Sepsis natural history, complications and prognosis: Difference between revisions
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===Mortality=== | ===Mortality=== | ||
Mortality can be estimated with the MEDS (Mortality in Emergency Department Sepsis) <ref name="pmid26901543">{{cite journal| author=Williams JM, Greenslade JH, Chu K, Brown AF, Lipman J| title=Severity Scores in Emergency Department Patients With Presumed Infection: A Prospective Validation Study. | journal=Crit Care Med | year= 2016 | volume= 44 | issue= 3 | pages= 539-47 | pmid=26901543 | doi=10.1097/CCM.0000000000001427 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26901543 }} </ref><ref name="pmid12626967">{{cite journal |author=Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW |title=Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule |journal=Crit. Care Med. |volume=31 |issue=3 |pages=670-5 |year=2003 |pmid=12626967 |doi=10.1097/01.CCM.0000054867.01688.D1}}</ref> and qSOFA<ref name="pmid26903335">{{cite journal| author=Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A et al.| title=Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). | journal=JAMA | year= 2016 | volume= 315 | issue= 8 | pages= 762-74 | pmid=26903335 | doi=10.1001/jama.2016.0288 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26903335 }} </ref> scores. More complicated scores such as the Apache, [[Sequential Organ Failure Assessment]] (SOFA), and Logistic Organ Dysfunction System (LODS) can be used as well. | Mortality can be estimated with the MEDS (Mortality in Emergency Department Sepsis) <ref name="pmid26901543">{{cite journal| author=Williams JM, Greenslade JH, Chu K, Brown AF, Lipman J| title=Severity Scores in Emergency Department Patients With Presumed Infection: A Prospective Validation Study. | journal=Crit Care Med | year= 2016 | volume= 44 | issue= 3 | pages= 539-47 | pmid=26901543 | doi=10.1097/CCM.0000000000001427 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26901543 }} </ref><ref name="pmid12626967">{{cite journal |author=Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW |title=Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule |journal=Crit. Care Med. |volume=31 |issue=3 |pages=670-5 |year=2003 |pmid=12626967 |doi=10.1097/01.CCM.0000054867.01688.D1}}</ref> and qSOFA<ref name="pmid26903335">{{cite journal| author=Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A et al.| title=Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). | journal=JAMA | year= 2016 | volume= 315 | issue= 8 | pages= 762-74 | pmid=26903335 | doi=10.1001/jama.2016.0288 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26903335 }} </ref> scores. More complicated scores such as the Apache, [[Sequential Organ Failure Assessment]] (SOFA), and Logistic Organ Dysfunction System (LODS) can be used as well. | ||
In comparative studies: | |||
* Sirs is more sensitive and qSOFA is more specific<ref name="pmid27876592">{{cite journal| author=Williams JM, Greenslade JH, McKenzie JV, Chu K, Brown AF, Lipman J| title=SIRS, qSOFA and organ dysfunction: insights from a prospective database of emergency department patients with infection. | journal=Chest | year= 2016 | volume= | issue= | pages= | pmid=27876592 | doi=10.1016/j.chest.2016.10.057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27876592 }} </ref> | |||
=====Mortality in Emergency Department Sepsis(MEDS) Point System<ref name="pmid26901543" />===== | =====Mortality in Emergency Department Sepsis(MEDS) Point System<ref name="pmid26901543" />===== | ||
Revision as of 00:57, 6 December 2016
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]
Synonyms and keywords: sepsis syndrome; septic shock; septicemia
Overview
There are many complications associated with sepsis, especially because it is a systemic phenomenon. Sepsis is a severe condition, and the prognosis of the patient will depend greatly on the condition and overall health of the patient. Many factors, such as age, hosts immune response, site of infection, type of infection, appropriate antibiotic therapy, and restoration of circulation of perfusion contribute to the overall prognosis.
Natural History
Complications
- Disseminated intravascular coagulation (DIC) can be the result of sepsis.
- Acute tubular necrosis (ATN) leading to acute renal failure, can be the result of hypoperfusion of the kidneys in sepsis (i.e. not enough blood gets to the kidney and they stop working properly). Acute kidney injury occurs in about 30% of patients and about 5% of patients need renal replacement therapy.[1]
- Arrhythmia is an abnormal heart rhythm; it can be the result of sepsis.
- Ileus or ischemic colitis can be the result (hypoperfusion) or cause of sepsis.
- Multiple organ dysfunction syndrome can be the result of sepsis.
