Comparative Predictive Accuracies of the Simplified Mortality Score for the Intensive Care Unit, Sepsis Severity Score, and Standard Severity Scores for 90-day Mortality in Sepsis Patients.

Background: The standard severity scores were used for predicting hospital mortality of intensive care unit (ICU) patients. Recently, the new predictive score, Simplified Mortality Score for the ICU (SMS-ICU), was developed for predicting 90-day mortality. Objective: To validate the ability of the SMS-ICU and compare with sepsis severity score (SSS) and original severity scores for predicting 90-day mortality in sepsis patients. Method: An analysis of retrospective data was conducted in the ICU of a university teaching hospital. Also, 90-day mortality was used for the primary outcome. Results: A total of 1,161 patients with sepsis were included. The 90-day mortality was 42.4%. The SMS-ICU presented the area under the receiver operating characteristic curve (AUROC) of 0.71, whereas the SSS had significantly higher AUROC than that of the SMS-ICU (AUROC 0.876, p < 0.001). The acute physiology and chronic health evaluation (APACHE) II and IV, and the simplified acute physiology scores (SAPS) II demonstrated good discrimination, with an AUROC above 0.90. The SMS-ICU provides poor calibration for 90-day mortality prediction, similar to the SSS and other standard severity scores. Furthermore, 90-day mortality was underestimated by the SMS-ICU, which had a standardized mortality ratio (SMR) of 1.36. The overall performance by Brier score demonstrated that the SMS-ICU was inferior to the SSS (0.222 and 0.169, respectively). Also, SAPS II presented the best overall performance with a Brier score of 0.092. Conclusion: The SMS-ICU indicated lower performance compared to the SSS, standard severity scores. Consequently, modifications are required to enhance the performance of the SMS-ICU. How to cite this article: Sathaporn N, Khwannimit B. Comparative Predictive Accuracies of the Simplified Mortality Score for the Intensive Care Unit, Sepsis Severity Score, and Standard Severity Scores for 90-day Mortality in Sepsis Patients. Indian J Crit Care Med 2024;28(4):343-348.

Comparison the accuracy of early warning scores with qSOFA and SIRS for predicting sepsis in the emergency department.

INTRODUCTION: The aims of this study were to evaluate the accuracy of early warnings scores including National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Mortality in Emergency Department Sepsis score (MEDS), Search Out Severity score (SOS) and compare them with quick Sequential Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) for detecting sepsis among infected patients at the emergency department (ED). METHODS: A retrospective study was conducted at ED of a university hospital. Primary outcome was sepsis defined by sepsis-2 definition. Secondary outcomes were sepsis defined by sepsis-3 definition, hospital admission and in-hospital mortality. RESULTS: A total of 652 (83.9%) from 777 infected patients were classified as sepsis by sepsis-2. MEWS and SOS outperformed other scores in predicting sepsis with the area under receiver operating characteristic curve (AUC) (95%CI) 0.845 (0.805-0.885) and 0.839 (0.799-0.879), followed by NEWS 0.800 (0.753-0.846), MEDS 0.608 (0.551-0.665) and qSOFA 0.657 (0.609-0.706) (p < .001 for all). MEWS ≥3 had a sensitivity of 87.7%, specificity of 69.6%, positive and negative likelihood ratio of 2.88 and 0.18 for predicting sepsis by sepsis-2. Whereas, MEDS and NEWS presented the highest AUC for predicting sepsis according to sepsis-3 (AUC 0.738 and 0.722). NEWS ≥7 predicted sepsis by sepsis-3 with 53.3% sensitivity, 80.9% specificity, 2.75 positive likelihood ratio (LR+) and 0.59 negative likelihood ratio. qSOFA had the highest LR+ of 3.69 for predicting hospital mortality. CONCLUSION: The early warning scores, qSOFA and SIRS had limited decision making for predicting sepsis and adverse outcomes among infected patients.

