Systemic Inflammatory Response Syndrome Criteria Research Articles

Updates in Sepsis Management Show Thoughtful Approach

Updates in Sepsis Management Show Thoughtful Approach

Improved hospital mortality rates after the implementation of emergency department sepsis teams.

Sepsis is a leading cause of mortality with more than 700,000 hospitalizations and 200,000 deaths annually in the United States. Early recognition of sepsis is critical for timely initiation of treatment and improved outcomes. We sought to evaluate. in-hospital mortality rates of patients diagnosed with sepsis before and after implementation of emergency department (ED) sepsis teams. This was a retrospective study of adult patients seen at a tertiary care ED diagnosed with sepsis and severe sepsis. Pre-implementation study time frame was 5/1/2018-4/30/2019 and post-implementation was 11/1/2019-9/30/2020. A six-month washout period was utilized after implementation of ED-based sepsis teams. Indications for sepsis team activation were: two systemic inflammatory response syndrome (SIRS) criteria with suspected infection or two SIRS with confirmed infection during workup. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation or median and quartiles depending on distribution. Multiple logistic regression compared mortality rates pre- and post-implementation while controlling for Charlson comorbidity index. Secondary objectives included comparing time metrics pre- and post-implementation. Student t-tests compared normally distributed variables and Wilcoxon rank sum tests compared non-normally distributed variables. There were 1188 participants included in the study; 553 before implementation of sepsis teams and 635 after implementation. Mean age of participants was 64years. Patients were 74.7% white and 22.6% black. Medicare was the most common health insurance (59%). Mortality rates were significantly lower post-implementation of sepsis teams compared to pre-implementation with an adjusted odds ratio of 0.472, (95%CI, 0.352-0.632). ED LOS (95%CI (-67.2--11.3), hospital LOS (95%CI, -1.0--0.002) and time to lactic acid (95%CI, -10.0- -3.0) and antibiotics (95%CI, -29.0--11.0) were all significantly lower after implementation. Implementation of ED sepsis teams decreased inpatient hospital mortality rates, ED length of stay and hospital length of stay.

Recent Advances in Bedside Device-Based Early Detection of Sepsis.

Early detection of sepsis is challenging to achieve with current diagnostic methods, leading to expenditures of $27 billion annually in the United States with significant associated mortality. Various scoring systems have been proposed such as the sequential organ failure assessment (SOFA) and systemic inflammatory response syndrome (SIRS) criteria for identification of sepsis, but their sensitivities range from 60% to 70% when used in the emergency department triage. Other methods for the recognition of sepsis may rely on laboratory work, in addition to vitals monitoring, and are often outpaced by the development of sepsis. Automated alerts have not shown any reduction in mortality thus far. New technology may fill a critical gap in the early detection of sepsis. The ideal bedside screening device for would demonstrate rapid time to result, high portability, and high sensitivity to not miss cases, but also reasonable specificity to prevent provider fatigue from excessive false alerts. Non-invasive end-organ perfusion devices analyzing lactate and capillary refill time (CRT) tend to perform well in speed and portability, but may be less sensitive. Biomarker devices demonstrate a wider array of performance metrics. Those analyzing a single biomarker tend to be more sensitive but are less specific to the diagnosis of sepsis than technologies that assess multiple biomarkers, which in turn have lower sensitivity. Additionally, biomarker devices are generally invasive requiring blood samples, which may or may not be feasible in all patients especially when serial draws are needed. Sepsis is a complex disease process and most likely will require a combination of improved technology in addition to vital signs and high-risk patient history for better recognition. This review examines recent advances in the device-based early detection of sepsis between 2017 and 2020 with emphasis on bedside diagnostics, divided into markers of perfusion and biomarkers commonly implicated in sepsis.

