Med J Chin PLA, Vol. 41, No. 4, April 1, 2016 295 [ ] (ICU)1992 2001 2012 ICU 1d (APACHE SOFA GCS ISS) 1992 2001 2012 A B C 28d ( )3 30 A 23 B 22 C 20 76.7% 73.3% 66.7% 3 28d 4 3 28d 17.4% 18.2% 25.0% A 77.8% 25.0% B 82.2% 41.7% C 72.2% 41.7% 33 1992 [ ] [ ] R631 R641 [ ] A [ ] 0577-7402(2016)04-0295-06 [DOI] 10.11855/j.issn.0577-7402.2016.04.07 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 400042, China * Corresponding author, E-mail: 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) [ ] [ ] 400042 ( ) [ ] E-mail dpzhangly@163.com
296 2016 4 1 41 4 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) 2001 2012 [6-7] [5-8] [9-10] [11] [12-13] ICU ICU 3 28d 1 1.1 >18 ICU 24h 38 30 23 7 58.9±18.5 ICU APACHE 21.4±8.5 7 23 ISS 23.3±8.2 1.2 1.2.1 2014 6 16 8:00am 2014 6 17 8:00am 1.2.2 1992 2001 2012 3 A B C 3 1.2.3 1d ( D ) ( CT ) ( ) 28d 28d 3 1.3 1992 2001 2012 3 1992 ( ) (SIRS 1992 2 >38 <36 >90 /min >12 000/mm 3 <4000/ mm 3 10% >20 / min PaCO 2 <32mmHg) 1992 2001 ( ) ( >38.3 >90 /min >30 /min C ) 2001 2012 [( )/ ] 3mmol/L 1mmol/L SOFA
Med J Chin PLA, Vol. 41, No. 4, April 1, 2016 297 >2 1.4 SAS 9.13 x±s χ 2 Fisher's P<0.05 logistic ROC 3 (AUC) P<0.05 2 2.1 ICU 38 30 23 7 3 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±17.8 59.1±15.0 58.7±16.3 Male/Female (n) 17/5 16/6 15/5 Blunt/Penetrating trauma (n) 18/5 17/5 16/4 ISS 26.6±11.1 28.6±10.4 27.0±9.9 AIS(head) 3 (n) 12 8 7 AIS(thorax) 3 (n) 7 6 6 AIS(abdomen) 3 (n) 4 5 4 AIS(extremities) 3 (n) 2 1 1 APACHE score 21.1±8.9 22.0±8.6 22.6±8.6 SOFA score 7.6±4.9 7.8±5.0 7.7±4.7 GCS score 11.6±4.7 11.7±4.8 11.8±4.6 Diabetes (n) 7 6 5 Renal dysfunction (n) 2 1 1 Respiratory dysfunction (n) 1 1 1 Liver dysfunction (n) 2 2 2 Heart dysfunction (n) 1 1 1 Immunodeficiency disease (n) 4 1 3 Sepsis/Total (n) 23/30 22/30 20/30 Prevalence of sepsis (%) 76.7 73.3 66.7 Death/Total (n) 4/23 4/22 4/20 28-day mortality (%) 17.4 18.2 20.0 Site of infections (n) Lung 18 17 15 Urogenital 5 5 5 Abdomen 3 3 1 Cranial 2 2 2 Other (knee) 1 0 0 Site of infections (n) G + bacteria 2 1 0 G bacteria 16 17 15 Fungi 3 3 3 2.2 ( ) ( ) / 28d / 28d 1 3 23 22 20 76.7% 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 2.4 3 A 77.8% 25.0% B 82.2% 41.7% C 72.2% 41.7%( 3) 3 ROC 0.5139 0.6250 0.5694 (P 0.05 1) 3 [4] ICU 3 76.7% 73.3% 66.7% 28d 17.4% 18.2% 25.0% 1992 ICU Wafaisade [14] 1993 2008 29 829 166
298 2016 4 1 41 4 2 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±8.9 22.0±8.6 22.6±8.6 21.4±8.5 SOFA score 7.6±4.9 7.8±5.0 7.7±4.7 7.6±4.6 GCS 8 (n) 7/23 7/22 6/20 9/30 ISS score 26.6±11.1 28.6±10.4 27.0±9.9 23.3±8.2 AIS (head) 3(n) 12 5 9 13 AIS (thorax) 3(n) 7 3 7 9 AIS (abdomen) 3(n) 4 1 3 5 AIS (extremities) 3(n) 2 0 2 2 Mechanismofinjury(n) Blunt 5 2 4 7 Penetrating 18 6 16 23 Chronic disease 7 1 8 9 Immunodeficiency disease 4 1 3 5 ICU hospitalization time (n) 5d 5 0 4 5 6-10d 3 1 4 5 >10d 14 6 11 18 Diagnostic/Therapeutic procedures within one week (n) Central venous catheter 13 1 10 14 Arterial catheter 4 1 3 4 Urinary catheter 19 22 16 22 Wound drainage tube 11 1 8 11 Dialysis 3 1 3 4 Artificial airways 19 5 19 26 Mechanical ventilation 16 5 15 22 Central venous nutrition 9 0 7 9 3 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 14 4 15 3 13 5 Negative 9 3 7 5 7 5 Sensitivity (%) 77.8 82.2 72.2 Specificity (%) 25.0 41.7 41.7 Positive predictive value (%) 60.9 68.2 65.0 Positive predictive value (%) 42.9 62.5 50.0 Correct diagnosis index 0.028 0.250 0.004 ICU ISS 9 10.2% 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
Med J Chin PLA, Vol. 41, No. 4, April 1, 2016 299 Sensitivity 1.00 0.75 0.50 0.25 ROC curve (area) 1991 Standard (0.5139) 2001 Standard (0.6250) 0.00 2012 Standard (0.5694) 0.00 0.25 0.50 0.75 1.00 1-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] 3 1992 2001 2012 [6-7] SIRS [5-6,17-18] SIRS [17] [19-20] 21 [21] SIRS [6,22] 3 [23-24] 1992 2001 2012 Table 1 some of the following SIRS + infection [5-7] 2014 ProCESS ARISE [25-26] [27-28] 2001 2012 1992 2001 [27] [27] [28] 1992 2001 2012 [5-7] 2001 2012 1992 [1,14,16] Biomarker premature [6-7] Biomarker [6,29]
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