and has been linked to clinical deterioration in non-traumatic brain injury (TBI). SIRS scores have also been shown to be predictive of length of stay and mortality in trauma patients. We aimed to determine the prognostic utility of SIRS present at admission in trauma patients with isolated TBI. This was a 5-year retrospective cohort study of adults (≥18years) with isolated TBI admitted to a Level II trauma center. The prognostic value of SIRS, total SIRS scores, and each SIRS criterion was examined by Χ 2 and logistic regression analyses. Of the 330 patients identified, 50 (15.2%) met SIRS criteria. SIRS was significantly associated with poor outcome (P<0.001). Relative risk of poor outcome was 2.7 times higher in patients with a SIRS score of 2 on admission (P=0.007) and increased significantly to 6.5 times in patients with a SIRS score of 3 (P=0.002). Logistic regression demonstrated SIRS and each criterion to be significant independent prognostic factors (SIRS, P=0.030; body temperature, P=0.006; tachypnea, P=0.022, tachycardia P=0.023). SIRS at admission is an independent predictor of poor outcome in isolated TBI patients. These data demonstrate SIRS to be an important clinical tool that may be used in facilitating prognostication, particularly in elderly trauma patients. Future prospective studies aimed at therapeutic interventions to mitigate SIRS in TBI patients are warranted. Prognostic, Level III.

Older patients have increased risk of poor outcomes after low-velocity pedestrian-motor vehicle collisions.

BackgroundMotor vehicle collisions (MVCs) are a leading cause of injury in the US. While the probability of collision with a pedestrian (PMVC) has declined in recent years, the probability of a pedestrian fatality has risen. Our objective was to determine whether older age impacts potential outcomes in patients involved in low-velocity PMVCs.Materials and methodsWe performed a retrospective-cohort study of adult patients aged >14 years involved in low-velocity pedestrian–MVCs (<15 miles per hour [24.14 km/h]), presenting to an urban level I trauma center from January to November 2013. Subjects were identified via trauma registry and stratified: ages 15–49 years and ≥50 years. Electronic medical records were reviewed for demographics, vital signs, and laboratory results on initial presentation, presence or absence of systemic inflammatory response syndrome (SIRS), shock index (SI), injury-severity score (ISS), length of stay (LOS), and survival to discharge. For statistical analysis, χ2 or Student’s t-tests were utilized.ResultsOur study included 145 patients (77 female) with a mean age of 41.9±3 years; 95 patients were aged 15–49 years (mean 31.9±2.2 years), and 50 patients were aged ≥50 years or older (mean 62.44±2.9 years). Mean ISS was 10.05±1.95, mean SI was 0.68±0.03, and mean LOS was 3.67±0.57 days. A total of 41 patients met SIRS criteria on arrival, and nine patients expired (6.2%). Mean ISS (15.64±4.42 vs 7.1±1.64, P<0.001) and mean SI (0.75±0.07 vs 0.65±0.03, P=0.002) were higher in patients aged ≥50 years. Mean LOS was longer in older patients (5.22±1.14 vs 2.85±0.58 days, P<0.001). Older age was associated with SIRS on arrival (P=0.023) and associated with mortality (P=0.004).ConclusionAge ≥50 years is associated with greater severity of injury and poor outcomes for patients involved in low-velocity PMVCs. Increased clinical attention and resource allocation should be directed toward older patients after low-velocity PMVCs.

Application of the Third International Consensus Definitions for Sepsis (Sepsis-3) Classification: a retrospective population-based cohort study