Association Between Implementation of the Severe Sepsis and Septic Shock Early Management Bundle Performance Measure and Outcomes in Patients With Suspected Sepsis in US Hospitals

In October 2015, the Centers for Medicare & Medicaid Services began requiring US hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). To evaluate the association of SEP-1 implementation with sepsis treatment patterns and outcomes in diverse hospitals. This retrospective cohort study with interrupted time-series analysis and logistic regression models was conducted among adults admitted to 114 hospitals from October 2013 to December 2017 with suspected sepsis (blood culture orders, ≥2 systemic inflammatory response syndrome criteria, and acute organ dysfunction) within 24 hours of hospital arrival. Data analysis was conducted from September 2020 to September 2021. SEP-1 implementation in the fourth quarter (Q4) of 2015. The primary outcome was quarterly rates of risk-adjusted short-term mortality (in-hospital death or discharge to hospice). Secondary outcomes included lactate testing and administration of anti-methicillin-resistant Staphylococcus aureus (MRSA) or antipseudomonal β-lactam antibiotics within 24 hours of hospital arrival. Generalized estimating equations with robust sandwich variances were used to fit logistic regression models to assess for changes in level or trends in these outcomes, adjusting for baseline characteristics and severity of illness. The cohort included 117 510 patients (median [IQR] age, 67 years [55-78] years; 60 530 [51.5%] men and 56 980 [48.5%] women) with suspected sepsis. Lactate testing rates increased from 55.1% (95% CI, 53.9%-56.2%) in Q4 of 2013 to 76.7% (95% CI, 75.4%-78.0%) in Q4 of 2017, with a significant level change following SEP-1 implementation (odds ratio [OR], 1.34; 95% CI, 1.04-1.74). There were increases in use of anti-MRSA antibiotics (19.8% [95% CI, 18.9%-20.7%] in Q4 of 2013 to 26.3% [95% CI, 24.9%-27.7%] in Q4 of 2017) and antipseudomonal antibiotics (27.7% [95% CI, 26.7%-28.8%] in Q4 of 2013 to 40.5% [95% CI, 38.9%-42.0%] in Q4 of 2017), but these trends preceded SEP-1 and did not change with SEP-1 implementation. Unadjusted short-term mortality rates were similar in the pre-SEP-1 period (Q4 of 2013 through Q3 of 2015) vs the post-SEP-1 period (Q1 of 2016 through Q4 of 2017) (20.3% [95% CI, 20.0%-20.6%] vs 20.4% [95% CI, 20.1%-20.7%]), and SEP-1 implementation was not associated with changes in level (OR, 0.94; 95% CI, 0.68-1.29) or trend (OR, 1.00; 95% CI, 0.97-1.04) for risk-adjusted short-term mortality rates. In this cohort study, SEP-1 implementation was associated with an immediate increase in lactate testing rates, no change in already-increasing rates of broad-spectrum antibiotic use, and no change in short-term mortality rates for patients with suspected sepsis. Other approaches to decrease sepsis mortality may be warranted.

Evolving Definition and Diagnostic Criteria of Sepsis

For many years, the Systemic Inflammatory Response Syndrome (SIRS) criteria were primarily considered for the diagnosis of sepsis, promoting the importance of inflammation. The definition and dia gnostic criteria of sepsis has undergone a sizeable metamorphosis from the inception of standardized definitions of sepsis in 1991. In 1991, the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) convened in Chicago and emphasized that sepsis is an ‘ongoing process’ of infection and considered SIRS score of two or more for diagnosis of sepsis. SOFA scoring system is an easily calculated system using parameters that are usually obtained during routine care of patients. This ensures that delays are avoided from requirement of any special investigations, making it reproducible in any number of healthcare settings.

Modified Shock Index as an Indicator for Prognosis Among Sepsis Patients With and Without Comorbidities Presenting to the Emergency Department.

Objectives: Modified shock index (MSI) is a simple bedside tool used in the emergency department. There are a few studies suggesting MSI as a good prognostic indicator than shock index in sepsis patients. However, there is not enough research emphasizing the role of MSI in patients with comorbidities. Hence, this study aims to assess the predictive validity of MSI in predicting the prognosis of sepsis patients with and without co-morbidities.Methods: From January to December 2020, a prospective observational study was conducted in a tertiary care teaching hospital. Patients with sepsis diagnosed based on systemic inflammatory response syndrome criteria and quick sequential organ failure assessment (qSOFA) were included. The need for mechanical ventilation and step down from the intensive care unit were outcome variables, MSI was considered as a predictor variable, and co-morbidities as an explanatory variable.Results: Among people with co-morbidities, the MSI value on arrival to the emergency department had fair predictive validity in predicting the need for mechanical ventilation after 24 hours, as indicated by the area under the curve of 0.749 (95% CI: 0.600-0.897; p-value = 0.002) and a sensitivity of 68.75% in predicting mechanical ventilation after 24 hours (MSI ≥ 1.59). Among people without co-morbidities, the MSI value on arrival to the emergency department had fair predictive validity in predicting the need for mechanical ventilation after 24 hours, as indicated by the area under the curve of 0.879 (95% CI: 0.770-0.988; p-value <0.001) and a sensitivity of 83.33% in predicting the need for mechanical ventilation after 24 hours (MSI ≥ 1.67).Conclusion: MSI can be used as an indicator in predicting the prognosis of sepsis patients in the emergency department. A simple bedside calculation of the MSI can indicate the need for mechanical ventilation and step down from the intensive care unit after 24 hours in patients with co-morbidities and without co-morbidities.

