Pneumonia is the most common source of septic shock. This naturally leads to a comparison of qSOFA with the CURB65 prognostic score for pneumonia.
肺炎是感染性休克最常見的病因。很自然人們會(huì)將qSOFA與肺炎的CURB65預(yù)后評(píng)分進(jìn)行比較。
Comparison suggests that qSOFA over-estimates the mortality of a pneumonia patients. For example, consider a 50-year-old patient with pneumonia, respiratory rate of 24 breaths/minute, blood pressure of 95/65, BUN of 15 mg/dL, and normal mental status. According to qSOFA, this patient has sepsis and perhaps should be transferred to the ICU. However, according to the CURB65 score, this patient has a 0.6% mortality and could be sent home with oral antibiotics.
比較提示，qSOFA會(huì)高估肺炎患者的病死率。例如，一名50歲肺炎患者呼吸頻率24次/分，血壓95/65，BUN 15 mg/dL，意識(shí)狀態(tài)正常。根據(jù)qSOFA，該患者存在全身性感染，可能需要轉(zhuǎn)入ICU。而根據(jù)CURB65評(píng)分，該患者病死率為0.6%，可以回家口服抗生素治療。
This is an example of how qSOFA may be less specific in patients with primary pulmonary disease (as discussed above). A respiratory rate >22 is not particularly unusual or alarming in a patient with pneumonia (4). Thus, many pneumonia patients will start out with one qSOFA criteria, only requiring one additional criteria to become qSOFA-positive.
這個(gè)例子說明為何qSOFA在原發(fā)肺部疾病患者中特異性偏低（如上所述）。肺炎患者呼吸頻率> 22并不少見，且沒有警示價(jià)值(4)。因此，許多肺炎患者據(jù)此就滿足一項(xiàng)qSOFA標(biāo)準(zhǔn)，僅需要額外一項(xiàng)標(biāo)準(zhǔn)就成為qSOFA陽性。
A common approach to diagnosis is shown here. When a condition is suspected (e.g. pulmonary embolism), first a screening test is utilized. An ideal screening test has a high sensitivity, but is fast and easy to perform (e.g. D-dimer). Patients who have a positive screening test will need to proceed onward to a definitive test, which is often more expensive or difficult to perform, but has both high sensitivity and specificity (e.g. CT angiogram).
常見的診斷過程如上所述。懷疑某種疾病（如肺栓塞）時(shí)，首先采用篩查試驗(yàn)。理想的篩查試驗(yàn)應(yīng)當(dāng)具有較高的敏感性，而且快速簡(jiǎn)便（如D二聚體）。篩查試驗(yàn)陽性的患者需要進(jìn)一步接受確證實(shí)驗(yàn)，通常更加昂貴或難以實(shí)施，但具有很高的敏感性和特異性（如CT血管造影）。
The sepsis diagnostic algorithm seems to be designed with qSOFA as a screening test and SOFA as a definitive test. On face value this makes sense, because qSOFA is a simple and fast, whereas the full SOFA test is labor intensive.
全身性感染診斷流程中似乎將qSOFA作為篩查試驗(yàn)，而將SOFA作為確證試驗(yàn)。從表面看貌似是有道理的，因?yàn)閝SOFA簡(jiǎn)便快速，而完整的SOFA則需要耗費(fèi)大量人力。
However, the specificity of SOFA is actually lower than the specificity of qSOFA, making this test sequence illogical. Thus, SOFA adds little to qSOFA among patients outside the ICU (5).
但是，SOFA的特異性實(shí)際上低于qSOFA，使得這一檢查順序并不符合邏輯。因此，對(duì)于非ICU患者，與qSOFA相比，SOFA并無額外意義(5)。
Although evidence is provided regarding the performance of qSOFA and SOFA, there is no evidence provided about the performance of the combination of {qSOFA+SOFA}. Since qSOFA and SOFA scores are not statistically independent, it is difficult to predict how they will function in combination. To explore this, lets imagine two extreme possibilities: qSOFA and SOFA either being maximally concordant or maximally discordant:
雖然文中報(bào)告了qSOFA和SOFA預(yù)測(cè)準(zhǔn)確性的相關(guān)證據(jù)，但未提供聯(lián)合應(yīng)用qSOFA和SOFA的數(shù)據(jù)。因?yàn)閝SOFA和SOFA評(píng)分在統(tǒng)計(jì)學(xué)方面并不完全獨(dú)立，所以很難預(yù)測(cè)其聯(lián)合應(yīng)用的價(jià)值。為此，我們可以假設(shè)兩種極端的情況：qSOFA和SOFA完全一致或完全不一致：
Discordance improves the specificity of the combined test sequence, because only one test needs to be negative to exclude sepsis. However, discordance impairs the sensitivity, because both tests must be positive to rule in sepsis. The tests are almost certainly more concordant than discordant. Without evidence, the only definitive conclusion is that the combined tests have a sensitivity between 23-55% and a specificity between 84-100% (2).
