Dr. Stephanie Sibley stepped up to the plate last-minute and saved the day to host our first journal club of the year on September 13! It turned out to be an excellent showing and invigorating discussion (from what I was able to see – unfortunately I missed most of the first article). Dr. Carly Hagel and Dr. Theresa Robertson led the discussion about the new sepsis guidelines, walking us through the latest publication, The third international consensus definitions for sepsis and septic shock (Sepsis-3). The authors used a variety of methods – database interrogation, systematic literature review, and Delphi consensus with expert critical care physicians to create new and improved definitions for sepsis, septic shock, and pathophysiology of the syndrome. The table below outlines their new and improved definitions.SIRs is out and qSOFA is in…but is it useful for us?
The SOFA (sequential organ failure assessment) score is used in the ICU and is proposed by the task force as a means to clinically characterize a septic patient, not as a tool for management. The authors used database interrogation to identify a SOFA score of ≥2 as a predictor of increased mortality in patients with suspected infection. The quick bedside test that has been proposed to trigger rapid recognition and management in the ED is qSOFA…but it has not been validated outside of the ICU. [SIRS is now considered a tool to help clinicians to recognize infection in the first place, but does not represent a dysregulated response to such infection as occurs in sepsis (poor discriminant and concurrent validity).]
Carly + Theresa’s conclusion:
The published conclusion states that the updated definitions and clinical criteria should clarify long used descriptors and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing it. This conclusion is not supported by the data they quote. The SOFA is a predictor of mortality and has not been validated outside of the ICU setting. Nor has the qSOFA. Neither will facilitate earlier recognition – rather may be able to predict mortality in ICU patients.
The article chosen outlined the changes, but in order to find the selection criteria used for inclusion/exclusion of the specific databases used to support their work you will have to read the following:
- Seymour CW, Liu V, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis. JAMA. Doi:10.1001/jama.2016.0288
- Shankar-Hari M, Phillips G, Levy ML, et al. Assessment of definition of clinical criteria for septic shock. JAMA. Doi.10.1001/jama.2016.0289
It will be interesting to see where this new guideline goes and what discussion follows in the critical care, emergency, and hospital inpatient communities.
The staff article chosen is one that we are all familiar with after filling out those pink sheets in the ED, involving our very own Dr. Marco Sivilotti: Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. Dr. Sibley graciously hosted us in her amazing new place, sharing some statistical knowledge to give insight into the derivation process used to come up with this tool. The most important take away here for our practical purposes is that it is a derivation study. Before we put it to clinical use, it’s important to follow the next phase – validation. Once validated, this tool proposes to help the clinician to identify adult patients with syncope who are at risk of a serious adverse event within 30 days of disposition from the ED. Unlike most clinical tools that we are used to using, this one hopes to allow us to risk stratify patients who present with syncope who are considered both high and low risk by our clinical judgment. We had an interesting discussion as a group with the frustrations of syncope and what we thought about each of the factors included in the tool. Unfortunately he wasn’t able to attend, but feel free to probe Marco for more details – as usual he will have a wealth of information and opinions to share! For a users’ guide to clinical decision rules, see this JAMA article.
We eagerly await the next update on the Canadian Syncope Risk Score!