A prospective study on clinical pharmacist intervention in assessing the management and treatment outcome of sepsis

Sepsis is defined as a life threatening organ dysfunction caused by a dysregulated host response to an infection. When people suffer from sepsis, it results in widespread inflammation, swelling and blood clotting. This study targeted to assess the management and treatment outcome of sepsis. The study aims to identify the treatment patterns followed in various departments of hospital, to provide counseling to patients/bystanders, to give awareness to nursing professionals for early identification of sepsis. The study is a prospective observational study conducted for a period of one year. Patients and their caregivers were educated for special care on sepsis. An awareness session was provided to nursing professionals on early identification and care on sepsis. A total of 115 patients were recruited for the study that was screened for sepsis by Systemic Inflammatory Response Syndrome criteria. The result of the study indicated that there is a higher prevalence of sepsis patients with pulmonary disorders. Majority (63%) of the patients were provided with cephalosporins to treat the infection. 85% of the patients had a past history of diseases. Counseling was provided during ward rounds to patients and bystanders. 95% of the patients have recovered from the disease condition.The primary treatment provided, the details of the patients who were subjected to culture studies, treatment provided during discharge, patient counseling and educational programs to nurses were done during the study.

Effects of the peripherally acting \u03bc-opioid receptor antagonist methylnaltrexone on acute pancreatitis severity: study protocol for a multicentre double-blind randomised placebo-controlled interventional trial, the PAMORA-AP trial

BackgroundModerate to severe acute pancreatitis (AP) is associated with a high rate of complications and increased mortality, yet no targeted pharmacologic treatment currently exists. As pain is a dominant symptom in AP, patients are exposed to excess levels of both endo- and exogenous opioids, which may have harmful effects on the course of AP. This trial investigates the effects of the peripherally acting μ-opioid receptor antagonist (PAMORA) methylnaltrexone on disease severity and clinical outcomes in patients with moderate to severe AP.MethodsPAMORA-AP is a multicentre, investigator-initiated, double-blind, randomised, placebo-controlled, interventional trial, which will be conducted at four referral centres for acute pancreatitis in Denmark. Ninety patients with early-onset AP (pain onset within 48 h) as well as predicted moderate to severe disease (two or more systemic inflammatory response syndrome criteria upon admission) will be prospectively included. Subsequently, participants will be randomised (1:1) to intravenous treatment with either methylnaltrexone or matching placebo (Ringer’s lactate) during 5 days of admission. The primary endpoint will be the group difference in disease severity as defined and measured by the Pancreatitis Activity Scoring System (PASS) score 48 h after randomisation. Secondary endpoints include daily PASS scores; disease severity according to the Atlanta classification; quantification of need for analgesics, nutritional support, intravenous fluid resuscitation and antibiotics; duration of hospital admissions, readmission rates and mortality. Pain intensity and gut function will be self-reported using validated questionnaires. Exploratory endpoints include circulating levels of pro-and anti-inflammatory markers, polyethylene glycol recovery from the urine, circulating levels of blood markers of intestinal permeability, the prevalence of pancreatic complications on computed tomography (CT) scans, and colon transit time assessed using a CT-based radiopaque marker method.DiscussionThis trial aims to evaluate the PAMORA methylnaltrexone as a novel targeted pharmacotherapy in patients with moderate to severe AP with the potential benefit of improved patient outcomes.Trial registrationClinicalTrials.govNCT04743570. Registered on 28 January 2021. EudraCT 2020-002313-18.