Comparison the accuracy and trending ability of cardiac index measured by the fourth- generation of FloTrac with the PiCCO device in septic shock patients

Background/aim: FloTrac/Vigileo is a noncalibrated arterial pressure waveform analysis for cardiac index (CI) monitoring. The aim of our study was to compare the CI measured by the 4th generation of FloTrac with PiCCO in septic shock patients. Materials and methods: We simultaneously measured the CI using FloTrac (CIv) and compared it with the CI derived from transpulmonary thermodilution (CItd) as well as the pulse contour-derived CI using PiCCO (CIp). Results: Thirty-one septic shock patients were included. The CIv correlated with CItd (r = 0.62, P < 0.0001). The Bland-Altman analysis showed a bias of 0.14, and the limits of agreement were ­1.62­1.91 L/min/m2 with a percentage error of 47.4%. However, the concordance rate between CIv and CItd was 93.6%. The comparison of CIv with CIp (n = 352 paired measurements) revealed a bias of -0.16, and the limits of agreement were ­1.45­1.79 L/min/m2 with a percentage error of 44.8%. The overall correlation coefficient between CIv and CIp was 0.63 (P < 0.0001), and the concordance rate was 85.4%. Conclusion: The 4th generation of FloTrac has not acceptable agreement to assess CI; however, it has the ability to tracked changes of CI, when compared with the transpulmonary thermodilution method by PiCCO.

A comparison of ventricular systolic function indices provided by VolumeView/EV1000™ and left ventricular ejection fraction by echocardiography among septic shock patients.

The aim of this study was to compare the cardiac function index (CFI) and global ejection fraction (GEF) obtained by VolumeView/EV1000™, with the left ventricular ejection fraction (LVEF) by echocardiography in septic shock patients. A prospective observational study was conducted in a medical intensive care unit of a tertiary, teaching university hospital. Thirty-two, mechanical-ventilated septic shock patients were included in this study. We simultaneously measured CFI and GEF with LVEF. The correlation of CFI, GEF along with LVEF and ability of CFI and GEF to predict LVEF ≥ 40, 50 and 60% were evaluated. There were 192 pairs of CFI, GEF and LVEF. CFI was significantly correlated with GEF (r = 0.82, P < 0.0001). A significant correlation was observed between CFI and LVEF (r = 0.56, P < 0.0001) and GEF and LVEF (r = 0.71, P < 0.0001). The CFI and GEF had a good predictive ability for estimating LVEF ≥ 40, 50 and 60%, with an area under receiving operating characteristic (AUC) 0.875-0.934. The CFI ≥ 3/min predicted LVEF ≥ 40% with sensitivity 95.1% and specificity 48.3%. The GEF ≥ 15%, estimated LVEF ≥ 40% with sensitivity 92.6% and specificity 69%. There were 40 thermodilution and LVEF measurements obtained before and after norepinephrine adjustment. Blood pressure as well as the cardiac index were significantly increased, whereas there were no changes in CFI, GEF and LVEF values. Conclusions: Both CFI and GEF obtained by VolumeView/EV1000™, correlated with LVEF, so as to provide a reliable estimation of LV systolic function in septic shock patients.

A Comparison of Residents' Knowledge Regarding the Surviving Sepsis Campaign 2012 Guideline.

