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1 Med J Chin PLA, Vol. 41, No. 4, April 1, [ ] (ICU) ICU 1d (APACHE SOFA GCS ISS) A B C 28d ( )3 30 A 23 B 22 C % 73.3% 66.7% 3 28d d 17.4% 18.2% 25.0% A 77.8% 25.0% B 82.2% 41.7% C 72.2% 41.7% [ ] [ ] R631 R641 [ ] A [ ] (2016) [DOI] /j.issn Diagnosis of post-traumatic sepsis according to "Sepsis guidelines": a cross-sectional survey of sepsis in a trauma intensive care unit TANG Hao, LIU Dong, ZHANG Hua-yu, LI Yang, CHANG Ming-tao, ZHANG Xiu-zhu, JIANG Dong-po, ZHANG Lian-yang * Trauma Center, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing , China * Corresponding author, dpzhangly@163.com This work was supported by the National Key Technology Research and Development Program of China (2012BAI11B01) [Abstract] Objective To investigate the prevalence and risk factors of post-traumatic sepsis, and to evaluate the rationality of the 1992, 2001 and 2012 international sepsis definitions in diagnosing post-traumatic sepsis in a trauma intensive care unit (ICU)inChina.Methods A one-day cross-sectional survey of trauma patients who met the inclusion criteria was conducted from 8:00 a.m., June 16, 2014 to 8:00 a.m., June 17, 2014 in the trauma ICU of Daping Hospital. The survey data included demographic information, clinical characteristics, pertinent scores (APACHE, SOFA, GCS, ISS) and injury mechanism. According to the definition of sepsis as depicted in the 1992, 2001, and 2012 "International Guideline of Sepsis", the patients were divided into A, B and C groups. The infection site, infection pathogens, and key medical treatment were recorded, the infection identified, and the 28- day mortality recorded. A positive pathogen culture of respiratory and urinary tracts, blood, cerebrospinal fluid, and wound secretion was adopted as the diagnostic "gold standard" for septic infection. The diagnostic sensitivity and specificity of the three versions of the guidelines were statistically analyzed and the diagnostic feasibility of each definition was assessed. Results A total of 30 trauma patients were enrolled, twenty-three patients met the 1992 sepsis criteria, 22 met the 2001 criteria, and 20 met the 2012 criteria. The prevalence rates were 76.7%, 73.3%, and 66.7%, respectively, and there was no significant statistical difference. Four patients died within 28 days, which was in line with the diagnostic criteria of the three versions of the sepsis criteria. The 28-day mortality in the three sepsis guidelines groups was 17.4%, 18.2%, and 25.0%, respectively, indicating no statistical difference. By adopting culture- [ ] (2012BAI11B01) [ ] [ ] ( ) [ ] dpzhangly@163.com

2 positive pathogens as the "gold standard" of septic infection, the diagnostic sensitivity and specificity of the group A was 77.8% and 25.0%, respectively, that of the group B, 82.2% and 41.7%, respectively, and that of the group C, 72.2% and 41.7%, respectively. No statistical difference was found in diagnostic performance among the three versions of sepsis criteria. Conclusion The prevalence of sepsis is high in the ICU trauma patients. There is no difference in diagnostic performance for post-traumatic sepsis among the three versions of the diagnostic criteria. The 1992 international sepsis criteria is relatively simple and may be more feasible for the diagnosis of post-traumatic sepsis. [Key words] wounds and injuries; sepsis; prevalence; diagnosis ICU ICU ICU >35% >27% >50% [1] ICU 12.4% [2] ICU 46.9% [3] [4] 1992 (ACCP) (SCCM) (systemic inflammatory response syndrome SIRS) [5] ACCP SCCM (ESICM) (ATS) [6-7] [5-8] [9-10] [11] [12-13] ICU ICU 3 28d >18 ICU 24h ±18.5 ICU APACHE 21.4± ISS 23.3± :00am :00am A B C d ( D ) ( CT ) ( ) 28d 28d ( ) (SIRS >38 <36 >90 /min >12 000/mm 3 <4000/ mm 3 10% >20 / min PaCO 2 <32mmHg) ( ) ( >38.3 >90 /min >30 /min C ) [( )/ ] 3mmol/L 1mmol/L SOFA

