Comparing Quick Sequential Organ Failure Assessment Scores to End-tidal Carbon Dioxide as Mortality Predictors in Prehospital Patients with Suspected Sepsis

Abstract

IntroductionEarly identification of sepsis significantly improves outcomes, suggesting a role for prehospital screening. An end-tidal carbon dioxide (ETCO2) value ≤ 25 mmHg predicts mortality and severe sepsis when used as part of a prehospital screening tool. Recently, the Quick Sequential Organ Failure Assessment (qSOFA) score was also derived as a tool for predicting poor outcomes in potentially septic patients.MethodsWe conducted a retrospective cohort study among patients transported by emergency medical services to compare the use of ETCO2 ≤ 25 mmHg with qSOFA score of ≥ 2 as a predictor of mortality or diagnosis of severe sepsis in prehospital patients with suspected sepsis.ResultsBy comparison of receiver operator characteristic curves, ETCO2 had a higher discriminatory power to predict mortality, sepsis, and severe sepsis than qSOFA.ConclusionBoth non-invasive measures were easily obtainable by prehospital personnel, with ETCO2 performing slightly better as an outcome predictor.

Combination of Prehospital NT-proBNP with qSOFA and NEWS to Predict Sepsis and Sepsis-Related Mortality

“…Hospital-based strategies have been developed for the early screening of sepsis, both in the intensive care units (ICU), such as the Sequential Organ Failure Assessment (SOFA) scores [ 11 ], and out of the ICU, such as the quick Sequential Organ Failure Assessment (qSOFA) or the National Early Warning Score 2 (NEWS2) [ 12 ] [ 13 ]. Additionally, other strategies based on the use of biomarkers such as lactate [ 14 ], C-reactive protein or procalcitonin [ 15 ], and adrenomedullin [ 16 ], the application of end-tidal carbon dioxide [ 17 ] or phenotyping [ 18 ] has been also proposed. In this sense, efforts to detect bedside sepsis by the EMS personnel are based on similar strategies to the ones adopted in the hospital setting, i.e., early warning scores, point-of-care (POC) testing, and specific training, but adapted to prehospital care [ 19 ].…”

End‐tidal carbon dioxide measured at emergency department triage outperforms standard triage vital signs in predicting in‐hospital mortality and intensive care unit admission

“…[7][8][9][10][11] It has a significant association with lactate and anion gap elevation and has found to be an indicator of DKA in pediatric and adult populations. [12][13][14][15][16][17] Furthermore, numerous studies have shown ETCO 2 to have a strong association with acute disease severity and mortality in sepsis, trauma, and shock. 7,13,[18][19][20][21][22][23][24][25][26] Prior studies have explored the clinical utility of adding ETCO 2 to the initial triage assessment of patients.…”

“…[12][13][14][15][16][17] Furthermore, numerous studies have shown ETCO 2 to have a strong association with acute disease severity and mortality in sepsis, trauma, and shock. 7,13,[18][19][20][21][22][23][24][25][26] Prior studies have explored the clinical utility of adding ETCO 2 to the initial triage assessment of patients. Such studies have suggested that an aberrant ETCO 2 may be a sensitive indicator of illness or injury and when compared to all prehospital vital signs, ETCO 2 was the most predictive and consistent for mortality.…”

The sensitivity of qSOFA calculated at triage and during emergency department treatment to rapidly identify sepsis patients

“…Large administrative data analyzed by the SEPSIS-3 authors suggested that a qSOFA score of ≥ 2 would rapidly identify non-ICU patients “more likely to have poor outcomes typical of sepsis,” defined as in-hospital mortality > 10%, with an area under the receiver operating characteristic (AUROC) curve of 0.81 (compared to 0.76 for the SIRS criteria; p = 0.01) 1 , 15 . The authors concluded that the new definitions should “facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis 1 .” Since this assertion in 2016, numerous authors have analyzed the usefulness of qSOFA in retrospective and prospective cohorts at different points in the care continuum from pre-hospital 16 , 17 to initial triage 18 – 20 to the period of ED management 20 , 21 to in-patient wards and the ICU 15 ; have looked at it as a screening tool for all patients presenting to the ED 22 or for those with suspected infection 23 , 24 ; have investigated dynamic changes in qSOFA during ED stay 20 , 25 ; have analyzed its accuracy as a predictor of ICU admission, length of stay, and in-hospital mortality 26 ; have tried to improve the performance of qSOFA by add various biomarkers including lactate 27 , 28 , procalcitonin 29 , monocyte distribution width 30 , and CRP combined with mid-regional proadrenomedullin 31 or vital sign measures including heart rate variability 32 , EtCO 2 33 , and shock index 19 ; have examined its utility in high and low resource settings 27 , 29 , 34 ; and have compared it to other scoring systems including SIRS, MEWS, NEWS, and conventional SOFA 35 , 36 . All of these studies provide important clinical information and have various limitations mainly related to the data sets used, the presence or absence of serial qSOFA values, the clinical setting where the studies were performed, and the overall mortality of the cohorts.…”