BACKGROUND: Recently, Surviving Sepsis Campaign (SSC) guideline was updated. Our objective was to evaluate the knowledge of residents in different departments regarding the SSC 2012. METHODS: A cross-sectional, descriptive self-questionnaire was distributed to interns and residents in the Departments of Internal Medicine, Surgery, and Emergency Medicine. RESULTS: The response rate was 136 (89%) from 153 residents. The residents included 46 (33%) interns, 42 (31%) internal medicine residents, 41 (30%) surgical residents, and 7 (5%) emergency residents. Regarding the definitions of severe sepsis and septic shock, only 44 (32.4%) residents were able to differentiate the severity of sepsis. The surgical residents had a significantly lower rate of correct answers than that of internal medicine residents (12.2% vs. 45.2, P = 0.001), emergency residents (12.2% vs. 57.1%, P = 0.005), and interns (12.2% vs. 34.8%, P = 0.014). Only 77 (51.5%) residents would measure blood lactate in patients with sepsis. In respect to the dose of fluid resuscitation, only 72 (52.9%) residents gave the recommended fluid (30 ml/kg) within the first 3 h. Surgical residents had a significantly lesser percentage of correct answers than that of internal medicine residents (29.3% vs. 69%, P < 0.0001) and interns (29.3% vs. 60.8%, P = 0.003). About 123 (90.4%) and 115 (84.6%) residents knew the appropriate targets for mean arterial pressure and vasopressors, respectively. Most residents could give antimicrobial drugs (73.5%) and steroids (93.4%) appropriately in the treatment of patients with septic shock. However, only half of the residents knew the target range of blood sugar control in patients with sepsis. CONCLUSIONS: Our residents' knowledge about the SSC 2012 is not satisfactory. Further instruction concerning sepsis management is required.

Quality of Dying in the Medical Intensive Care Unit: Comparison between Thai Buddhists and Thai Muslims.

BACKGROUND AND AIMS: Religious belief is an important aspect that influences the life of a patient, especially in Asia. We aim to compare the quality of death in an Intensive Care Unit (ICU) between Buddhists and Muslims from the perspectives of the relatives of the patients and the nurses and physicians. SUBJECTS AND METHODS: This was a cohort study of critically ill patients who died after admission to a medical ICU in Songklanagarind Hospital in Thailand between 2015 and 2016. We interviewed by telephone the relatives of patients. The nurses and physicians who cared for the patients responded to a self-questionnaire. RESULTS: A total of 112 patients were enrolled in the study. The quality of death and dying-1 scores in Thai Buddhists and Muslim patients rated by the relatives (8 vs. 8, P = 0.55), nurses (8 vs. 8, P = 0.28), and physicians (7 vs. 7, P = 0.74) were not different. The ratings by the nurses correlated with the relatives (rs = 0.41, P < 0.001) but did not correlate with the physicians (rs = 0.15, P = 0.12). Compared with Buddhist patients, Muslim patients were more likely to have documentation in place at the time of the death of do not resuscitate (100% vs. 80.2%, P = 0.02) and withholding and withdrawing life support (100% vs. 80.2%, P = 0.02). CONCLUSION: There was no difference in the quality of dying and death between Thai Buddhists and Muslims. However, some elements of palliative care were not similar.

Impact of positive fluid balance on mortality and length of stay in septic shock patients.

BACKGROUND: Fluid management is important in critically patients. The aim of this study was to determine the relationship between fluid balance and adverse outcomes of septic shock. METHODS: A retrospective study was conducted in the medical Intensive Care Unit (ICU) of a tertiary university hospital in Thailand, over a 7-year period. RESULTS: A total of 1048 patients with an ICU mortality rate of 47% were enrolled. The median cumulative fluid intake at 24, 48, and 72 h from septic shock onset were 4.2, 7.7, and 10.5 L, respectively. Nonsurvivors had a significantly higher median cumulative fluid intake at 24, 48, and 72 h (4.6 vs. 3.9 L, 8.2 vs. 7.1 L, and 11.4 vs. 9.9 L, respectively, P < 0.001 for all). Nonsurvivors also had a significantly higher cumulative and mean fluid balance within 72 h (5.4 vs. 4.4 L and 2.8 vs. 1.6 L, P < 0.001 for both). In multivariate logistic regression analysis, mean fluid balance quartile within 72 h, was independently associated with an increase in ICU and hospital mortality. Quartile 3 and 4 have statistically significant increases in mortality compared with quartile 1 (odds ratio [95% confidence interval] 3.04 [1.9-4.48] and 4.16 [2.49-6.95] for ICU mortality and 2.75 [1.74-4.36] and 3.16 [1.87-5.35] for hospital mortality, respectively, P < 0.001 for all). In addition, the higher amount of mean fluid balance was associated with prolonged ICU stays. CONCLUSIONS: Positive fluid balance over 3 days is associated with increased ICU and hospital mortality along with prolonged ICU stays in septic shock patients.