不一致性會(huì)提高聯(lián)合檢測(cè)的特異性，因?yàn)橹灰渲幸豁?xiàng)結(jié)果陰性就可以排除全身性感染。但是，不一致性會(huì)影響敏感性，因?yàn)橹挥袃身?xiàng)檢測(cè)都陽性才能診斷全身性感染。兩項(xiàng)檢查更多情況下趨于一致而非不一致。盡管沒有證據(jù)證實(shí)，目前唯一的結(jié)論是聯(lián)合檢測(cè)的敏感性約23-55%，特異性84-100% (2)。
As discussed above the sensitivity of {qSOFA+SOFA} for mortality is likely <55%. however,="" the="" most="" important="" patients="" to="" identify="" are="" patients="" who="" receive="" critical="" care="" and="" subsequently="">survive (i.e. truly benefit from their ICU care). These ICU survivors may initially look less ill than the patients who die. Therefore, the sensitivity of {qSOFA+SOFA} for ICU survivors is likely lower than for nonsurvivors (i.e., <>
如上所述，聯(lián)合應(yīng)用qSOFA和SOFA對(duì)病死率的敏感性很可能<><>
Finally, the sensitivity of the 'suspected infection' criteria is unknown (but almost certainly below 100%). Taking all of these factors into account, the sensitivity of Sepsis-III criteria for sepsis could be under 50% (6).
最后，“可疑感染”標(biāo)準(zhǔn)的敏感性尚屬未知（但幾乎肯定低于100%）。鑒于上述各種因素，全身性感染-III標(biāo)準(zhǔn)對(duì)全身性感染診斷的敏感性可能不足50% (6)。
Sepsis-III has been endorsed by the Society of Critical Care Medicine, the American Thoracic Society, and the American Association of Critical Care Nurses. However, it has not been endorsed by the American College of Chest Physicians, the Infectious Disease Society of America, any of the Emergency Medicine societies, or any of the hospital medicine societies. It is difficult to call this a consensus guideline without support from Emergency Physicians or Hospitalists, who diagnose sepsis most often.
全身性感染-III得到了由美國(guó)危重病學(xué)會(huì)(SCCM)、美國(guó)胸科學(xué)會(huì)(ATS)、美國(guó)重癥護(hù)理學(xué)會(huì)(AACCN)的認(rèn)可。然而，該標(biāo)準(zhǔn)并未得到美國(guó)胸科醫(yī)師學(xué)院(ACCP)、美國(guó)傳染病學(xué)會(huì)(IDSA)、所有急診醫(yī)學(xué)學(xué)會(huì)或任何醫(yī)院醫(yī)學(xué)學(xué)會(huì)的批準(zhǔn)。如果沒有最常診斷全身性感染的急診醫(yī)師或醫(yī)院醫(yī)師(hospitalist)的支持，該標(biāo)準(zhǔn)就很難稱為共識(shí)指南。
[Update: since posting this, the American College of Chest Physicians has issued a strong statement opposing Sepsis III]
【更新：本文公開發(fā)表后，美國(guó)胸科醫(yī)師學(xué)會(huì)提出了反對(duì)膿毒癥III的強(qiáng)烈聲明】
Sepsis-III remains a subjective definition, with little guidance regarding what exactly is meant by “suspected infection.”全身性感染-III仍然是主觀定義，對(duì)“可疑感染”的準(zhǔn)確含義沒有明確規(guī)定。
qSOFA and SOFA are predictors of mortality, they are not tests of sepsis. qSOFA和SOFA是病死率的預(yù)測(cè)指標(biāo)，而非全身性感染的診斷指標(biāo)。
Sepsis-III is less specific for infection compared to Sepsis-II. The only thing that differentiates Sepsis-III from a screening test to identify sicker patients is the 'suspected infection' component. 全身性感染-III對(duì)感染的診斷特異性低于全身性感染-II。全身性感染-III與重癥患者篩查試驗(yàn)的唯一差別是“可疑感染”。
Compared to SIRS, qSOFA is more specific (but less sensitive) for predicting mortality. 與SIRS相比，qSOFA對(duì)預(yù)測(cè)病死率的特異性較高（但敏感性較低）。
Based on available retrospective data, the sensitivity of Sepsis-III for sepsis is <55% among="" patients="" outside="" of="" the="" icu.=""><>
Prospective validation is needed to determine the real-world performance of Sepsis-III. 需要前瞻性研究驗(yàn)證全身性感染-III在實(shí)際工作中的準(zhǔn)確性。
1. Misunderstanding of qSOFA isn't technically a failure of Sepsis-III, but rather our failure to correctly apply the definition. Nonetheless, qSOFA and SOFA components are emphasized in Sepsis-III (with scant discussion of the 'suspected infection' component). Thus, this may be an easy mistake to make.