Utility of specific laboratory biomarkers to predict severe sepsis in pediatric patients with SIRS.

To identify the association between readily available laboratory biomarkers and the development of severe sepsis in children presenting to the emergency department (ED) with systemic inflammatory response syndrome (SIRS). In this retrospective cohort study, ED patient encounters from June 2018 to June 2019 that triggered an automated sepsis alert based on SIRS criteria were analyzed. Encounters were included if the patient had any of the following laboratory tests sent within 6h of ED arrival: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), lactic acid, and procalcitonin. For each of the biomarkers, a receiver operating characteristic (ROC) curve was created for our primary outcome, severe sepsis within 24h of ED disposition, and our secondary outcome, severe sepsis with a positive bacterial culture. For each ROC curve, we calculated the area under the curve (AUC) with 95% confidence intervals (95% CI) and created cutoff points to achieve 90% sensitivity and 90% sensitivity for the primary and secondary outcomes. During the study period, 4349/61,195 (7.1%) encounters triggered an automated sepsis alert. Of those, 1207/4349 (27.8%) had one of the candidate biomarkers sent within 6h of ED arrival and were included in the study. A total of 100/1207 (8.3%) met criteria for severe sepsis within 24h of arrival, and 41/100 severe sepsis cases (41%) were deemed culture-positive. Procalcitonin had the highest AUC for identifying severe sepsis [0.62 (95% CI 0.52-0.73)] while ESR and CRP had the highest AUC for culture-positive sepsis [0.68 (95% CI 0.47-0.89) and 0.67 (95% CI 0.53-0.81), respectively]. At 90% sensitivity for detecting severe sepsis, all of the biomarker threshold values fell within that laboratory test's normal range. At 90% specificity for severe sepsis, threshold values were as follows: procalcitonin 2.72ng/mL, CRP 16.79mg/dL, ESR 79.5mm/h and lactic acid 3.6mmol/L. Our data indicate that CRP, ESR, lactic acid, and procalcitonin elevations were all specific, but not sensitive, in identifying children in the ED with SIRS who go on to develop severe sepsis.

Delayed Presentation and Mortality in Children With Sepsis in a Public Tertiary Care Hospital in Tanzania.

Background: Over 40% of the global burden of sepsis occurs in children under 5 years of age, making pediatric sepsis the top cause of death for this age group. Prior studies have shown that outcomes in children with sepsis improve by minimizing the time between symptom onset and treatment. This is a challenge in resource-limited settings where access to definitive care is limited.Methods: A secondary analysis was performed on data from 1,803 patients (28 days−14 years old) who presented to the emergency department (ED) at Muhimbili National Hospital (MNH) from July 1, 2016 to June 30, 2017 with a suspected infection and ≥2 clinical systemic inflammatory response syndrome criteria. The objective of this study was to determine the relationship between delayed presentation to definitive care (>48 h between fever onset and presentation to the ED) and mortality, as well as the association between socioeconomic status (SES) and delayed presentation. Multivariable logistic regression models tested the two relationships of interest. We report both unadjusted and adjusted odds ratios and 95% confidence intervals.Results: During the study period, 11.3% (n = 203) of children who presented to MNH with sepsis died inhospital. Delayed presentation was more common in non-survivors (n = 90/151, 60%) compared to survivors (n = 614/1,353, 45%) (p ≤ 0.01). Children who had delayed presentation to definitive care, compared to those who did not, had an adjusted odds ratio for mortality of 1.85 (95% CI: 1.17–3.00).Conclusions: Delayed presentation was an independent risk factor for mortality in this cohort, emphasizing the importance of timely presentation to care for pediatric sepsis patients. Potential interventions include more efficient referral networks and emergency transportation systems to MNH. Additional clinics or hospitals with pediatric critical care may reduce pediatric sepsis mortality in Tanzania, as well as parental education programs for recognizing pediatric sepsis.