Validating the APACHE IV score in predicting length of stay in the intensive care unit among patients with sepsis.

The Acute Physiology and Chronic Health Evaluation (APACHE) IV model can predict the intensive care unit (ICU) length of stay (LOS) in critically ill patients. Thus, this study aimed to validate the performance of the APACHE IV score in predicting ICU LOS among patients with sepsis. This retrospective study was conducted in the medical ICU of a tertiary university between 2017 and 2020. A total of 1,039 sepsis patients were enrolled. Patients with an ICU stay of 1 and > 3 days accounted for 20.1% and 43.9%. The overall observed and APACHE IV predicted ICU LOS were 6.3 ± 6.5 and 6.8 ± 6.5, respectively. The APACHE IV slightly over-predicted ICU LOS with standardized length of stay ratio 0.95 (95% CI 0.89-1.02). The predicted ICU LOS based on the APACHE IV score was statistically longer than the observed ICU LOS (p < 0.001) and were poorly correlated (R2 = 0.02, p < 0.001), especially in patients with a lower severity of illness. In conclusions the APACHE IV model poorly predicted ICU LOS in patients with sepsis. The APACHE IV score needs to be modified or we need to make a new specific model to predict ICU stays in patients with sepsis.

Risk Factor for Superimposed Nosocomial Bloodstream Infections in Hospitalized Patients with COVID-19.

Introduction: Corticosteroids are a component of the standard therapy for patients with coronavirus disease 2019 (COVID-19) because of the immunological dysregulation and hyperinflammation associated with the condition. This study aimed to evaluate the potential risk factors for nosocomial bloodstream infections in hospitalized patients with COVID-19, including the exploration of corticosteroid dosage and treatment duration. Materials and Methods: A retrospective cohort study of hospitalized patients with COVID-19 was conducted in a tertiary care hospital. We performed univariate and multivariate analyses of various parameters to identify risk factors for nosocomial bloodstream infection. Results: Of 252 patients, 19% had nosocomial bloodstream infections. The mortality rate of nosocomial bloodstream infections was 62.5%. Multivariate analysis revealed that male sex (odds ratio [OR] 3.43; 95% confidence interval [CI]: 1.60-7.33), receiving methylprednisolone (OR: 3.01; 95% CI: 1.24-7.31), receiving an equivalent dexamethasone dose of 6-12 mg/day (OR: 7.49; 95% CI: 2.08-26.94), and leukocytosis on admission (OR: 4.13; 95% CI: 1.89-9.01) were significant predictors of nosocomial bloodstream infections. Conclusion: Unmodified risk variables for nosocomial bloodstream infections included male sex and leukocytosis at admission. Using methylprednisolone and obtaining a cumulative dosage of dexamethasone were adjusted risk variables associated with superimposed nosocomial bloodstream infections in hospitalized patients with COVID-19.

