EM Journal Club: SOFA and qSOFA utility? and Kidney Injury with Contrast?

May 18, 2017

Articles:

An Emergency Department Validation of the SEP-3 Sepsis and Septic Shock Definitions and Comparison With 1992 Consensus Definitions.  Henning et al.  Annals of Emergency Medicine 2017

This was a secondary analysis of 3 prospectively collected, observational cohorts of 7,754 Ed patients with suspected infection, aged 18 years and older to evaluate the performance of the SEP-3 qSOFA criteria and revised shock definition to the previous 1992 consensus criteria of sepsis, severe sepsis and shock.  The primary outcome was all-cause in hospital mortality. 7,637 patients were included in the analysis as 117 had no documented mental status. The mortality rate for patients with qSOFA score greater than or equal to 2 was 14.2% (95% CI 12.2% to 16.2%), with a sensitivity of 52% (95% CI 46% to 57%) and specificity of 86% (95% CI 85% to 87%) to predict mortality. The original SIRS based 1992 consensus sepsis definition had a 6.8% (95% CI 6.0% to 7.7%) mortality rate, sensitivity of 83% (95% CI 79% to 87%), and specificity of 50% (95% CI 49% to 51%). The SEP-3 septic shock mortality was 23% (95% CI 16% to 30%), with a sensitivity of 12% (95% CI 11% to 13%) and specificity of 98.4% (95% CI 98.1% to 98.7%). The original 1992 septic shock definition had a 22% (95% CI 17% to 27%) mortality rate, sensitivity of 23% (95% CI 18% to 28%), and specificity of 96.6% (95% CI 96.2% to 97.0%).  In conclusion, the SEP-3 definitions had improved specificity but lower sensitivity compared to the original 1992 consensus definition whereas the 1992 consensus definition was more sensitive but less specific in predicting mortality. From an emergency medicine perspective, using a more sensitive criteria may be preferred to screen and identify individuals who may benefit from early treatment.

 

Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for in-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit, Raith et al.  JAMA 2017

This was a retrospective cohort analysis of 184, 875 patients with an infection-related primary admission diagnosis in 182 Australian and New Zealand intensive care units (ICUs) from 2000 through 2015.  The aim of the study was to determine if an increase of 2 or more points in the SOFA score have greater prognostic accuracy in patients who are critically ill with suspected infection than 2 or more points in the SIRS criteria or qSOFA score points. The primary outcome was in-hospital mortality. In-hospital mortality or ICU length of stay (LOS) of 3 days or more was a composite secondary outcome. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC). Adjusted analyses were performed using a model of baseline risk determined using variables independent of the scoring systems. Conclusion: An increase in SOFA score of 2 or more had greater prognostic accuracy for in-hospital mortality in ICU patients than SIRS criteria or the qSOFA score suggesting that SIRS criteria and qSOFA may have limited utility for predicting mortality in an ICU setting.

 

Risk of Acute Kidney Injury after Intravenous Contrast Media Administration. Hinson et al. Annals of Emergency Medicine 2017

Bottom Line:  This was a single center, retrospective cohort study at an academic hospital from 2009-2014 to determine if IV contrast for CT increased the risk for primary outcome of acute kidney injury and secondary outcomes of CKD, Dialysis, renal transplant at 6 months.  Essentially, how often does AKI occur after CT scan with and without contrast?  16,801 patients studied who started with creatinine between 0.4 and 4.0.  Logistic regression modeling was used with propensity scoring to test for independent association of contrast administration and the primary and secondary outcomes.  There was no significant differences between AKI rates, even among patients with worse baseline renal function.  There was also no significant increased CKD, dialysis, or renal transplant at 6 months for patients who received IV contrast.  The results suggest that the use of IV contrast for CT scanning is not associated with nephrotoxic effects with the laboratory-based outcome of AKI and the other patient-centered outcomes measured.  As Emergency Physicians, we should have less hesitancy or reluctance to obtain potentially life-saving IV contrast CT imaging when indicated.

 

Contrast CT Scans in the Emergency Department Do Not Increase Risk of Adverse Renal Outcomes, Heller et al.  Western Journal of Emergency Medicine 2017

Bottom line:  This was a single-center retrospective, computerized chart review at an academic hospital from 2005-2010 to determine if IV contrast causes death or dialysis and if contrast induced nephropathy was higher in the patients who received IV contrast.  There were 6,954 patients admitted to the hospital who received IV contrast, and initial creatinine of less than 1.6.  There was no significant difference in deaths, dialysis, or contrast induced nephropathy among the group that received IV contrast or just plain CT.  All the patients in the study who underwent dialysis (0.3% vs 0%) had a significant medical problem requiring surgery or other critical illness.  For patients admitted to the hospital with normal renal function, IV contrast did not have any associated negative consequences.  Further studies are needed, including a prospective, randomized, blinded, well-controlled trial..

Other resources:

Improving Journal Club Presentations, or, I can present that paper in under 10 minutes, Schwartz et al, Evidence Based Medicine, 2007

Don’t kill the Beans:  The Specter of Contrast-induced Nephropathy, Taming the SRU, 5/2017 

 

 

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