SOFA score in septic patients: incremental prognostic value over age, comorbidities, and parameters of sepsis severity.

Several widely used scoring systems for septic patients have been validated in an ICU setting, and may not be appropriate for other settings like Emergency Departments (ED) or High-Dependency Units (HDU), where a relevant number of these patients are managed. The purpose of this study is to find reliable tools for prognostic assessment of septic patients managed in an ED-HDU. In 742 patients diagnosed with sepsis/severe sepsis/septic shock, not-intubated, admitted in ED between June 2008 and April 2016, SOFA, qSOFA, PIRO, MEWS, Charlson Comorbidity Index, MEDS, and APACHE II were calculated at ED admission (T0); SOFA and MEWS were also calculated after 24 h of ED-High-Dependency Unit stay (T1). Discrimination and incremental prognostic value of SOFA score over demographic data and parameters of sepsis severity were tested. Primary outcome is 28-day mortality. Twenty-eight day mortality rate is 31%. The different scores show a modest-to-moderate discrimination (T0 SOFA 0.695; T1 SOFA 0.741; qSOFA 0.625; T0 MEWS 0.662; T1 MEWS 0.729; PIRO: 0.646; APACHE II 0.756; Charlson Comorbidity Index 0.596; MEDS 0.674, all p < 0.001). At a multivariate stepwise Cox analysis, including age, Charlson Comorbidity Index, MEWS, and lactates, SOFA shows an incremental prognostic ability both at T0 (RR 1.165, IC 95% 1.009-1.224, p < 0.0001) and T1 (RR 1.168, IC 95% 1.104-1.234, p < 0.0001). SOFA score shows a moderate prognostic stratification ability, and demonstrates an incremental prognostic value over the previous medical conditions and clinical parameters in septic patients.

A case of combined septic and obstructive shock: usefulness of bedside integrated cardiothoracic emergency ultrasonography.

A 59-year-old woman presented at the emergency department with cough and weakness that started a few days before. She had a history of breast cancer treated with mastectomy with negative followup. Physical examination revealed tachycardia and tachypnea, normal blood pressure, lower lobe crackles bilaterally, and jugular venous distention. Laboratory data underlined neutrophilic leukocytosis, mild renal failure, and high procalcitonin. Chest radiography revealed bilateral nodular lesions, presumably secondary. Patient was treated with fluid therapy and broad-spectrum antibiotic therapy because of suspected sepsis. In clinical revaluation patient showed systolic hypotension unresponsive to fluid resuscitation. Because of suspected pulmonary embolism an echocardiography was performed revealing normal dimensions of right ventricle with presence of a hypoechoic mass involving tricuspid annulus and obstructing the opening of anterior tricuspid flap; inferior vena cava appeared dilated and not collapsible. Subsequently, chest ultrasonography was performed, confirming multiple rounded lesions involving the pleura bilaterally, compatible with metastasis, and absence of interstitial syndrome. Finally a computed tomography scan of chest excluded pulmonary embolism and confirmed the presence of the obstructive mass responsible for hemodynamic instability together with pulmonary sepsis.