Frequency of alterations in qSOFA, SIRS, MEWS and NEWS scores during the emergency department stay in infectious patients: a prospective study

BackgroundFor emergency department (ED) patients with suspected infection, a vital sign-based clinical rule is often calculated shortly after the patient arrives. The clinical rule score (normal or abnormal) provides information about diagnosis and/or prognosis. Since vital signs vary over time, the clinical rule scores can change as well. In this prospective multicentre study, we investigate how often the scores of four frequently used clinical rules change during the ED stay of patients with suspected infection.MethodsAdult (≥ 18 years) patients with suspected infection were prospectively included in three Dutch EDs between March 2016 and December 2019. Vital signs were measured in 30-min intervals and the quick Sequential Organ Failure Assessment (qSOFA) score, the Systemic Inflammatory Response Syndrome (SIRS) criteria, the Modified Early Warning Score and the National Early Warning Score (NEWS) score were calculated. Using the established cut-off points, we analysed how often alterations in clinical rule scores occurred (i.e. switched from normal to abnormal or vice versa). In addition, we investigated which vital signs caused most alterations.ResultsWe included 1433 patients, of whom a clinical rule score changed once or more in 637 (44.5%) patients. In 6.7–17.5% (depending on the clinical rule) of patients with an initial negative clinical rule score, a positive score occurred later during ED stay. In over half (54.3–65.0%) of patients with an initial positive clinical rule score, the score became negative later on. The respiratory rate caused most (51.2%) alterations.ConclusionAfter ED arrival, alterations in qSOFA, SIRS, MEWS and/or NEWS score are present in almost half of patients with suspected infection. The most contributing vital sign to these alterations was the respiratory rate. One in 6–15 patients displayed an abnormal clinical rule score after a normal initial score. Clinicians should be aware of the frequency of these alterations in clinical rule scores, as clinical rules are widely used for diagnosis and/or prognosis and the optimal moment of assessing them is unknown.

1156 NELA – Time to Antibiotics

Abstract Introduction Early administration of antibiotics is vital in patients that have intra-abdominal sepsis. The National Emergency Laparotomy Audit (NELA) 2019 found only 19% of patients with suspected sepsis received antibiotics in the first hour. The aim of this project was to audit the current time to antibiotics in patients who underwent an emergency laparotomy in our District General Hospital (DGH) in Wales. Method This was a retrospective audit of all patients that underwent an emergency laparotomy between January to July 2019. Data was collected from the NELA database and Clinical Notes. Results 33 patients underwent an emergency laparotomy, 2 patients were excluded leaving a total of 31 patients. 55% of patients received antibiotics prior to theatre. 61% of patients triggered the systemic inflammatory response syndrome (SIRS) criteria on admission but only 47% of these patients received antibiotics. Of those that received antibiotics only 16% had them prescribed within 1 hour of arriving to the hospital. 41% of patients waited over an hour from the antibiotics being prescribed to receiving them and 1 patient did not receive the antibiotics at all. Conclusions This project shows there are many areas for improvement. Although antibiotics maybe prescribed, clear communication with nursing staff is important, so that they can be given in a timely manner. It is also important simple measures, like working cannulas, do not prevent administration of antibiotics. Re-audit of these results is vital after education. Some patients may not require antibiotics – but missing those that do could cost lives!

Reducing Sepsis Hospitalisations through a Standardized Quality Improvement Program in Skilled Nursing Facilities

Context: Sepsis hospitalisations with subsequent skilled nursing facility (SNF) admissions have had an annual cost of $41 billion in the United States. There has been a limited amount of literature on early interventions for sepsis in long-term care. Objective: To assess the impact of a pilot sepsis quality improvement program (SQIP) aimed at early identification and intervention in 10 partnering SNFs in New York City. Methods: Obtained baseline data of sepsis hospitalisations in 2017 among 10 SNFs. A SQIP was implemented utilizing the systemic inflammatory response syndrome criteria with a modified threshold temperature of 37.2°C (99.0°F). Sepsis hospitalisations were reported and validated for the intervention period in 2018 and compared to the baseline. A cost savings analysis was completed by utilizing local hospital billing records. Findings: Overall, there was a reduction of 54 sepsis hospitalisations when comparing the intervention period (183 sepsis hospitalisations) to the baseline (237 sepsis hospitalisations), a 22.8% decrease (p Limitations: Implementation at each facility was voluntary, so there may have been varying degrees of SQIP implementation. However, the hospital primary diagnosis of sepsis and cost were accurately reported. Implications: A SQIP in a long-term care setting could reduce avoidable hospitalisations and offer cost savings. The SQIP reported is a complex intervention and needs to be methodologically understood as such. The intervention shows promise and important insights into its implementation and evaluation have been developed which would be helpful in further evaluation.

