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Room a a08. mcgee-utility of qsofa lactate sepsis_(en)

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Room a a08. mcgee-utility of qsofa lactate sepsis_(en)

  1. 1. Utility of Q SOFA & SIRS Criteria for diagnosis of Sepsis & Prediction of Mortality William T. McGee, M.D. MHA, FCCM, FCCP Critical Care Medicine Associate Professor of Medicine and Surgery University of Massachusetts 759 Chestnut Street, Springfield, MA 01199 Tel: 413-794-5439 | Fax: 413-794-3987 william.mcgee@baystatehealth.org
  2. 2.  55 y/o morbidly obese (138 kg) male  cc: severe abdominal pain for ~2 days  (+) anorexia, nausea and dysuria  T 101.5°F, BP 134/68, HR 110, RR 20, 98% on room air (+) dry mucous membranes, tachycardia, diffuse lower abd. pain  Basic labs, an iv line and crystalloid fluids - wide open  WBC 23K , no bands, lactate of 4 mmol/L  Urine analysis urinary tract infection  All other labs are unremarkable.  Appropriate antibiotics are started.  Discharged home on HD 3 Case Kalantari - West J Emerg Med. 2017
  3. 3. National Hospital Discharge Database Source: CDC.org
  4. 4. qSOFA Confusion RR≥22 SBP ≤100
  5. 5. qSOFA
  6. 6. qSOFA
  7. 7. qSOFA fails validation Churpek MM - Am J Respir Crit Care Med. 2017
  8. 8. Modified from criteria published in: Balk, R., Crit Care Clinics. 2000; 16:337-351; Kleinpell, R. Crit Care Nurs Clin N Am. 2003; 15:27-34. Cardiovascular: Tachycardia Hypotension Altered CVP & PAOP Renal: Oliguria Anuria  Creatinine Hematologic:  Platelets  PT/INR,  aPTT  Protein C  D-dimer Hepatic: Jaundice,  Liver enzymes  Albumin CNS: Altered consciousness Confusion Respiratory: Tachypnea  PaO2  PaO2/FiO2 ratio Metabolic: Metabolic Acidosis  Lactate level  Lactate Clearance Identifying Acute Organ Dysfunction as a Marker of (Severe) Sepsis
  9. 9. Sepsis Mortality Increases with the Number of Organ Dysfunctions Angus DC, et al. Crit Care Med. 2001;29:1303-1310. 21.2 44.3 64.5 76.2 0 10 20 30 40 50 60 70 80 90 One Two Three Four or More Mortality(%) Organ Dysfunctions
  10. 10. A Comparison of the Quick-SOFA and Systemic Inflammatory Response Syndrome Criteria for the Diagnosis of Sepsis and Prediction of Mortality Rodrigo Serafim, MD, José Andrade Gomes, MD, Jorge Salluh, MD, PhD, Pedro Póvoa, MD, PhD CHEST Volume 153, Issue 3, Pages 646-655 (March 2018) DOI: 10.1016/j.chest.2017.12.015 Copyright © 2017 American College of Chest Physicians Terms and Conditions
  11. 11. Figure 1 CHEST 2018 153, 646-655DOI: (10.1016/j.chest.2017.12.015) Copyright © 2017 American College of Chest Physicians Terms and Conditions
  12. 12. Figure 4 CHEST 2018 153, 646-655DOI: (10.1016/j.chest.2017.12.015) Copyright © 2017 American College of Chest Physicians Terms and Conditions
  13. 13. Figure 5 CHEST 2018 153, 646-655DOI: (10.1016/j.chest.2017.12.015) Copyright © 2017 American College of Chest Physicians Terms and Conditions
  14. 14. Quick score q Sofa https://www.mdcalc.com/qsofa- quick-sofa-score-sepsis
  15. 15. Lactate controversy
  16. 16.  55 y/o morbidly obese (138 kg) male  cc: severe abdominal pain for ~2 days  (+) anorexia, nausea and dysuria  T 101.5°F, BP 134/68, HR 110, RR 20, 98% on room air (+) dry mucous membranes, tachycardia, diffuse lower abd. pain  Basic labs, an iv line and crystalloid fluids - wide open  WBC 23K , no bands, lactate of 4 mmol/L  Urine analysis urinary tract infection  All other labs are unremarkable.  Appropriate antibiotics are started.  Discharged home on HD 3 Case Kalantari - West J Emerg Med. 2017
  17. 17. Serum Lactate as a Predictor of Mortality in Emergency Department Patients with Infection  Prospective cohort study, urban ED  1,278 consecutive patients  Inclusion criteria: ≥18 years, serum lactate level obtained, admission with infection-related diagnosis Shapiro, N., Ann of Emer Med. 2005; 45:524-528.. Lactate (mmol/L) 0-2.4 2.5-3.9 >4.0 28-day in-hospital mortality, % 4.9 9.0 28.4 Death within 3 days, % 1.5 4.5 22.4
  18. 18. Nguyen HB - Crit Care Med. 2004 Aug;32(8):1637-42.
  19. 19. CaO2 = Hb x 1.39 x SaO2 + paO2 x 0.0003 DO2 = CO x CaO2 ; CO = SV x HR DO2 = SV x HR x (Hb x 1.39 x SaO2 + paO2 x 0.0003) Oxygen delivery equation
  20. 20. DO2 = SV x HR x (Hb x 1.39 x SaO2 + paO2 x 0.0003) Oxygen delivery equation
  21. 21. Lactate production Marik PE, Bellomo R. OA Critical Care 2013
  22. 22. Epinephrine and lactate James JH - Lancet 1999 ;354(9177):505-8.
  23. 23. (1) Elevated lactate in septic shock is not (ALWAYS) due to anaerobic metabolism (2) Elevated lactate in septic shock is also due to stimulation of beta-2 adrenergic receptors (3) Lactate clearance in shock is a good marker of successful resuscitation and persistence is correlated with Death https://emcrit.org/pulmcrit/understanding-lactate-in-sepsis- using-it-to-our-advantage/
  24. 24. Lactate can help guide resuscitation • We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion. (Weak recommendation; low quality of evidence)
  25. 25. (1) Elevated lactate needs to be corrected or your patient will die (2) Systemic organ dysfunction is correlated with Death ARDS; AKI ( dialysis ) (3) Sepsis criteria better at diagnosing infection; Q Sofa better at prediocting mortality (4) A combined score may have synergies! Key points https://emcrit.org/pulmcrit/understanding-lactate-in-sepsis- using-it-to-our-advantage/

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