【转贴】[JAMA最新论文]：全身性感染新的临床标准的评估

转载自CSCCM JAMA新sepsis的 定义 http://mp.weixin.qq.com/s?__biz= ... T3h7Ks4G10QhDqrX#rd

Original Investigation | CARING FOR THE CRITICALLY ILL PATIENT
Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
Christopher W. Seymour, Vincent X. Liu, Theodore J. Iwashyna, et al.JAMA. 2016; 315(8): 762-774. doi:10.1001/jama.2016.0288IMPORTANCE 重要性

The Third International Consensus Definitions Task Force defined sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection." The performance of clinical criteria for this sepsis definition is unknown.

第三次国际共识定义特别小组将全身性感染定义为“感染引起的宿主反应失调所导致的致命性器官功能障碍”。这一全身性感染定义的临床标准的准确性尚属未知。

OBJECTIVE 目的

To evaluate the validity of clinical criteria to identify patients with suspected infection who are at risk of sepsis.

评价临床标准鉴别有发生全身性感染风险的可疑感染患者的效度。

DESIGN, SETTINGS, AND POPULATION 设计，场景及人群

Among 1.3 million electronic health record encounters from January 1, 2010, to December 31, 2012, at 12 hospitals in southwestern Pennsylvania, we identified those with suspected infection in whom to compare criteria. Confirmatory analyses were performed in 4 data sets of 706 399 out-of-hospital and hospital encounters at 165 US and non-US hospitals ranging from January 1, 2008, until December 31, 2013.

从西南宾夕法尼亚州12家医院从2010年1月1日至2012年12月31日间共1300000份电子病历中，我们找出可疑感染患者进行临床标准的比较。我们用2008年1月1日至2013年12月31日间165家美国及非美国医院的706399份院外及院内病历的4个数据集进行确证分析。

EXPOSURES 暴露

Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, Logistic Organ Dysfunction System (LODS) score, and a new model derived using multivariable logistic regression in a split sample, the quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score (range, 0-3 points, with 1 point each for systolic hypotension [≤ 100 mmHg], tachypnea [ ≥ 22/min], or altered mentation).

序贯性（感染相关）器官功能衰竭评价(SOFA)评分、全身炎症反应综合征(SIRS)标准，Logistic器官功能障碍系统(LODS)评分，以及采用独立样本通过多因素logistic回归分析构建的一个新模型，即快速序贯性（感染相关）器官功能衰竭评估(qSOFA)评分（范围0-3分，收缩压低[≤ 100 mmHg]，呼吸频数[≥ 22次/分]，或意识状态改变）。

MAIN OUTCOMES AND MEASURES 主要结局和指标

For construct validity, pairwise agreement was assessed. For predictive validity, the discrimination for outcomes (primary: in-hospital mortality; secondary: in-hospital mortality or intensive care unit [ICU] length of stay ≥ 3 days) more common in sepsis than uncomplicated infection was determined. Results were expressed as the fold change in outcome over deciles of baseline risk of death and area under the receiver operating characteristic curve (AUROC).

我们使用配对一致性分析评估结构效度。对于预测效度，我们分析了预后指标（主要：住院病死率；次要：住院病死率或ICU住院日≥ 3天）在全身性感染患者是否较无并发症的感染患者更常见。结果表示为根据基线死亡风险十分位区间预后指标改变的倍数，以及受试者工作特征曲线下面积(AUROC)。

RESULTS 结果

In the primary cohort, 148907 encounters had suspected infection (n=74453 derivation; n = 74454 validation), of whom 6347 (4%) died. Among ICU encounters in the validation cohort (n = 7932 with suspected infection, of whom 1289 [16%] died), the predictive validity for in-hospital mortality was lower for SIRS (AUROC = 0.64; 95% CI, 0.62-0.66) and qSOFA (AUROC = 0.66; 95% CI, 0.64-0.68) vs SOFA (AUROC = 0.74; 95% CI, 0.73-0.76; P < .001 for both) or LODS (AUROC = 0.75; 95% CI, 0.73-0.76; P < .001 for both). Among non-ICU encounters in the validation cohort (n = 66 522 with suspected infection, of whom 1886 [3%] died), qSOFA had predictive validity (AUROC = 0.81; 95% CI, 0.80-0.82) that was greater than SOFA (AUROC = 0.79; 95% CI, 0.78-0.80; P < .001) and SIRS (AUROC = 0.76; 95% CI, 0.75-0.77; P < .001). Relative to qSOFA scores lower than 2, encounters with qSOFA scores of 2 or higher had a 3- to 14-fold increase in hospital mortality across baseline risk deciles. Findings were similar in external data sets and for the secondary outcome.

在主要队列中，共有148970名患者怀疑感染（n=74453起源集；n=74454验证集），其中6347名患者 (4%) 死亡。在验证队列的ICU患者中（n=7932怀疑感染，其中1289名患者 [16%] 死亡），SIRS (AUROC = 0.64; 95% CI, 0.62-0.66) 和qSOFA (AUROC = 0.66; 95% CI, 0.64-0.68) 对于住院病死率的预测效度低于SOFA (AUROC = 0.74; 95% CI, 0.73-0.76; P值均< .001) 或LODS (AUROC = 0.75; 95% CI, 0.73-0.76; P值均 < .001)。在验证队列的非ICU患者中（n=66522怀疑感染，其中1886名患者[3%]死亡）, qSOFA的预测效度 (AUROC = 0.81; 95% CI, 0.80-0.82) 高于SOFA (AUROC = 0.79; 95% CI, 0.78-0.80; P < .001) 及SIRS (AUROC = 0.76; 95% CI, 0.75-0.77; P < .001)。在基线风险十分位区间中，与qSOFA评分< 2相比，qSOFA评分≥ 2者住院病死率升高3至14倍。采用外部数据集或次要预后指标也能够得到相似发现。

CONCLUSIONS AND RELEVANCE 结论及意义

在可疑感染的ICU患者中，SOFA对住院病死率的预测效度与更为复杂的LODS评分并无显著差异，但优于SIRS和qSOFA，因此支持这一标准作为全身性感染的临床标准。对于怀疑感染的非ICU患者，qSOFA对于住院病死率的预测效度优于SOFA和SIRS，因而可用于提示可能存在全身性感染的指标。

分享。

原文

新宇心语 发表于 2016-2-25  16:21
原文

有三篇呢，没传够。

water21 发表于 2016-2-25  22:46
有三篇呢，没传够。

我就看见2篇

另一个，那个第三个你补充吧，哈哈

新宇心语 发表于 2016-2-26  09:01
另一个，那个第三个你补充吧，哈哈

传完了。其实这一期都是重症专题。http://jama.jamanetwork.com/issue.aspx

其实我觉得看定义和这几个文献，远不如看dxy上猫版的帖子来得容易明白。