Comparison of MEWS, QSOFA and MEDS Scores in the Prognosis of Patients with Sepsis in Emergency Department

Yıl 2023, Cilt: 5 Sayı: 3, 189 - 195, 01.11.2023

Emrah Arı , Ömer Faruk Demir , Maşide Arı , Yıldız Yıldırımer Çelik , Abdurrahman Gülmez

https://doi.org/10.38175/phnx.1316208

Öz

Objective: Sepsis is a syndrome with high mortality rate. Early diagnosis and rapid intervention are of great importance in the prognosis of sepsis patients in emergency departments. Scoring systems have been developed to assist health personnel in determining the severity of the disease.
In our study, it was aimed to determine which of these scoring systems was more reliable by comparing the power of Modified Early Warning Score (MEWS), rapid Sequential Organ Failure Evaluation Score (qSOFA) and Emergency Service Sepsis Mortality Score (MEDS) in predicting prognosis and mortality.
Materials and Methods: Patients with sepsis between the dates 01.04.2017-01.04.2019 in the Emergency Department Clinic of the University of Health Sciences, Diskapi Yildirim Beyazit Education and Research Hospital have been included retrospectively. The demographic and clinical characteristics of the patients have been recorded and MEWS, qSOFA, MEDS scores have been calculated. The patients were divided into two groups as died and survivors. The group of patients who died was composed of patients who died due to sepsis in the first 28 days.
Results: A total of 315 patients with an average age of 73.4±14.6 have been included in the study. 52,4%(n=165) of the patients are male. The most common source of infection is the respiratory system with 57,5%(n=181). It has been found that 47,6%(n=150) of the patients have died. The MEDS (ROC=0.78) has a significant distinguishing ability in the 28-day mortality prediction. When MEDS≥9, its sensitivity in predicting mortality is 95,3%, specificity is 37,6%, and its negative predictive value is 89,9%. On the other hand, while MEWS≥5, sensitivity, specificity, and negative predictive value are 77,3%, 47,3%, 69,6% respectively (ROC=0.66). Finally, qSOFA≥2, sensitivity, specificity, and negative predictive value are 84%, 41,8%, 74,2% respectively (ROC=0.67). The power of MEDSin predicting mortality has been found better than qSOFA and MEWS (p<0.001).
Conclusion: Within the scope of this study, MEDS has been found to have the highest sensitivity and negative predictive value in predicting mortality. The ability of qSOFA and MEWS in predicting mortality are similar.

Anahtar Kelimeler

MEDS, MEWS, MORTALITY, QSOFA, SEPSIS

Acil Servisteki Sepsisli Hastaların Prognozunda MEWS, qSOFA ve MEDS Skorlarının Karşlaştırılması

Öz

Amaç: Sepsis, tedavideki tüm gelişmelere rağmen mortalitesi yüksek seyreden bir sendromdur. Acil servislerde sepsis hastalarının prognozunda erken tanı ve hızlı müdahale büyük önem arz etmektedir. Hastalığın ciddiyetinin belirlenmesinde sağlık personeline yardımcı skorlama sistemleri geliştirilmiştir.
Çalışmamızda, bu skorlama sistemlerinden Modifiye Erken Uyarı Skoru (MEWS), hızlı Ardışık Organ Yetmezliği Değerlendirme Puanı (qSOFA) ve Acil Serviste Sepsis Mortalite Skoru (MEDS) ‘nun prognoz ve mortaliteyi öngörmedeki güçleri karşılaştırılarak, hangisinin daha güvenilir olduğunun belirlenmesi amaçlandı.
Gereç ve Yöntem: Çalışmaya Sağlık Bilimleri Üniversitesi Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Acil Servis Kliniği ‘nde 01.04.2017-01.04.2019 tarihleri arasında sepsis tanısı konulan hastalar retrospektif olarak dahil edildi. Hastaların demografik ve klinik özellikleri kaydedilerek MEWS, qSOFA, MEDS puanları hesaplandı. Hastalar ölen ve sağ kalan olmak üzere iki grupta incelendi. Ölen hasta grubu ilk 28 günde sepsis nedeniyle ölen hastalardan oluşturuldu.
Bulgular: Çalışmaya yaş ortalaması 73.4±14.6 yıl ve %52,4 ‘ü(n=165) erkek olan toplam 315 hasta dahil edildi. En sık ek hastalık %54,2(n=171) ile hipertansiyondu. En sık enfeksiyon kaynağı %57,5(n=181) ile solunum sistemiydi. Hastaların %47,6 ’sının(n=150) öldüğü tespit edildi. MEDS, 28 günlükmortalite tahmininde en yüksek öngörüye sahipti (EAK=0.78). MEDS≥9 olduğunda mortaliteyi öngörmedeki sensitivitesi %95,3, spesifitesi %37,6 ve negatif prediktif değeri %89,9 idi. MEWS≥5 iken sensitivitesi %77,3, spesifitesi %47,3 ve negatif prediktif değeri %69,6 idi(EAK=0.66). QSOFA skoru≥2 iken sensitivitesi %84, spesifitesi %41,8 ve negatif prediktif değeri %74,2 idi (EAK=0.67).
MEDS’ in mortaliteyi öngörmedeki gücü qSOFA ve MEWS’den daha iyi bulundu (p<0.001).
Sonuç: Çalışmamızda MEDS skoru, mortalite tahmininde en yüksek sensitiviteye ve negatif öngörücülüğe sahip bulundu. qSOFA ve MEWS’in mortalite tahmin etmekteki güçleri ise benzerdi.