Validation of the prognostic scoring system for in-hospital mortality prediction in cardiogenic shock patients requiring veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: A few prognostic scoring systems have been developed for predicting mortality in patients with cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO), albeit with variations in performance. This study aimed to assess and compare various mortality prediction models in a cohort of patients receiving VA-ECMO following cardiogenic shock or arrest. METHODS: We retrospectively analyzed 77 patients with cardiogenic shock who were placed on VA-ECMO support between March 2014 and August 2021. The APACHE II, SAPS II, SAVE, Modified SAVE, ENCOURAGE, and ECMO-ACCEPTS scores were calculated for each patient to predict the in-hospital mortality. RESULTS: Fifty-six (72.7%) patients died. All prediction model scores, except the ECMO-ACCEPTS, differed significantly between non-survivors and survivors as follows: ENCOURAGE, 23 versus 16 (p < 0.001); SAVE, -6 versus -3 (p = 0.008); Modified SAVE, -5 versus 0 (p = 0.005); APACHE II, 32 versus 22 (p = 0.009); and SAPS II, 67 versus 49 (p = 0.002). The ENCOURAGE score demonstrated the best discriminatory ability with an area under the receiver-operating characteristic curve of 0.81 (95% confidence interval: 0.7-0.81). All prognostic scoring systems possessed limited calibration ability. However, the SAPS II, SAVE, and ENCOURAGE scores had lower Akaike and Bayesian information criteria values, which were consistent with the results of the Hosmer-Lemeshow C statistic test, indicating better performance than the other scores. CONCLUSIONS: The ENCOURAGE score can help predict in-hospital mortality in all subsets of VA-ECMO patients, even though it was originally designed to predict intensive care unit mortality in the post-acute myocardial infarction setting.

Prediction of fluid responsiveness in septic shock patients: comparing stroke volume variation by FloTrac/Vigileo and automated pulse pressure variation.

OBJECTIVES: The aim of this study was to assess and compare the ability of the automatically and continuously measured stroke volume variation (SVV) obtained by FloTrac/Vigileo, and pulse pressure variation (PPV) measured by an IntelliVue MP monitor, to predict fluid responsiveness in mechanically ventilated septic shock patients. METHOD: We conducted a prospective study on 42 septic shock patients. SVV, PPV and other haemodynamic data were recorded before and after fluid administration of 500 ml of 6% hydroxyethyl starch. Responders were defined as patients with an increase in stroke volume index of at least 15% after fluid loading. RESULTS: Twenty-four (57.1%) patients were classified as fluid responders. The baseline SVV correlated with the baseline PPV (r=0.96, P<0.001). SVV and PPV were significantly higher in responders than in nonresponders (15.5±4.5 vs. 8.2±3.3% and 16.4±5.2 vs. 8.3±3.5, respectively, P<0.001 for both). There was no difference between the area under the receiver operating characteristic curves of SVV [0.92, 95% confidence interval 0.832-1.00] and PPV (0.916, 95% confidence interval 0.829-1.00). The optimal threshold values in predicting fluid responsiveness were 10% for SVV (sensitivity 91.7% and specificity 83.3%) and 12% for PPV (sensitivity 83.3% and specificity 83.3%). Our results were independent of the site of arterial catheterisation. CONCLUSION: The SVV, obtained by FloTrac/Vigileo, and the automated PPV, obtained by the IntelliVue MP monitor, showed comparable performance in terms of predicting fluid responsiveness in passively ventilated septic shock patients, with a regular cardiac rhythm and a tidal volume not less than 8 ml kg(-1).

Agreements between mean arterial pressure from radial and femoral artery measurements in refractory shock patients.

Radial and femoral artery catheterization is the most common procedure for monitoring patients with shock. However, a disagreement in mean arterial pressure (MAP) between the two sites has been reported. Hence, the aim of this study was to compare the MAP from the radial artery (MAPradial) with that of the femoral artery (MAPfemoral) in patients with refractory shock. A prospective study was conducted in the medical intensive care unit. The radial and femoral were simultaneously measured MAP in the patients every hour, for 24 h. In total, 706 paired data points were obtained from 32 patients. MAPradial strongly correlated with MAPfemoral (r = 0.89, p < 0.0001). However, overall MAPradial was significantly lower than MAPfemoral 7.6 mmHg. The bias between MAPradial and MAPfemoral was - 7.6 mmHg (95% limits of agreement (LOA), - 24.1 to 8.9). In the subgroup of patients with MAPradial < 65 mmHg, MAPradial moderately correlated with MAPfemoral (r = 0.63) and the bias was increased to - 13.0 mmHg (95% LOA, - 28.8 to 2.9). There were 414 (58.6%) measurements in which the MAP gradient between the two sites was > 5 mmHg. In conclusion, the radial artery significantly underestimated MAP compared with the femoral artery in patients with refractory shock.

