Accuracy of the Age-Adjusted Quick SOFA Score in Children

Background

The sepsis 3 guidelines recommended the use of the Sepsis Related Organ Failure Assessment (SOFA) score for early identification of sepsis in adults (Singer 2016, PMID: 26903338). An abbreviated version of SOFA (Quick SOFA or qSOFA) includes variables available at the bedside in the ED (systolic BP, respiratory rate and mental status). The 2017 pediatric surviving sepsis guidelines acknowledge that there is insufficient evidence to endorse a specific sepsis trigger tool and recommend that each institution develop their own recognition bundle (Amer College Critical Care 2017, PMID: 28509730).

Primary Results

N = 864, Median age 2.5 years, IQR (9 month, 6 years)

Primary Outcome

PICU Transfer OR Death within 30 days: 23/864 (2.7%)

Death within 30 days: 6/864 (0.7%)

PICU Transfer: 18/864 (2.1%)

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PRIMARY OUTCOME: PICU TRANSFER AND/OR DEATH
SCORE	AUC (95%CI)	SN	SP	NPV	PPV
qSOFA	0.72 (0.57, 0.86)*	50.0%	93.3%	98.0%	22.5%
qSOFA + Lactate	0.67 (0.50, 0.84)	58.3%	76.3%	95.5%	17.5%
SIRS	0.64 (0.53, 0.74)	81.8%	45.8%	98.8%	4.3%
qPELOD-2	0.60 (0.45, 0.76)	22.2%	98.7%	97.4%	36.4%
*qSOFA had a significantly higher AUC than qSOFA + Lactate and qPELOD-2 but not SIRS

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qSOFA SCORE COMPONENT PERFORMANCE (AUC (95%CI))
Total Score (Positive ³ 2)	0.72 (0.57, 0.86)
Systolic Blood Pressure	0.56 (0.39, 0.74)
Level of Consciousness	0.74 (0.58, 0.90)
Respiratory Rate	0.54 (0.43, 0.66)

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Strengths

• Assesses age adjusted qSOFA accuracy in children in the ED setting
• Comparison of qSOFA accuracy to three other sepsis identification scores

Limitations

• Inclusion of a composite outcome with parameters of difference importance and no subgroup analysis by parameter
• Did not include all febrile ED patients, only those admitted who received antibiotics
• Small sample size and few patients having the outcome of interest (23/864 (2.7%))
• Test characteristics presented without 95% confidence intervals
• Significant amount of missing data, particularly for BP (69%), mental status (51%) and lactate (96%)
• No assessment of inter-rater reliability on the score parameters
• Generalizability of a non-academic Netherlands setting to the US is unclear

Author's Conclusions

“In conclusion, this is the first study to assess qSOFA criteria in a pediatric ED population. Since we compared qSOFA with other prognostic scores, our study contributes to current attempts to translate sepsis-3 criteria to children. qSOFA shows moderate prognostic accuracy for PICU transfer and/or mortality. The prognostic accuracy of qSOFA tends to be higher than SIRS and is significantly higher than qPELOD-2. Prognostic accuracy of qSOFA did not improve after inclusion of lactate. Prospective multicenter studies in larger ED populations of febrile children should be performed to further determine the utility of the qSOFA score in the pediatric ED. Pediatric sepsis researchers should assure that pediatric Sepsis-3 criteria are applicable to ED patients as well.” 

Our Conclusions

There are a number of design, results and applicability issues with this study ultimately making it difficult to interpret and apply its results. If the results can be validated in the US, qSOFA did not perform better than SIRS criteria but has the advantage of not including a laboratory result.

Potential Impact To Current Practice

It would be essential to validate qSOFA in a prospective, multicenter cohort including all febrile ED patients before it can be utilized.

Read More

Link: PEMCAR iBook (PDF)

REBEL EM: The SIRS & qSOFA Confusion in Sepsis

References: 

Davis AL, Carcillo JA, Aneja RK, Deymann AJ, Lin JC, Nguyen TC, et al. American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med. 2017;45(6):1061-93. PMID: 28509730