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) present clinical criteria for the classification of patients with sepsis. We investigated incidence and long-term outcomes of patients diagnosed with these classifications, which are currently unknown. We did a retrospective analysis using data from 30 239 participants from the USA who were aged at least 45 years and enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Patients were enrolled between Jan 25, 2003, and Oct 30, 2007, and we identified hospital admissions from Feb 5, 2003, to Dec 31, 2012, and applied three classifications: infection and systemic inflammatory response syndrome (SIRS) criteria, elevated sepsis-related organ failure assessment (SOFA) score from Sepsis-3, and elevated quick SOFA (qSOFA) score from Sepsis-3. We estimated incidence during the study period, in-hospital mortality, and 1-year mortality. Of 2593 first infection events, 1526 met SIRS criteria, 1080 met SOFA criteria, and 378 met qSOFA criteria. Incidence was 8·2 events (95% CI 7·8-8·7) per 1000 person-years for SIRS, 5·8 events (5·4-6·1) per 1000 person-years for SOFA, and 2·0 events (1·8-2·2) per 1000 person-years for qSOFA. In-hospital mortality was higher for patients with an elevated qSOFA score (67 [23%] of 295 patients died) than for those with an elevated SOFA score (125 [13%] of 960 patients died) or who met SIRS criteria (128 [9%] of 1392 patients died). Mortality at 1 year after discharge was also highest for patients with an elevated qSOFA score (29·4 deaths [95% CI 22·3-38·7] per 100 person-years) compared with those with an elevated SOFA score (22·6 deaths [19·2-26·6] per 100 person-years) or those who met SIRS criteria (14·7 deaths [12·5-17·2] per 100 person-years). SIRS, SOFA, and qSOFA classifications identified different incidences and mortality. Our findings support the use of the SOFA and qSOFA classifications to identify patients with infection who are at elevated risk of poor outcomes. These classifications could be used in future epidemiological assessments and studies of patients with infection. National Institute for Nursing Research, National Center for Research Resources, and National Institute of Neurological Disorders and Stroke.

Postpercutaneous Nephrolithotomy Systemic Inflammatory Response Syndrome Is Not Associated With Unplanned Readmission

To investigate the incidence of systemic inflammatory response syndrome (SIRS) following percutaneous nephrolithotomy (PCNL) and evaluate any association with unplanned 90-day readmission. We retrospectively reviewed consecutive patients undergoing PCNL in 2 dedicated endourologic practices between 2009 and 2013. We collected patient demographics, perioperative culture data, and operative characteristics. SIRS was defined as having 2 or more of the following: maximum white blood cell count >12,000 or <4000, temperature >38 or <34°C, heart rate >90, and respiratory rate >20 within the first 24 hours following PCNL. Proportions between groups were compared to identify significant associations. We identified 389 patients undergoing PCNL and 43% (167 of 389) met SIRS criteria, more commonly in patients with multiple PCNL accesses (OR 2.3; CI: 1.1-4.8, P = .025). Readmission was required in 8% (31 of 389), most commonly for infection (n = 21). Although possession of a struvite stone was associated with unplanned readmission (16% vs 4%, P < .01), SIRS in the absence of fever within 48 hours postoperative was not associated with readmission (29.4% vs 25.8%, P = .837). Nearly half of the patients undergoing PCNL met the criteria for SIRS within the first postoperative day. There was no association between SIRS and unplanned readmission in the postoperative PCNL patient. Despite discharge during the first postoperative day, patients with SIRS (without fever or struvite stones) had no increased risk for unplanned return. Our findings suggest that the development of SIRS immediately following PCNL does not preclude safe discharge on the first postoperative day.

Abstract TP359: Admission Systemic Inflammatory Response Syndrome and Outcome Following Intracerebral Hemorrhage in a Multicenter Study