Ability of a modified Sequential Organ Failure Assessment score to predict mortality among sepsis patients in a resource-limited setting.

BACKGROUND: Some variables of the Sequential Organ Failure Assessment (SOFA) score are not routinely measured in sepsis patients, especially in countries with limited resources. Therefore, this study was conducted to evaluate the accuracy of the modified SOFA (mSOFA) and compared its ability to predict mortality in sepsis patients to that of the original SOFA score. METHODS: Sepsis patients admitted to the medical intensive care unit of Songklanagarind Hospital between 2011 and 2018 were retrospectively analyzed. The primary outcome was all-cause in-hospital mortality. RESULTS: A total of 1,522 sepsis patients were enrolled. The mean SOFA and mSOFA scores were 9.7±4.3 and 8.8±3.9, respectively. The discrimination of the mSOFA score was significantly higher than that of the SOFA score for all-cause in-hospital mortality (area under the receiver operating characteristic curve, 0.891 [95% confidence interval, 0.875-0.907] vs. 0.879 [0.862-0.896]; P<0.001), all-cause intensive care unit (ICU) mortality (0.880 [0.863-0.898] vs. 0.871 [0.853-0.889], P=0.01) and all-cause 28-day mortality (0.887 [0.871-0.904] vs. 0.874 [0.856-0.892], P<0.001). The ability of mSOFA score to predict all-cause in-hospital and 28-day mortality was higher than that of the SOFA score within the subgroups of sepsis according to age, sepsis severity and serum lactate levels. The mSOFA score was demonstrated to have a performance similar to the original SOFA score regarding the prediction of mortality in sepsis patients with cirrhosis or hepatic dysfunction. CONCLUSIONS: The mSOFA score was a good alternative to the original SOFA core in predicting mortality among sepsis patients admitted to the ICU.

The Concentration of Large Extracellular Vesicles Differentiates Early Septic Shock From Infection.

Septic shock represents a subset of sepsis with severe physiological aberrations and a higher mortality rate than sepsis alone. Currently, the laboratory tools which can be used to identify the state of septic shock are limited. In pre-clinical studies, extracellular vesicles (EVs), especially large EVs (lEVs), have been demonstrated a role as functional inflammatory mediators of sepsis. However, its longitudinal trend during the disease course has not been explored. In this study, the quantities and subtypes of plasma-derived lEVs were longitudinally compared between patients with septic shock (n = 21) and non-sepsis infection (n = 9), who presented within 48 h of their symptom onset. Blood specimens were collected for seven consecutive days after hospital admission. lEVs quantification and subtyping were performed using an imaging flow cytometer. The experiments revealed a higher lEVs concentration in septic shock patients than infected patients at the onset of the disease. In septic shock patients, lEVs concentration decreased over time as opposed to infected patients whose lEVs concentration is relatively static throughout the study period. The major contributors of lEVs in both septic shock and infected patients were of non-leukocyte origins; platelets, erythrocytes, and endothelial cells released approximately 40, 25, and 15% of lEVs, respectively. Among lEVs of leukocyte origins, neutrophils produced the highest number of EVs. Nevertheless, the proportion of each subtype of lEVs among the given amount of lEVs produced was similar between septic shock and infected patients. These findings raise the possibility of employing lEVs enumeration as a septic shock identifying tool, although larger studies with a more diverse group of participants are warranted to extrapolate the findings to a general population.

Comparison of knowledge and confidence between medical students as leaders and followers in simulated resuscitation.

