G218(P) A new sepsis tool: improving the management of children with suspected sepsis in our emergency department, with an unexpected bonus

ObjectiveTo derive and validate a new clinical prediction rule to risk-stratify emergency department (ED) patients admitted with suspected sepsis.DesignRetrospective prognostic study of prospectively collected data.SettingED.ParticipantsPatients aged ≥18 years who met two Systemic Inflammatory Response Syndrome criteria or one Red Flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted.Primary outcome measureIn-hospital all-cause mortality.MethodThe data were divided into derivation and validation cohorts. The simplified-Mortality in Severe Sepsis in the ED score and quick-SOFA scores, refractory hypotension and lactate were collectively termed ‘component scores’ and cumulatively termed the ‘Risk-stratification of ED suspected Sepsis (REDS) score’. Each patient in the derivation cohort received a score (0–3) for each component score. The REDS score ranged from 0 to 12. The component scores were subject to univariate and multivariate logistic regression analyses. The receiver operator characteristic (ROC) curves for the REDS and the components scores were constructed and their cut-off points identified. Scores above the cut-off points were deemed high-risk. The area under the ROC (AUROC) curves and sensitivity for mortality of the high-risk category of the REDS score and component scores were compared. The REDS score was internally validated.Results2115 patients of whom 282 (13.3%) died in hospital. Derivation cohort: 1078 patients with 140 deaths (13%). The AUROC curve with 95% CI, cut-off point and sensitivity for mortality (95% CI) of the high-risk category of the REDS score were: derivation: 0.78 (0.75 to 0.80); ≥3; 85.0 (78 to 90.5). Validation: 0.74 (0.71 to 0.76); ≥3; 84.5 (77.5 to 90.0). The AUROC curve and the sensitivity for mortality of the REDS score was better than that of the component scores. Specificity and mortality rates for REDS scores of ≥3, ≥5 and ≥7 were 54.8%, 88.8% and 96.9% and 21.8%, 36.0% and 49.1%, respectively.ConclusionThe REDS score is a simple and objective score to risk-stratify ED patients with suspected sepsis.

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The Mortality in Emergency Department Sepsis Score as a Predictor of 1-Month Mortality among Adult Patients with Sepsis: Weighing the Evidence

ISRN Emergency Medicine ◽

10.1155/2013/896802 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Bayushi Eka Putra ◽

Ling Tiah

Keyword(s):

Emergency Department ◽

Outcome Measure ◽

Selection Process ◽

Area Under The Curve ◽

C Reactive Protein ◽

Consensus Process ◽

Suspected Sepsis ◽

Reactive Protein ◽

Sepsis Score ◽

Better Than

Objective. To evaluate the performance of Mortality in Emergency Department Sepsis (MEDS) score in comparison to biomarkers as a predictor of mortality in adult emergency department (ED) patients with sepsis. Methods. A literature search was performed using PubMed, ScienceDirect, SpringerLink, and Ovid databases. Studies were appraised by using the C2010 Consensus Process for Levels of Evidence for prognostic studies. The respective values for area under the curve (AUC) were obtained from the selected articles. Results. Four relevant articles met the selection process. Three studies defined the 1-month mortality as death occurring within 28 days of ED presentation, while the remaining one subcategorised the outcome measure as (5-day) early and (6- to 30-day) late mortality. In all four studies, the MEDS score performed better than the respective comparators (C-reactive protein, lactate, procalcitonin, and interleukin-6) in predicting mortality with an AUC ranging from 0.78 to 0.89 across the studies. Conclusion. The MEDS score has a better prognostic value than the respective comparators in predicting 1-month mortality in adult ED patients with suspected sepsis.

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Academy of Emergency Medicine and Care-Society of Clinical Biochemistry and Clinical Molecular Biology consensus recommendations for clinical use of sepsis biomarkers in the emergency department

Emergency Care Journal ◽

10.4081/ecj.2017.6877 ◽

2017 ◽

Vol 13 (2) ◽

Cited By ~ 2

Author(s):

Giuseppe Lippi ◽

Martina Montagnana ◽

Fiamma Balboni ◽

Andrea Bellone ◽

Ivo Casagranda ◽

...