Background and Purpose: Systemic Inflammatory Response Syndrome (SIRS) has been shown to predict outcomes after intracerebral hemorrhage (ICH) in a single-center cohort. We hypothesized that SIRS would predict outcomes in a multicenter multi-ethnic cohort of ICH patients. Methods: The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a multi-center observational study of ICH among whites, blacks, and Hispanics. SIRS on admission was defined according to standard criteria as 2 or more of the following: (1) body temperature 38°C, (2) heart rate &gt; 90 beats per minute, (3) respiratory rate &gt; 20/minute, or (4) white blood cell count 12,000/mm3. Patients were excluded if they died within 72 hours of admission, or if missing vital signs or laboratory tests did not allow for assessment of SIRS on admission. Associations of SIRS with baseline characteristics, infection, and poor outcomes (modified Rankin Scale 3-6) at discharge and 3 months were assessed using t-tests, chi-square, and logistic regression. Results: Of 2411 patients included, 340 (14%) met SIRS criteria at admission. Patients with SIRS were younger (58.0 vs. 62.3 years; p&lt;.0001) and more likely to have intraventricular hemorrhage (IVH) (52.9% vs. 36.5%; p&lt;.0001), higher baseline ICH volume (25.2 vs. 17.4; p&lt;.0001), and lower baseline Glasgow Coma Score (GCS; 10.7 vs. 13.1; p&lt;.0001). SIRS was not associated with subsequent infection (OR 1.40, 95%CI 0.84-2.34). In unadjusted analyses, SIRS was associated with poor outcome at discharge (OR 2.0, 95%CI 1.5-2.7) and 3-months (OR 1.8, 95%CI 1.4-2.3). In patients with milder ICH (ICH score 0-2), SIRS was associated with poor mRS at discharge and 3 months, but SIRS was not related to outcomes for patients with baseline ICH score 3-5. After adjusting for age, IVH, ICH volume, GCS, ICH location, and pre-onset mRS, SIRS was no longer associated with poor outcomes. Conclusions: SIRS at admission is an indicator of stroke severity and thus a predictor of poor functional outcome, but not infection, after ICH. Further study is needed to better understand systemic inflammation after ICH.

253 Electronic Best Practice Advisories' Effectiveness in Detecting Sepsis in the Emergency Department

The incidence of severe sepsis is 750,000 cases per year in the U.S. and Canada, causing significant morbidity and mortality. Current guidelines from the Surviving Sepsis Campaign (SSC) recommend administering appropriate antibiotics within the first 3 hours of recognition of severe sepsis and septic shock; delayed antibiotic treatment is associated with increased morbidity. Best practice advisories (BPAs) are reminder tools within the Epic electronic health record (EHR) system that provide clinical decision support. This study aims to evaluate if BPAs are effective at detecting potentially septic patients in an emergency department (ED) setting. A structured retrospective review of medical records was conducted at an academic urban emergency department (annual visits >85,000) of patients who initially met systemic inflammatory response syndrome (SIRS) criteria after an electronic BPA was implemented (March 1, 2014 to March 30, 2014 and the first 7-day monthly period of April 1, 2014 to September 30, 2014). The BPA Sepsis Risk Scoring System was created based on the SSC guidelines and guided by the Detecting and Treating Sepsis manual from Epic Systems. A score >2.5 meant that a patient met SIRS criteria, is potentially septic, and triggered the BPA. The definitive diagnosis of sepsis for ED SIRS visits was based upon final diagnostic related group (DRG) coding and further established by imaging modalities, urinalysis, and physical exam findings on chart review. BPAs’ sensitivity, specificity, PPV, NPV was calculated and 95% confidence intervals (CI) established. Over the course of the study period, 13,906 records were screened, 565 BPAs fired and 313 cases of sepsis were confirmed (2.3% prevalence). The BPAs’ sensitivity and specificity was 74.5% (95% CI 69.2-79.1%) and 97.6% (95% CI 97.3-97.8%) respectively, with positive and negative predictive values of 41.2% (95% CI 37.2-45.4%) and 99.4% (95% CI 99.3-99.5%) respectively. The BPA’s positive and negative likelihood ratios (LR) (weighted for prevalence) were 0.70 (95% CI 0.62-0.79) and 0.006 (95% CI 0.005-0.008). No significant changes were noted in the BPA sensitivity or specificity when confined to severe sepsis or septic shock. BPAs were an effective EHR-based tool that detected potentially septic patients with moderate sensitivity and high specificity in our ED. The test’s high negative LR and negative predictive value make it valuable in excluding sepsis as differential diagnosis in a general ED population. Future directions for follow-up studies include cost analysis, morbidity/mortality studies, and multicenter comparisons of other quality metrics that can be improved by having a system such as BPA that reduces time to appropriate medical intervention.