OBJECTIVES: To compare both the knowledge and self-reported confidence levels between medical students as the team leaders and followers in shock resuscitation simulation training. METHODS: A cross-sectional study was conducted with all fifth-year medical students participating in a shock resuscitation simulation-based training between May 2017 and March 2018. The simulation class was a 3-hour session that consisted of 4 shock type scenarios as well as a post-training debriefing. Medical students were assigned into groups of 4-5 members, in which they freely selected a leader, and the rest filled the roles of followers. Of 139 medical students, 32 students were leaders. A 10-question pre-test and post-test determined knowledge assessment. At the end of the class, the students completed a 5-point Likert scale confidence level evaluation questionnaire. A t-test was applied to compare knowledge scores and confidence levels between the leaders and followers. RESULTS: At the end of the class, the knowledge scores between the leaders (M=6.72, SD=1.51) and followers (M=6.93, SD=1.26) were not different (t(137)= -0.81, p=0.42). In addition, the student confidence levels were also similar between the leaders (M=3.63, SD=0.55) and followers (M=3.41, SD=0.64) after training (t(137)=1.70, p=0.09). CONCLUSIONS: The knowledge and confidence levels were not different between either the leaders or followers in simulated resuscitation. With time-limit simulation training, we suggested every student may not need to fulfil the leadership role, but a well-designed course and constructive debriefing are recommended. Future studies should evaluate skills and longitudinal effects of the leader role.

Distinguishing Sepsis From Infection by Neutrophil Dysfunction: A Promising Role of CXCR2 Surface Level.

Sepsis is one of the well-established diseases with specific patterns of neutrophil dysfunctions. Previous studies demonstrated sepsis-related neutrophil dysfunctions in comparison with subjects without infection. Since sepsis and infection are recently recognized as distinctive processes, whether these neutrophil dysfunctions are associated with sepsis or infection are not known. Therefore, we longitudinally compared neutrophil functions, widely-cited as exhibiting sepsis-related changes, between patients with septic shock and infection. The surface level of cluster of differentiation 64 (CD64), C-C motif chemokine receptor 2 (CCR2), C-X-C motif chemokine receptor 2 (CXCR2); apoptosis; and NETosis were measured from peripheral blood neutrophils for seven consecutive days using flow cytometry. The between-group comparisons of neutrophil functions were made both on a day-by-day basis and as linear regression between time and measured neutrophil functions (sepsis status included as model predictors). Our study found that, among neutrophil functions studied, only CXCR2 surface level is associated with sepsis. At disease onset, CXCR2 level decrease, with a dose-response relationship with clinical severity. Its level reverts to resemble infected patients by the end of the week. The relationship between CD64 surface level, CCR2 surface level, NETosis, and sepsis are mediated through the effect of infection. Apoptosis activity between these groups are similar, hence, not sepsis-related.

Validation the performance of New York Sepsis Severity Score compared with Sepsis Severity Score in predicting hospital mortality among sepsis patients.

PURPOSE: The aim of this study was to compare the performance of the New York Sepsis Severity Score (NYSSS) with the Sepsis Severity Score (SSS) and Acute Physiology and Chronic Health Evaluation and Simplified Acute Physiology Scores for predicting mortality in sepsis patients. METHOD: A retrospective analysis was conducted in the intensive care unit. The primary outcome was in-hospital mortality. RESULTS: Overall 1680 sepsis patients were enrolled. The hospital mortality rate was 44.4%. The NYSSS underestimated actual mortality with standard mortality ratio (SMR) of 1.28 (95%CI 1.19-1.38). However, the SSS slightly overestimated the actual mortality with an SMR of 0.94 (0.88-1.01). The NYSSS had moderate discrimination with an AUC of 0.772 (0.750-0.794), in contrast to the SSS which had good discrimination with an AUC of 0.889 (0.873-0.904). The AUC of the SSS was statistically higher than that of the NYSSS. The AUCs of both the NYSSS and SSS were significantly lower than other standard severity scores. The calibrations for all severity scores were poor. The SSS had better overall performance than the NYSSS (Brier score 0.149 and 0.201, respectively). CONCLUSION: The SSS had better discrimination and overall performance than the NYSSS. However, both sepsis severity scores were poorly calibrated.