- Meningitis, infection of the tissue that covers the brain and spinal cord, can be a complication or cause of sepsis.
- Osteomyelitis is an infection of the bone; it can be the cause or result of sepsis.
- Endocarditis, infection of the inner surface of heart which is in contact with blood, can also be a complication or cause of sepsis.
- Pyaemia — causes abscesses.
Prognosis
Sepsis
SIRS criteria identify 88% of patients who have severe sepsis (infection plus organ failure).[2]
Septic shock
About 12% of of patients with sepsis progress to septic shock within 48 hours. Among variables studied (which did not include procalcitonin, predictors of progression to septic shock were:[3]
- nonpersistent hypotension
- bandemia at least 10%
- lactate at least 4.0 mmol/L
- past medical of coronary artery disease
- female gender
Mortality
Mortality can be estimated with the MEDS (Mortality in Emergency Department Sepsis) [4][5] and qSOFA[6] scores. More complicated scores such as the Apache, Sequential Organ Failure Assessment (SOFA), and Logistic Organ Dysfunction System (LODS) can be used as well.
In comparative studies:
- Sirs is more sensitive and qSOFA is more specific[7]
Mortality in Emergency Department Sepsis(MEDS) Point System[4]
The components and their scores for the MEDS are:
- Rapidly progressing terminal co-morbid illness - 6 points
- If the patient is older than 65 years of age - 3 points
- If the granulocytic bands are greater than 5% - 3 points
- If the patient has tachypnea or hypoxia - 3 points
- If the patient is in shock - 3 points
- If the patient has a platelet count of less than 150,000 mm3 - 3 points
- If the patient has an altered mental status - 2 points
- If the patient is a resident of a nursing home - 2 points
- If the patient has a lower respiratory infection - 2 points
The total score will be added up and that total will correlate to the mortality percentage with a 95% confidence interval. The following are the point ranges associated with various mortality percentages.
- 0-4 points total - 0.6% mortality rate
- 5-7 points total - 5% mortality rate
- 8-12 points total - 19% mortality rate
- 13-15 points total - 32% mortality rate
- 15+ points total - 40% mortality rate
The area under the receiver operating characteristic curve for the MEDs score is 0.92.[4]
qSOFA
The qSOFA score is one point each for: [6]
- Systolic hypotension [≤100 mm Hg]
- Tachypnea [≥22/min]
- Altered mentation
A score of two or more predictors mortality with an area under the receiver operating characteristic curve of 0.66 when studied in diverse patients. This accuracy is less than for the full SOFA score.[6]
References
- ↑ Kellum JA, Chawla LS, Keener C, Singbartl K, Palevsky PM, Pike FL; et al. (2016). "The Effects of Alternative Resuscitation Strategies on Acute Kidney Injury in Patients with Septic Shock". Am J Respir Crit Care Med. 193 (3): 281–7. doi:10.1164/rccm.201505-0995OC. PMC 4803059. PMID 26398704.
- ↑ Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R (2015). "Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis". N Engl J Med. doi:10.1056/NEJMoa1415236. PMID 25776936.
- ↑ Capp R, Horton CL, Takhar SS, Ginde AA, Peak DA, Zane R; et al. (2015). "Predictors of Patients Who Present to the Emergency Department With Sepsis and Progress to Septic Shock Between 4 and 48 Hours of Emergency Department Arrival". Crit Care Med. doi:10.1097/CCM.0000000000000861. PMID 25668750.
- ↑ 4.0 4.1 4.2 Williams JM, Greenslade JH, Chu K, Brown AF, Lipman J (2016). "Severity Scores in Emergency Department Patients With Presumed Infection: A Prospective Validation Study". Crit Care Med. 44 (3): 539–47. doi:10.1097/CCM.0000000000001427. PMID 26901543.
- ↑ Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW (2003). "Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule". Crit. Care Med. 31 (3): 670–5. doi:10.1097/01.CCM.0000054867.01688.D1. PMID 12626967.
- ↑ 6.0 6.1 6.2 Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A; et al. (2016). "Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)". JAMA. 315 (8): 762–74. doi:10.1001/jama.2016.0288. PMID 26903335.
- ↑ Williams JM, Greenslade JH, McKenzie JV, Chu K, Brown AF, Lipman J (2016). "SIRS, qSOFA and organ dysfunction: insights from a prospective database of emergency department patients with infection". Chest. doi:10.1016/j.chest.2016.10.057. PMID 27876592.