對(duì)qSOFA的誤解并非全身性感染-III定義在技術(shù)上的失敗，而是我們不能準(zhǔn)確應(yīng)用這一定義。無論如何，全身性感染-III定義中對(duì)qSOFA和SOFA的各組分進(jìn)行了強(qiáng)調(diào)（關(guān)于“可疑感染”部分的討論較少）。因此，這是個(gè)很容易犯的錯(cuò)誤。
2. All evidence discussed here pertains to patients outside the ICU. The primary clinical utility of sepsis definitions is to determine who is sick and who needs to be admitted to the ICU. Sensitivity and specificity values are obtained from eTable 3 in the supplemental data accompanying Seymour et al. Please note that there appears to be a discrepancy between the text of the article and the table regarding the performance of the SIRS criteria, with data shown here being based on eTable 3 (The text states that for patients outside the ICU, '55% of decedents had 2 or more SIRS criteria, whereas 81% of survivors had less than 2 SIRS criteria' – this is inconsistent with the eTable 3 which shows values of 64% and 65%, respectively).
本文討論的所有證據(jù)都來自非ICU患者。全身性感染定義最主要的臨床用途即發(fā)現(xiàn)病情危重需要收入ICU的患者。敏感性和特異性數(shù)據(jù)來自Seymour等補(bǔ)充數(shù)據(jù)的表3。需要注意的是，正文和表格里關(guān)于SIRS標(biāo)準(zhǔn)的診斷準(zhǔn)確性的描述似乎并不一致，本文數(shù)據(jù)基于表3（正文中描述非ICU患者，“55%的死亡者具備2條或以上SIRS標(biāo)準(zhǔn)，而81%的存活者具備2條以下的SIRS標(biāo)準(zhǔn)”—這與表3中所述的數(shù)據(jù)不符，分別為64%和65%）。
3. A receiver-operator curve (ROC curve) is a graph of the sensitivity vs. specificity of a test at every possible value of the test. This is a useful method to compare the overall performance of two tests, independent of any specific cutoff. A perfect test would have an area under the ROC curve of 1.0, whereas a completely worthless test would have an area of 0.5. However, once you've selected a cutoff point, the area under the ROC curve is less relevant than the sensitivity and specificity of the cutoff that has been selected.
受試者工作特征曲線（ROC曲線）是用于評(píng)價(jià)某項(xiàng)檢查在任何可能結(jié)果時(shí)敏感性和特異性的曲線圖。該曲線可用于比較兩種檢查方法的整體準(zhǔn)確性，而與各自的臨界值無關(guān)。一項(xiàng)完美的檢查ROC曲線下面積為1.0，而完全無價(jià)值的檢查面積為0.5。然而，一旦選定了臨界值，ROC曲線下面積就與選定臨界值所對(duì)應(yīng)的敏感性和特異性不太相關(guān)。
4. Respiratory rate clearly has enormous prognostic value in pneumonia, but the cutoff of 22 b/m is too low in this disease process. I usually start getting substantially more worried when the respiratory rate is above 30, consistent with the CURB65 score.
呼吸頻率顯然對(duì)肺炎的預(yù)后具有重大意義，但臨界值22次/分對(duì)于該病而言過低。我通常在呼吸頻率超過30時(shí)才會(huì)更加擔(dān)心，這與CURB65是一致的。
5. SOFA performs better among ICU patients. However, clinically the definition of sepsis is mostly useful outside the ICU (e.g. identifying patients who require ICU transfer).
SOFA對(duì)ICU患者的價(jià)值更高些。然而，臨床上全身性感染的定義在ICU以外更有用（例如發(fā)現(xiàn)需要轉(zhuǎn)入ICU的患者）。
6. The fact that the 'definition' of sepsis may not capture most patients who require ICU care for infection management creates some strange linguistic problems. I suppose that if we accept the Sepsis-III definition then, by definition, it must have a performance of 100%?
全身性感染的“定義”有可能無法篩選出大多數(shù)需要收入ICU接受感染控制的患者，這樣就會(huì)帶來一些奇怪的語言問題。我認(rèn)為如果我們接受全身性感染-III定義，那么，根據(jù)定義，其準(zhǔn)確性應(yīng)當(dāng)達(dá)到100%？
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