Utility of neutrophil CD64 in distinguishing bacterial infection from inflammation in severe alcoholic hepatitis fulfilling SIRS criteria

To assess utility of neutrophilCD64 (nCD64) expression in differentiating bacterial infection from inflammation in patients with severe alcoholic hepatitis (SAH) fulfilling systemic inflammatory response syndrome criteria. Patients with SAH and infection (n = 58), SAH without infection (n = 70), and healthy controls (n = 20) were included. Neutrophil CD64 expression by flowcytometry, serum Procalcitonin (ELISA) and C-reactive protein (Nephelometry) and neutrophil–lymphocyte ratio (NLR) were studied. Percentage of neutrophils with CD64 expression (nCD64%) was significantly higher in patients with SAH and infection than in those without infection and controls [76.2% (56.9–86.5) vs. 16% (12.6–23.1) vs. 7.05% (1.4–9.5), p < 0.05], as was their mean fluorescence intensity [MFI; 1431 (229–1828) vs. 853 (20–968) vs. 99.5 (54.7–140.7), p < 0.05]. Using a cut-off of 27%, the sensitivity and specificity of nCD64% to diagnose bacterial infection was 94% and 81%, respectively, with area under curve (AUC) of 0.95. At a cut-off value of 0.261 ng/ml, the sensitivity and specificity of serum procalcitonin was 83% and 72%, respectively, with AUC of 0.86. Serum CRP, total leukocyte count, NLR had AUCs of 0.78, 0.63 and 0.64, respectively. Quantitative measurement of nCD64 can better distinguish systemic bacterial infection and inflammation in SAH as compared to traditional biomarkers.

Comparative study of the performance of SOFA and qSOFA versus SIRS criteria for predicting mortality among septic patients admitted to the intensive care unit

Abstract Background Sepsis is considered one of a life-threatening condition among intensive care unit (ICU) patients. Although, there are evidence-based management guidelines, sepsis still remains a leading cause of death with in-hospital mortality ranging from 22.8% to 48.7%. Previously sepsis was defined as systemic inflammatory response to infection, which could be diagnosed by meeting two or more Systemic Inflammatory Response Syndrome (SIRS) criteria, along with a known or suspected infection. Even though the SIRS criteria were sensitive, but they were not specific enough to differentiate between sepsis and other inflammatory conditions. Objective To compare between the ability of SOFA score, the quick SOFA (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) to predict ICU mortality. Patients and Methods Randomized prospective comparative study conducted in El Haram Specialized Hospital. The study included 75 patients. We calculated SOFA, SIRS, and qSOFA scores based on physiological and laboratory data that were collected upon admission to the ICU. Standard criteria were applied with a threshold of 2 or more points for each scoring system. The baseline SOFA score was assumed to be zero for patients without a known preexisting organ dysfunction. The baseline total SOFA score was considered to be 4 for patients undergoing chronic dialysis, and 2 or 3 for cirrhotic patients, depending on baseline bilirubin levels. Results ROC curve analysis between survival and each of SIRS, qSOFA and SOFA, it shows that SOFA score presented the best discrimination with an AUC of 0.993 (95% CI 0.981–100). Conclusion In patients with suspected infection admitted to an ICU, an increase in SOFA score had greater prognostic accuracy for in-hospital mortality than SIRS criteria or qSOFA. These findings suggest that SIRS and qSOFA may have limited use for predicting mortality in an ICU setting.

A comparison of the infection related critical illness scores for predicting mortality in patients with infection or suspected infection: a network Meta-analysis