Anahtar Kelimeler

MEDS, MEWS, Mortalite, qSOFA, Sepsis

Kaynakça

• Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R et al. Surviving Sepsis Campaign: International Guidelines forManagement of Sepsis and Septic Shock: 2016. Intensive care medicine. 2017; 43(3):304-377.
• Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M et al. The Third International Consensus Definitions forSepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315(8):801-810
• Pong JZ, Fook-Chong S, Koh ZX, Samsudin MI, Tagami T, Chiew CJ et al. Combining Heart Rate Variability with Disease Severity Score Variables for Mortality Risk Stratification in Septic Patients Presenting at the Emergency Department.International Journal of Environmental Research and Public Health. 2019; 16(10):1725.
• Stenhouse C, Coates S, Tivey M, Allsop P, Parke T. Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward. Br J Anaesth.1999, 84:663P.
• Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a Modified early Warning score in medicaladmission. Q J Med. 2001; 94(10):521-526
• Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW. Mortality in Emergency Department Sepsis (MEDS) score:A prospectively derived and validated clinical prediction rule. Critical Care Medicine. 2003; 31(3):670-675.
• Rannikko J, Syrjänen J, Seiskari T, Aittoniemi J, Huttunen R. Sepsis- related mortality in 497 cases with blood culture-positive sepsis in an emergency department. Int J. Infect Dis. 2017; 58:52-57.
• Milbrandt EB, Eldadah B, Nayfield S, Hadley E, Angus DC. Toward an integrated research agenda for critical illness in aging. American journal of respiratory and critical care medicine. 2010; 182(8), 995-1003.
• Madsen TE, Napoli AM. The DISPARITY‐II Study: Delays to Antibiotic Administration in Women With Severe Sepsis or Septic Shock. Academic Emergency Medicine. 2014; 21(12):1499- 1502.
• Park HK, Kim WY, Kim MC, Jung W, Ko BS. Quick sequential organ failure assessment compared to systemic inflammatory response syndrome for predicting sepsis in emergency department. J Crit Care.2017; 42:12-17.
• Raith EP, Udy AA, Bailey M, McGloughlin S, MacIsaac C, Bellomo R et al. Prognostic Accuracy of the SOFA Score, SIRS Criteria, andqSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit. JAMA. 2017; 317(3):290- 300.
• Degoricija V, Sharma M, Legac A, Gradiser M, Sefer S, Vucicević Z. Survival analysis of 314 episodes of sepsis in medicalintensive care unit in university hospital. Croat Med J. 2006; 47(3):385-397.
• Ay A. Sepsis, ağır sepsis ve septik şok hastalarında trombosit/lökosit, TNF-alfa ve IL-6 değerlerinin mortalite ve morbidite üzerine etkisinin araştırılması. Derince Eğitim ve Araştırma Hastanesi: Sağlık Bilimleri Üniversitesi; 2017.
• Iwashyna TJ, Cooke CR, Wunsch H, Kahn JM. The Population Burden of Long-Term Survivorship afterSevere Sepsis Among Older Americans. J Am Geriatr Soc. 2012; 60(6):1070-1077.
• Baykara N, Akalın H, Arslantaş MK, Hancı V, Çağlayan Ç, Kahveci F et al. Epidemiology of sepsis in intensive care units in Turkey: a multicenter, point-prevalence study. Critical Care Medicine. 2018; 22(1):93.
• Çınar E. Pnömoni. İçinde: Türkdoğan KA, eds. Pratik Acil Tıp. İstanbul:EMA; 2020. s.83-85
• Quenot JP, Binquet C, Kara F, Martinet O, Ganster F, Navellou JC et al. The epidemiology of septic shock in French intensive care units: the prospective multicenter cohort EPISS study. Critical Care Medicine. 2013; 17(2): R65 .
• Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H et al. Sepsis in European intensive care units: results of the SOAP study. Critical Care Medicine. 2006;34(2):344-353.
• Chen QH, Shao J, Liu WL, Wang HL, Liu L, Gu XH et al. Predictive accuracy of Sepsis-3 definitions for mortality amongadult critically ill patients with suspected infection. Chinese medical journal. 2019;132(10):1147-1153.
• Gao Y, Zhu J, Yin C, Zhu J, Zhu T, Liu L. Effects of Target Temperature Management on the Outcome of SepticPatients with Fever. Biomed Res Int. 2017;2017:3906032.
• Silvestre J, Póvoa P, Coelho L, Almeida E, Moreira P, Fernandes A et al. Is C-reactive protein a good prognostic marker in septicpatients? Intensive Care Med. 2009;35(5):909- 913.
• Sundén-Cullberg J, Rylance R, Svefors J, Norrby-Teglund A, Björk J, Inghammar M. Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU. Crit Care Med. 2017;45(4):591-599.
• Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV et al. Serum lactate is associated with mortality insevere sepsis independent of organ failure and shock. Crit Care Med. 2009;37(5):1670-1677.
• Cakır Madenci Ö, Yakupoğlu S, Benzonana N, Yücel N, Akbaba D, Orçun Kaptanağası A. Evaluation of soluble CD14 subtype (presepsin)in burn sepsis. Burns. 2014;40(4):664-669.
• Klenzak J, Himmelfarb J. Sepsis and the Kidney. Critical Care Clinics. 2005;21(2):211-222.
• Eidelman LA, Putterman D, Putterman C, Sprung CL. The spectrum of septic encephalopathy.Definitions, etiologies, and mortalities. JAMA. 1996;275(6):470-473, 275(6):470-3.
• Moreno RP, Metnitz B, Adler L, Hoechtl A, Bauer P, Metnitz PG. Sepsis mortality prediction based on predisposition,infection and response. Intensive Care Medicine. 2008;34(3):496-504.
• Salvo I, de Cian W, Musicco M, Langer M, Piadena R, Wolfler A et al. The Italian SEPSIS study: preliminary results on the incidence and evolution of SIRS, sepsis, severe sepsis and septic shock. Intensive Care Med. 1995;21 Suppl 2:S244-249.
• Ghanem-Zoubi NO, Vardi M, Laor A, Weber G, Bitterman H. Assessment of disease-severity scoring systems forpatients with sepsis in general internal medicine departments. Crit Care Med. 2011;15(2):R95.
• Vorwerk C, Loryman B, Coats TJ, Stephenson JA, Gray LD, Reddy G et al. Prediction of mortality in adult emergency departmentpatients with sepsis. Emerg Med J. 2009;26(4):254- 258.
• Churpek MM, Snyder A, Han X, Sokol S, Pettit N, Howell MD et al. Quick Sepsis-related Organ Failure Assessment, SystemicInflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients outside the Intensive Care Unit. American journal of respiratory and critical care medicine. 2017;195(7):906-911.
• Bulut M, Cebicci H, Sigirli D, Sak A, Durmus O, Top AA et al. The comparison of modified early warning score with rapidemergency medicine score: a prospective multicentre observational cohort study on medical and surgical patients presenting to emergency department. Emerg Med J. 2014 Jun;31(6):476-481.
• Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A et al. Assessment of Clinical Criteria for Sepsis: For theThird International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb;315(8):762-774.
• Freund Y, Lemachatti N, Krastinova E, Van Laer M, Claessens YE, Avondo A et al. Prognostic accuracy of sepsis-3 criteria for in- hospital mortality among patients with suspected infection presenting to the emergency department.Jama. 2017;317(3):301-308.
• Wang JY, Chen YX, Guo SB, Mei X, Yang P. Predictive performance of quick Sepsis-related Organ FailureAssessment for mortality and ICU admission in patients with infection at the ED. Am J Emerg Med. 2016;34(9):1788-1793.
• April MD, Aguirre J, Tannenbaum LI, Moore T, Pingree A, Thaxton RE et al. Sepsis Clinical Criteria in Emergency Department Patients Admitted to an Intensive Care Unit: An External Validation Study of Quick Sequential OrganFailure Assessment. J Emerg Med. 2017 May;52(5):622- 631.
• Finkelsztein EJ, Jones DS, Ma KC, Pabón MA, Delgado T, Nakahira K et al. Comparison of qSOFA and SIRS for predicting adverseoutcomes of patients with suspicion of sepsis outside the intensive care unit. Crit Care Med. 2017;21(1):73.
• Chang SH, Hsieh CH, Weng YM, Hsieh MS, Goh ZNL, Chen HY et al. Performance Assessment of the Mortality in Emergency Department Sepsis Score, Modified Early Warning Score, Rapid Emergency Medicine Score, and Rapid Acute Physiology Score in Predicting Survival Outcomes of Adult Renal Abscess Patients in theED. Biomed Res Int. 2018;2018:6983568.
• Howell MD, Donnino MW, Talmor D, Clardy P, Ngo L, Shapiro NI. Performance of Severity of Illness Scoring Systems inEmergency Department Patients with Infection. Acad Emerg Med. 2007;14(8):709-714.
• Lee CC, Chen SY, Tsai CL, Wu SC, Chiang WC, Wang JL et al. Prognostıc Value Of Mortalıty In Emergency Department Sepsıs Score, Procalcitonin, And C-Reactive Proteın In Patients Wıth Sepsis At The Emergency Department. SHOCK. 2008;29(3):322-327.
• Chen YX, Li CS. Risk stratification and prognostic performance of the predisposition, infection, response, and organ dysfunction (PIRO) scoring system in septic patients in the emergency department: a cohort study. Crit Care Med. 2014;18(2):R74.
• Gunes Ozaydin M, Guneysel O, Saridogan F, Ozaydin V. Are scoring systems sufficient for predicting mortality due to sepsis in the emergency department? Turkish Journal of Emergency Medicine. 2016;17(1):25-28.