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Clinical Biochemistry ◽

Clinical Information ◽

Clinical Value ◽

Suspected Sepsis ◽

Consensus Document ◽

Diagnostic Threshold ◽

High Negative Predictive Value ◽

Routine Assessment

Increasing evidence is emerging that the measurement of circulating biomarkers may be clinically useful for diagnosing and monitoring sepsis. Eight members of AcEMC (Academy of Emergency Medicine and Care) and eight members of SIBioC (Italian Society of Clinical Biochemistry and Laboratory Medicine) were identified by the two scientific societies for producing a consensus document aimed to define practical recommendations about the use of biomarkers for diagnosing of sepsis and managing antibiotic therapy in the emergency department (ED). The cumulative opinions allowed defining three grade A recommendations (i.e., highly recommended indications), entailing ordering modality (biomarkers always available on prescription), practical use (results should be interpreted according to clinical information) and test ordering defined according to biomarker kinetics. Additional grade B recommendations (i.e., potentially valuable indications) entailed general agreement that biomarkers assessment may be of clinical value in the diagnostic approach of ED patients with suspected sepsis, suggestion for combined assessment of procalcitonin (PCT) and Creactive protein (CRP), free availability of the selected biomarker(s) on prescription, adoption of diagnostic threshold prioritizing high negative predictive value, preference for more analytically sensitive techniques, along with potential clinical usefulness of measuring PCT for monitoring antibiotic treatment, with serial testing defined according to biomarker kinetics. PCT and CRP were the two biomarkers that received the largest consensus as sepsis biomarkers (grade B recommendation), and a grade B recommendation was also reached for routine assessment of blood lactate. The assessment of biomarkers other than PCT and CRP was discouraged, with exception of presepsin for which substantial uncertainty in favor or against remained.

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Use of Physician-Estimated and Patient Self-Reported Weights to Guide Initial Fluid Resuscitation in Emergency Department Patients With Suspected Sepsis

Journal of Intensive Care Medicine ◽

10.1177/0885066620917902 ◽

2020 ◽

pp. 088506662091790

Author(s):

Jeremy K. Lessing ◽

William J. H. Ford ◽

Peter A. Steel ◽

Sunday Clark ◽

Rahul Sharma ◽

...

Keyword(s):

Emergency Department ◽

Fluid Resuscitation ◽

Fluid Therapy ◽

Intravenous Fluid ◽

Medical Providers ◽

Suspected Sepsis ◽

Intravenous Fluid Therapy ◽

Multiple Levels ◽

Emergency Department Patients ◽

Elevated Lactate

Background: Knowledge of patient weight is required to guide initial intravenous fluid therapy for patients with sepsis-associated hypotension or elevated lactate. Previous studies have shown patients are better estimators of their weight than medical providers are; critically ill patients, however, may be unable to provide this information. Objectives: This study compares the accuracy of physician-estimated and patient self-reported weights to subsequent inpatient bed/stretcher scale weights for guiding initial protocol-based intravenous fluid therapy in the treatment of emergency department patients with suspected sepsis. Methods: Adult patients presenting with a suspected diagnosis of severe sepsis to a large, urban, academic emergency department had either physician-estimated or patient self-reported weights recorded on presentation. All patients had subsequent inpatient bed/stretcher scale weights recorded on the first day of hospitalization. Results: Physician-estimated and patient self-reported weights linearly correlated ( P < .001) with inpatient bed/stretcher scale weights. Median accuracy error for physicians (5.4% [2.0-10.1]) and patients (3.9% [1.6-6.4]) was not significantly different ( P = .28). Physician-estimated and patient self-reported weights accuracy was determined at multiple levels: within 5% (46%, 57%, respectively), 10% (75%, 90%), 15% (90%, 95%), and 20% (100%, 95%) error tolerances, as well accurate estimates within 5 kg (69.2%, 70.0%). Conclusions: Both physician-estimated and patient self-reported weights are reliable when calculating initial protocol-based intravenous fluid resuscitation for emergency department patients with sepsis.

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Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department

PEDIATRICS ◽

10.1542/peds.2010-2895 ◽

2011 ◽

Vol 127 (3) ◽

pp. e758-e766 ◽

Cited By ~ 124

Author(s):

A. T. Cruz ◽

A. M. Perry ◽

E. A. Williams ◽

J. M. Graf ◽

E. R. Wuestner ◽

...

Keyword(s):

Emergency Department ◽

Suspected Sepsis ◽

Goal Directed Therapy

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Role of presepsin for the evaluation of sepsis in the emergency department

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2014-0199 ◽

2014 ◽

Vol 0 (0) ◽

Cited By ~ 2

Author(s):

Elisa Pizzolato ◽

Marco Ulla ◽

Claudia Galluzzo ◽

Manuela Lucchiari ◽

Tilde Manetta ◽

...