To evaluate the prognostic accuracy of the sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) criteria in predicting the mortality in patients with infection or suspected infection by using network Meta-analysis. Five databases including Wanfang Data, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), PubMed, Web of Science were searched from February 23, 2016 to September 5, 2020 to identify the relevant literatures comparing the prognostic accuracy of two or more scores for mortality in patients with infection or suspected infection. The literatures screening, data extraction and the quality assessment of the included studies were all conducted independently by two reviewers. Stata 14.0 software was used to test the heterogeneity between the original studies of pairwise comparison of each of the three scoring systems. Ring inconsistency test was used to judge the consistency between direct comparison and indirect comparison. Then network Meta-analysis was performed and the results were ranked. The predictive ability of the three scoring systems was evaluated by surface under cumulative ranking curve (SUCRA). A "comparison-correction" funnel plot was drawn to assess whether there was publication bias in the included studies. A total of 38 studies were enrolled, the overall quality was high. Network meta-analysis showed that SOFA had a great prognostic performance in predicting mortality for patients with infection or suspected infection, which was followed by qSOFA [mean difference (MD) = 0.07, 95% confidence interval (95%CI) was 0.05-0.09] and SIRS scores (MD = 0.16, 95%CI was 0.14-0.18), and the qSOFA score was better than SIRS score (MD = 0.09, 95%CI was 0.07-0.11). In the order of predicting the death risk of patients with infection or suspected infection, SOFA score had higher predictive value, followed by qSOFA score, and SIRS score was the lowest, with SUCRA values of 1.0, 0.5 and 0, respectively. Funnel plot showed that all the studies were distributed on both sides of the midline, but the distribution was not symmetrical, suggesting that there was a high possibility of publication bias and small sample effect. SOFA score had the best prognostic performance in predicting mortality of patients with infection or suspected infection as compared with qSOFA score and SIRS score. However, the funnel plot showed that included literatures may exist small sample effects or publication bias. So the final results should be validated by more prospective studies with multicenters and large samples.

S112 Isolated Organ Failure Increases Morbidity But Not Mortality in Patients With Necrotizing Pancreatitis—A Single Tertiary Center Experience in 581 Patients

Introduction: Necrotizing pancreatitis (NP) has a variable clinical course and it is essential to identify determinants associated with high risk of mortality and poor clinical outcomes. Specific clinical outcomes of NP patients with selected forms of organ failure (OF) have not been well characterized. We aimed to evaluate differences in clinical outcomes of isolated organ failure (IOF), multiple organ failure (MOF) and no persistent organ failure (NPOF) in patients with NP. Methods: We performed a post hoc analysis of a prospectively maintained database of 581 NP patients managed at our center between 2009 to 2020. Patients diagnosed with OF on admission with evidence of persistent OF (POF, duration of OF ≥ 48h) were classified as IOF or MOF (≥ 2 organs involved) per the Modified Marshall Score. Baseline characteristics including demographics, ASA score, etiology of NP, systemic inflammatory response syndrome (SIRS) criteria, and clinical outcomes were recorded. Differences in clinical outcomes after development of selected forms of OF were evaluated using the Mann-Whitney U test, χ2 test or Fisher's exact test as appropriate. P < 0.05 was considered significant. Results: Among 581 patients with NP, 167 (28.7%) developed POF. Mean age was 51.3 years and 391 (67.3%) were male. Thirty-six (6.2%) patients had IOF: 16 had isolated acute kidney injury (IAKI), 18 respiratory failure, and 2 cardiovascular failure. Compared to MOF, IOF patients were less likely to have SIRS at 48h of admission (58.3% vs 78.6%, P = 0.014), require intervention (47.2% vs 68.7%, P < 0.0001) or ICU admission (58.3% vs 92.4%, P < 0.0001), had shorter median total length of stay (LOS, 21.5d vs 35d, P = 0.001), lower incidence of ASA IV (2.8% vs 18.3%, P = 0.046), and lower inpatient mortality (2.8% vs 22.1%, P = 0.007). Compared to NPOF, IOF patients had a higher need for ICU admission (58.3% vs 21.5%, P < 0.0001) and longer median total LOS (21.5d vs 14d, P = 0.001), although inpatient mortality did not differ (2.8% vs 4.3%, P = 1). Comparing subtypes of IOF, IAKI required less ICU admission (31.3% vs 77.8%, P = 0.006) and had lower median ICU LOS (2d vs 8d, P = 0.034), other parameters did not significantly differ. Conclusion: Our results suggest that IOF disease trajectory is different from MOF and more similar to NPOF as mortality was not affected despite increased morbidity. Furthermore, MOF presented more likely in patients with more comorbidities given the higher number of ASA IV patients.Figure 1.: Patient cohort flowchart based on development of selected forms of organ failure. NP: Necrotizing pancreatitis; OF: Organ failure; POF: Persistent organ failure; NPOF: No persistent organ failure; IOF: Isolated organ failure; MOF: Multiple organ failure; IRF: Isolated respiratory failure; IAKI: Isolated acute kidney injury; ICVF: Isolated cardiovascular failure.Table 1.: Table Characteristics, Severity Predictors and Clinical Outcomes in Specific Subgroups of Patients With Necrotizing Pancreatitis

Performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for predicting 30-day adverse outcomes in patients with suspected infection.