3 Med J Chin PLA, Vol. 41, No. 4, April 1, >2 1.4 SAS 9.13 x±s χ 2 Fisher's P<0.05 logistic ROC 3 (AUC) P< ICU ISS AIS 3 ICU APACHE SOFA GCS ( ) 1 1 Tab.1 Demographic/clinical data of sepsis patients Item Group A Group B Group C Age(year) 57.9± ± ±16.3 Male/Female (n) 17/5 16/6 15/5 Blunt/Penetrating trauma (n) 18/5 17/5 16/4 ISS 26.6± ± ±9.9 AIS(head) 3 (n) AIS(thorax) 3 (n) AIS(abdomen) 3 (n) AIS(extremities) 3 (n) APACHE score 21.1± ± ±8.6 SOFA score 7.6± ± ±4.7 GCS score 11.6± ± ±4.6 Diabetes (n) Renal dysfunction (n) Respiratory dysfunction (n) Liver dysfunction (n) Heart dysfunction (n) Immunodeficiency disease (n) Sepsis/Total (n) 23/30 22/30 20/30 Prevalence of sepsis (%) Death/Total (n) 4/23 4/22 4/20 28-day mortality (%) Site of infections (n) Lung Urogenital Abdomen Cranial Other (knee) Site of infections (n) G + bacteria G bacteria Fungi ( ) ( ) / 28d / 28d % 73.3% 66.7% (P 0.05) 3 28d 4 28d 17.4% 18.2% 25.0% (P 0.05) 2.3 >65 ICU APACHE SOFA GCS 8 ISS AIS 3 ( 5d 6~10d >10d) 1 / ( ) 2A (P 0.05) B C A 77.8% 25.0% B 82.2% 41.7% C 72.2% 41.7%( 3) 3 ROC (P ) 3 [4] ICU % 73.3% 66.7% 28d 17.4% 18.2% 25.0% 1992 ICU Wafaisade [14]

4 Tab. 2 Relevant risk factors for the incidence of sepsis Variable Group A Group B Group C Total Male/Total (n) 17/23 16/22 15/20 23/30 Age>65/Total (n) 10/23 10/22 8/20 13/30 APACHE score 21.1± ± ± ±8.5 SOFA score 7.6± ± ± ±4.6 GCS 8 (n) 7/23 7/22 6/20 9/30 ISS score 26.6± ± ± ±8.2 AIS (head) 3(n) AIS (thorax) 3(n) AIS (abdomen) 3(n) AIS (extremities) 3(n) Mechanismofinjury(n) Blunt Penetrating Chronic disease Immunodeficiency disease ICU hospitalization time (n) 5d d >10d Diagnostic/Therapeutic procedures within one week (n) Central venous catheter Arterial catheter Urinary catheter Wound drainage tube Dialysis Artificial airways Mechanical ventilation Central venous nutrition Tab. 3 Pathogens cultivation of the three groups Item Group A Group B Group C Sepsis (n=23) Non-sepsis (n=7) Sepsis (n=22) Non-sepsis (n=8) Sepsis (n=20) Non-sepsis (n=10) Positive Negative Sensitivity (%) Specificity (%) Positive predictive value (%) Positive predictive value (%) Correct diagnosis index ICU ISS % 19.4% 2004 Osborn [15] 2 2.0% 23.1% ISS 13±11 ISS (27.0±9.9 ) Osborn [15] Wafaisade [14] 28d Wafaisade [14] GCS 8 ISS ICU

5 Med J Chin PLA, Vol. 41, No. 4, April 1, Sensitivity ROC curve (area) 1991 Standard (0.5139) 2001 Standard (0.6250) Standard (0.5694) Specificity 1 3 ROC Fig.1 ROC curves of diagnostic value of three sepsis guidelines Osborn [15] ISS RTS(revised trauma score) GCS 2012 SOFA ICU [16] Wafaisade [14] [6-7] SIRS [5-6,17-18] SIRS [17] [19-20] 21 [21] SIRS [6,22] 3 [23-24] Table 1 some of the following SIRS + infection [5-7] 2014 ProCESS ARISE [25-26] [27-28] [27] [27] [28] [5-7] [1,14,16] Biomarker premature [6-7] Biomarker [6,29]

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