Keyword(s):

Emergency Department ◽

Septic Shock ◽

Early Diagnosis ◽

Bacterial Infections ◽

Acute Phase Proteins ◽

Great Sensitivity ◽

Healthy Population ◽

Suspected Sepsis ◽

Gold Standard Method ◽

Suspected Infection

AbstractSepsis, severe sepsis and septic shock are among the most common conditions handled in the emergency department (ED). According to new Sepsis Guidelines, early diagnosis and treatment are the keys to improve survival. Plasma C-reactive protein (CRP) and procalcitonin (PCT) levels, when associated with documented or suspected infection, are now part of the definitions of sepsis. Blood culture is the gold standard method for detecting microorganisms but it requires too much time for results to be known. Sensitive biomarkers are required for early diagnosis and as indexes of prognosis sepsis. CRP is one of the acute phase proteins synthesized by the liver: it has a great sensitivity but a very poor specificity for bacterial infections. Moreover, the evolution of sepsis does not correlate with CRP plasma changes. In recent years PCT has been widely used for sepsis differential diagnosis, because of its close correlation with infections, but it still retains some limitations and false positivity (such as in multiple trauma and burns). Soluble CD14 subtype (sCD14-ST), also known as presepsin, is a novel and promising biomarker that has been shown to increase significantly in patients with sepsis, in comparison to the healthy population. Studies pointed out the capability of this biomarker for diagnosing sepsis, assessing the severity of the disease and providing a prognostic evaluation of patient outcome. In this mini review we mainly focused on presepsin: we evaluate its diagnostic and prognostic roles in patients presenting to the ED with systemic inflammatory response syndrome (SIRS), suspected sepsis or septic shock.

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A 29-mRNA host response test from blood accurately distinguishes bacterial and viral infections among emergency department patients

Intensive Care Medicine Experimental ◽

10.1186/s40635-021-00394-8 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Asimina Safarika ◽

James W. Wacker ◽

Konstantinos Katsaros ◽

Nicky Solomonidi ◽

George Giannikopoulos ◽

...

Keyword(s):

Emergency Department ◽

Host Response ◽

Viral Infections ◽

Acute Infection ◽

Chronic Obstructive ◽

Infection Status ◽

Suspected Sepsis ◽

Response Test ◽

Cell Counts ◽

Rule Out

Abstract Background Whether or not to administer antibiotics is a common and challenging clinical decision in patients with suspected infections presenting to the emergency department (ED). We prospectively validate InSep, a 29-mRNA blood-based host response test for the prediction of bacterial and viral infections. Methods The PROMPT trial is a prospective, non-interventional, multi-center clinical study that enrolled 397 adult patients presenting to the ED with signs of acute infection and at least one vital sign change. The infection status was adjudicated using chart review (including a syndromic molecular respiratory panel, procalcitonin and C-reactive protein) by three infectious disease physicians blinded to InSep results. InSep (version BVN-2) was performed using PAXgene Blood RNA processed and quantified on NanoString nCounter SPRINT. InSep results (likelihood of bacterial and viral infection) were compared to the adjudicated infection status. Results Subject mean age was 64 years, comorbidities were significant for diabetes (17.1%), chronic obstructive pulmonary disease (13.6%), and severe neurological disease (6.8%); 16.9% of subjects were immunocompromised. Infections were adjudicated as bacterial (14.1%), viral (11.3%) and noninfected (0.25%): 74.1% of subjects were adjudicated as indeterminate. InSep distinguished bacterial vs. viral/noninfected patients and viral vs. bacterial/noninfected patients using consensus adjudication with AUROCs of 0.94 (95% CI 0.90–0.99) and 0.90 (95% CI 0.83–0.96), respectively. AUROCs for bacterial vs. viral/noninfected patients were 0.88 (95% CI 0.79–0.96) for PCT, 0.80 (95% CI 0.72–89) for CRP and 0.78 (95% CI 0.69–0.87) for white blood cell counts (of note, the latter biomarkers were provided as part of clinical adjudication). To enable clinical actionability, InSep incorporates score cutoffs to allocate patients into interpretation bands. The Very Likely (rule in) InSep bacterial band showed a specificity of 98% compared to 94% for the corresponding PCT band (> 0.5 µg/L); the Very Unlikely (rule-out) band showed a sensitivity of 95% for InSep compared to 86% for PCT. For the detection of viral infections, InSep demonstrated a specificity of 93% for the Very Likely band (rule in) and a sensitivity of 96% for the Very Unlikely band (rule out). Conclusions InSep demonstrated high accuracy for predicting the presence of both bacterial and viral infections in ED patients with suspected acute infections or suspected sepsis. When translated into a rapid, point-of-care test, InSep will provide ED physicians with actionable results supporting early informed treatment decisions to improve patient outcomes while upholding antimicrobial stewardship. Registration number at Clinicaltrials.gov NCT 03295825.

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