MP30-03 IS PREOPERATIVE ANTIBIOTIC PROPHYLAXIS FOR HIGH-RISK PATIENTS NECESSARY BEFORE PERCUTANEOUS NEPHROLITHOTOMY? A RETROSPECTIVE REVIEW OF 7 VS 2 VS 0 DAY THERAPY

You have accessJournal of UrologyStone Disease: Surgical Therapy III1 Apr 2015MP30-03 IS PREOPERATIVE ANTIBIOTIC PROPHYLAXIS FOR HIGH-RISK PATIENTS NECESSARY BEFORE PERCUTANEOUS NEPHROLITHOTOMY? A RETROSPECTIVE REVIEW OF 7 VS 2 VS 0 DAY THERAPY Jeffrey Larson, Aaron Potretzke, Alana Desai, and Brian Benway Jeffrey LarsonJeffrey Larson More articles by this author , Aaron PotretzkeAaron Potretzke More articles by this author , Alana DesaiAlana Desai More articles by this author , and Brian BenwayBrian Benway More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.585AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Postoperative infection after percutaneous nephrolithotomy (PCNL) is a serious complication that can occur despite sterile urine. Previous studies have suggested that extended preoperative antibiotic therapy can reduce the risk of systemic inflammatory response syndrome (SIRS) in high-risk patients with sterile urine. The goal of this study is to investigate our expanded series comparing 7 vs 2 vs 0 days preoperative antibiotics in high-risk patients with sterile preoperative urine. METHODS We retrospectively reviewed 292 consecutive PCNLs performed by two surgeons at one institution between 2012 and 2014. Patients with positive preoperative urine cultures were excluded and those with sterile urine were divided into low- (excluded from this study) or high-risk (previous UTI, dilated pelvicaliceal system, or stone ≥20mm) groups. Patients in the high-risk group were treated with either 7, 2 or 0 days preoperative antibiotic prophylaxis prior to PCNL. This cohort was used in univariate and multivariate regression models to predict postoperative fever and SIRS. RESULTS Of the 292 patients, 192 (65.7%) had sterile urine of which 140 (47.9%) met high-risk criteria and were treated with either 7 days (27 pts), 2 days (40 pts) or 0 days (72 pts) prophylactic antibiotics. All three groups were similar in age, gender and duration of surgery. In patients treated with 7, 2 and 0 days preoperative antibiotic prophylaxis, 1 (3.7%), 2 (5%) and 3 (4.2%) patients met SIRS criteria. There was no significant difference between groups (Table 1). CONCLUSIONS Our previous study demonstrated that preoperative antibiotic prophylaxis of 7 vs 2 days was equivalent in preventing SIRS and infectious complications in high risk PCNL patients. The current study did not find a difference in postoperative infection between patients treated with extended prophylactic preoperative antibiotics and those given only perioperative antibiotic therapy on the day of surgery. Our results suggest that routine antibiotic prophylaxis in patients with sterile preoperative urine is not necessary to prevent postoperative infection. Table 1. Baseline characteristics Baseline patient characteristics 7-day 2-day 0-day p-value Number of patients 27 40 72 Mean age, years (SD) 55 (15.9) 57.8 (18.4) 56.5 (13.3) 0.562 Female gender (%) 17 (63) 23 (57.5) 33 (45.8) 0.05 Pelvicalyectasis, No. (%) 9 (33.3) 15 (37.5) 33 (45.8) 0.437 History of UTI, No. (%) 13 (48.1) 17 (42.5) 35 (48.6) 0.398 Stone ≥ 20mm, No. (%) 23 (85.2) 29 (72.5) 51 (70.8) 0.531 Mean stone size, (SD) 22.9 (8.5) 24.2 (12.3) 23.9 (12.1) 0.284 Surgery duration, min (SD) 141(54.9) 149(62.6) 104(38.5) 0.074 Infection Outcomes Postoperative fever, No. (%) 1 (3.7) 0 1 (1.4) 1 Met SIRS criteria, No. (%) 1 (3.7) 2 (5) 3 (4.2) 1 SIRS = Systemic Inflammatory Response Syndrome © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e347-e348 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Larson More articles by this author Aaron Potretzke More articles by this author Alana Desai More articles by this author Brian Benway More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...