Comparison of the accuracy of three early warning scores with SOFA score for predicting mortality in adult sepsis and septic shock patients admitted to intensive care unit.

BACKGROUND: The purpose of this study was to compare the accuracy of the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS) and Search Out Severity (SOS), with the quick Sequential Organ Failure Assessment (qSOFA) and SOFA scores, to predict outcomes in sepsis patients. METHODS: A retrospective study was conducted in intensive care unit of university teaching hospital. RESULTS: A total of 1,589 sepsis patients were enrolled. The SOFA score had the best accuracy to predict hospital mortality, with an area under the receiver operating characteristic curve (AUC) of 0.880 followed by SOS (0.878), MEWS (0.858), qSOFA (0.847) and NEWS (0.833). The SOS score provided a similar performance with SOFA score in predicting mortality. CONCLUSION: The SOS presents nearly as good as the SOFA score, to predict mortality among sepsis patients admitted to the ICU. The early warning score is another, alternative tool to use for risk stratification and sepsis screening for ICU sepsis patients.

Validation of the LOD score compared with APACHE II score in prediction of the hospital outcome in critically ill patients.

The Logistic Organ Dysfunction score (LOD) is an organ dysfunction score that can predict hospital mortality. The aim of this study was to validate the performance of the LOD score compared with the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in a mixed intensive care unit (ICU) at a tertiary referral university hospital in Thailand. The data were collected prospectively on consecutive ICU admissions over a 24 month period from July1, 2004 until June 30, 2006. Discrimination was evaluated by the area under the receiver operating characteristic curve (AUROC). The calibration was assessed by the Hosmer-Lemeshow goodness-of-fit H statistic. The overall fit of the model was evaluated by the Brier's score. Overall, 1,429 patients were enrolled during the study period. The mortality in the ICU was 20.9% and in the hospital was 27.9%. The median ICU and hospital lengths of stay were 3 and 18 days, respectively, for all patients. Both models showed excellent discrimination. The AUROC for the LOD and APACHE II were 0.860 [95% confidence interval (CI) = 0.838-0.882] and 0.898 (95% Cl = 0.879-0.917), respectively. The LOD score had perfect calibration with the Hosmer-Lemeshow goodness-of-fit H chi-2 = 10 (p = 0.44). However, the APACHE II had poor calibration with the Hosmer-Lemeshow goodness-of-fit H chi-2 = 75.69 (p < 0.001). Brier's score showed the overall fit for both models were 0.123 (95%Cl = 0.107-0.141) and 0.114 (0.098-0.132) for the LOD and APACHE II, respectively. Thus, the LOD score was found to be accurate for predicting hospital mortality for general critically ill patients in Thailand.

Serial evaluation of the MODS, SOFA and LOD scores to predict ICU mortality in mixed critically ill patients.

OBJECTIVE: To perform a serial assessment and compare ability in predicting the intensive care unit (ICU) mortality of the multiple organ dysfunction score (MODS), sequential organ failure assessment (SOFA) and logistic organ dysfunction (LOD) score. MATERIAL AND METHOD: The data were collected prospectively on consecutive ICU admissions over a 24-month period at a tertiary referral university hospital. The MODS, SOFA, and LOD scores were calculated on initial and repeated every 24 hrs. RESULTS: Two thousand fifty four patients were enrolled in the present study. The maximum and delta-scores of all the organ dysfunction scores correlated with ICU mortality. The maximum score of all models had better ability for predicting ICU mortality than initial or delta score. The areas under the receiver operating characteristic curve (AUC) for maximum scores was 0.892 for the MODS, 0.907 for the SOFA, and 0.92for the LOD. No statistical difference existed between all maximum scores and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. CONCLUSION: Serial assessment of organ dysfunction during the ICU stay is reliable with ICU mortality. The maximum scores is the best discrimination comparable with APACHE II score in predicting ICU mortality.