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Room a a08. mcgee-utility of qsofa lactate sepsis_(en)
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. 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
9. 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
10.
11. 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
19. 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
20. 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
21. Nguyen HB - Crit Care Med. 2004 Aug;32(8):1637-42.
22. 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
23. DO2 = SV x HR x (Hb x 1.39 x SaO2 + paO2 x 0.0003)
Oxygen delivery equation
26. (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/
27. 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)
28. (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/