The use of the quick sequential organ failure assessment score (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to identify patients at high risk for adverse outcomes in the emergency department (ED) remains controversial due to their low predictive performance and lack of supporting evidence. This study aimed to determine the predictive performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for adverse outcomes. All adult patients admitted to the ED with suspected infection were prospectively included. qSOFA scores ≥ 2, SIRS score ≥ 2 were defined as risk-positive for adverse outcome. Furthermore, combination‑1, which was defined as either qSOFA or SIRS positivity, and combination‑2, which was defined as both qSOFA and SIRS positivity, were also considered as risk-positive for adverse outcome. The predictive performance of qSOFA, SIRS, combination‑1, and combination‑2 for acomposite adverse outcome within 30days, including mortality, intensive care unit (ICU) admission, and non-ICU hospitalization, were determined. Atotal of 350patients were included in the analysis. The composite outcome occurred in 211 (60.3%) patients within 30days: mortality in 84(24%), ICU admission in 78(22.3%), and non-ICU hospitalization in 154 (44%). The sensitivity and specificity, respectively, were determined in predicting composite outcome as 0.34 and 0.93 for qSOFA, 0.81 and 0.31 for SIRS, 0.84 and 0.28 for combination‑1, and 0.31 and 0.96 for combination‑2. The study results suggest that qSOFA and combination‑2 could be auseful tool for confirming patients at high risk for adverse outcomes. Although SIRS and combination‑1 could be helpful for excluding high-risk patients, the requirement of white blood cell counts limits their utilization for screening.

Quick Sequential Organ Failure Assessment: Modifications for Identifying Maternal Morbidity and Mortality in Obstetrical Patients

Screening tools, including the Systemic Inflammatory Response Syndrome (SIRS) criteria and Sequential Organ Failure Assessment (SOFA) criteria, have not been validated in the pregnant population. We aimed to determine if pregnancy-specific modifications to the quick SOFA (qSOFA) can improve prediction of severe maternal morbidity in pregnant women with serious infections. We performed a retrospective cohort study of pregnant patients with severe infections admitted to a single institution from January 1, 2011, through December 31, 2017. The primary outcome was severe maternal morbidity, defined as a composite of adverse maternal outcomes: intensive care unit (ICU) admission for >48 hours, need for invasive monitoring (central line or arterial line), intubation, pharmacologic hemodynamic support (intravenous vasopressors or inotropes), and/or maternal death. A logistic regression was then applied and the resulting predictors were analyzed individually and in combination with receiver operating characteristic (ROC) curves to modify qSOFA for pregnancy, that is, qSOFA-P. Analysis of 104 pregnant patients with severe infections found that the standard qSOFA did not accurately predict severe maternal morbidity (ROC area under the curve [AUC] = 0.54, p = 0.49, sensitivity = 0.38, and specificity = 0.70). Pregnancy-specific modifications or "qSOFA-P" (respiratory rate [RR] ≥ 35 breaths/minute and systolic blood pressure [SBP] ≤ 85 mm Hg) significantly improved prediction of severe maternal morbidity (AUC = 0.77, p < 0.001, sensitivity = 0.79, and specificity = 0.74). The standard qSOFA is a poor screening tool in the prediction of severe maternal morbidity in pregnant patients with infections. A pregnancy-specific screening system, qSOFA-P, improved prediction of severe maternal morbidity in pregnant women with severe infections. Further prospective and large multicenter studies are needed to validate this scoring system in pregnant women. · Validated scoring systems for evaluating pregnant patients with sepsis are needed.. · Modifications to existing systems may improve the evaluation of pregnant patients with sepsis.. · The qSOFA-P (RR ≥ 35 breaths/minute and SBP ≤ 85 mm Hg) includes modifications to qSOFA, and improves the detection of patients who would develop severe maternal morbidity...

51-Year-Old Man With Ascites and Abdominal Pain

51-Year-Old Man With Ascites and Abdominal Pain