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qSOFA score not predictive of in-hospital mortality in emergency patients with decompensated liver cirrhosis

qSOFA-Score nicht prädiktiv für Krankenhaussterblichkeit bei Notfallpatienten mit dekompensierter Leberzirrhose

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Abstract

Background

Quick sequential organ failure assessement (qSOFA) has been validated for patients with presumed sepsis and the general emergency department (ED) population. However, it has not been validated in specific subgroups of ED patients with a high mortality. We aimed to investigate the prognostic performance of qSOFA with respect to in-hospital mortality, intensive care unit (ICU) admission, and length of hospitalisation in patients with decompensated liver cirrhosis. Furthermore, we compared qSOFA to systemic inflammatory response syndrome (SIRS), model of end stage liver disease score (MELD), and Child–Pugh criteria and evaluated whether addition of sodium (Na+) levels to qSOFA increases its prognostic performance.

Methods

This observational study included patients admitted with the diagnosis of decompensated liver cirrhosis. All patients with a complete set of vital parameters were included in this study.

Results

A total of 186 patients were included. A positive qSOFA score was not associated with in-hospital mortality, ICU admission, or length of hospitalisation (all p > 0.15). MELD scores reliably predicted need for ICU admission and in-hospital mortality (both p < 0.01), but not the length of hospitalisation. qSOFA-Na+ only moderately increased the diagnostic performance of qSOFA with regard to need for ICU admission (AUCICU[qSOFA] = 0.504 vs. AUCICU[qSOFA-Na+] = 0.609, p = 0.03), but not for in-hospital mortality (AUCdeath[qSOFA] = 0.513 vs. AUCdeath[qSOFA-Na+] = 0.592, p = 0.054).

Conclusion

qSOFA does not predict in-hospital mortality, ICU admission or length of hospitalisation in patients with decompensated liver cirrhosis. Extension of qSOFA with a disease-specific component, the qSOFA-Na+, moderately increased the diagnostic ability of qSOFA.

Zusammenfassung

Hintergrund

Der „quick sequential organ failure assessement“(qSOFA)-Score wurde zur Prädiktion der Mortalität sowohl bei Patienten mit Verdacht auf Sepsis als auch bei Notfallpatienten im Allgemeinen validiert. Eine Validierung bei bestimmten Untergruppen von Notfallpatienten mit hoher Mortalität ist jedoch noch nicht erfolgt. Ziel dieser Arbeit war es, die prognostische Wertigkeit bei Patienten, die sich mit dekompensierter Leberzirrhose in der Notaufnahme vorstellen, in Bezug auf Krankenhaussterblichkeit, Verlegung auf die Intensivstation und Krankenhausverweildauer zu analysieren. Des Weiteren wurde qSOFA mit „systemic inflammatory response syndrome“(SIRS)-, „model of end stage liver disease score“(MELD)- und Child-Pugh-Kriterien verglichen. Es wurde überprüft, ob die Einbeziehung des Natriumspiegels (Na+) in qSOFA die prognostische Wertigkeit erhöht.

Methoden

Alle Patienten mit der Aufnahmediagnose einer dekompensierten Leberzirrhose, die sich über einen Zeitraum von 10 Jahren in der Notaufnahme des Universitätsklinikums Bern, Schweiz, vorstellten, wurden in die Beobachtungsstudie eingeschlossen. Die Dokumentation der Vitalparameter musste vollständig sein.

Ergebnisse

In die Studie wurden 186 Patienten eingeschlossen. Der MELD-Score war sowohl mit der Krankenhaussterblichkeit als auch mit der notfallmäßigen Verlegung auf die Intensivstation assoziiert (je p < 0,01), nicht jedoch mit der Krankenhausverweildauer. Ein positiver qSOFA-Score (≥2 Punkte) war dagegen nicht mit der Krankenhaussterblichkeit, Verlegung auf die Intensivstation oder Krankenhausverweildauer assoziiert (je p > 0,15). Eine Erweiterung des qSOFA-Scores um die Natriumkomponente (qSOFA-Na+) erhöhte die Vorhersagekraft bezüglich der notfallmäßigen Verlegung auf die Intensivstation moderat (AUC[qSOFA] = 0,504 vs. AUC[qSOFA-Na+] = 0,609, p = 0,03), die bezüglich der Krankenhaussterblichkeit dagegen nicht (AUC[qSOFA] = 0,513 vs. AUC[qSOFA-Na+] = 0,592, p = 0,054).

Schlussfolgerung

Der qSOFA-Score besitzt keine ausreichende Vorhersagekraft für die Krankenhaussterblichkeit, notfallmäßige Verlegung auf die Intensivstation oder Krankenhausverweildauer bei Patienten mit dekompensierter Leberzirrhose. Eine Erweiterung des qSOFA-Scores um eine erkrankungsspezifische Natriumkomponente erhöht die prognostische Wertigkeit moderat.

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Authors and Affiliations

  1. Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    M. Müller, D. Srivastava & A. K. Exadaktylos

  2. Department of Intensive Care, Inselspital, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland

    J. C. Schefold &  C. A. Pfortmueller

  3. Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    A. B. Leichtle

  4. Department of Emergency Medicine and General Internal Medicine, Hirslandenklinik am Park, Zurich, Switzerland

    G. Lindner

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  1. M. Müller
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Correspondence to C. A. Pfortmueller.

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Conflict of interest

M. Müller, J. C. Schefold, A. B. Leichtle, D. Srivastava, G. Lindner, A. K. Exadaktylos and C. A. Pfortmueller declare that they have no competing interests.

The study was approved by the regional ethics committee of the Canton of Bern, Switzerland (KEK: 14-02-13). Individual informed consent was waived by the ethics committee.

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Müller, M., Schefold, J.C., Leichtle, A.B. et al. qSOFA score not predictive of in-hospital mortality in emergency patients with decompensated liver cirrhosis. Med Klin Intensivmed Notfmed 114, 724–732 (2019). https://doi.org/10.1007/s00063-018-0477-z

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