What are the elements of the SOFA score and qSOFA score?
SOFA (0-4, score of > or = 2 –> at least 10% mortality in humans):
1. PaO2
2. Platelets
3. Serum bilirubin
4. Hypotension
5. GCS
6. Serum creat (mg/dL)
qSOFA (> or =2 increases likelihood of poor outcome)
1. Altered mentation
2. SBP < or = 100mmHg
3. RR > or = 22mmHg
What are the elements of the APPLE scores in dogs? (acute patient physiologic and laboratory evaluation)
APPLE full: (max score 80)
1. Creat
2. WBC
3. Albumin
4. SpO2
5. Tbil
6. Mentation score
7. RR
8. Age
9. Fluid score
10. Lactate
APPLE fast: (max score 50)
1. Glucose
2. Albumin
3. Lactate
4. PLT
5. Mentation score
What are the elements of the APPLE scores in cats
APPLE full: (max score 80)
1. Mentation score
2. Temperature
3. MAP
4. Lactate
5. PCV
6. BUN
7. Chloride
8. Body cavity fluid score
APPLE fast: (max score 50)
1. Mentation score
2. Temperature
3. MAP
4. Lactate
5. PCV
What are the criteria for SIRS diagnosis in dogs and cats?
Depends on reference
Dogs 2/4 changes required
Cats 3/4 changes required
- Temperature
- Dogs: <38.1or > 39.2
- Cats: <37.8 or > 40 - HR
- Dogs: > 120bpm
- Cats: <140 or > 225bpm - RR
- Dogs: > 20brpm
- Cats: > 40 rpm - WBC (x 10^9/L); %bands
- Dogs: < 6 or > 16; > 3%
- Cats: < 5 or > 19
What was the outcome of the 2015 study looking at usefulness of point-of-care glucometer to identify septic peritonitis in dogs?
- The glucose concentration difference between whole blood and peritoneal effusion using POC glucometer cannot be used to reliably identify septic peritonitis (lots of false negatives using cutoff of 20mg/dL, Sp 100% but Se 40%)
- Difference between plasma and peritoneal fluid as well as plasma and peritoneal fluid supernatant had acceptable sensitivity (80-88%) when using > 20mg/dL cutoff but Sp decreased to ~80% ; specificity improved when using > 38mg/dL cutoff (with same Se)
Define sepsis and septic shock
- Sepsis-3 definitions:
- Sepsis: life threatening organ dysfunction caused by a dysregulated host response to infection (organ dysfunction defined as change in SOFA score ≥ 2)
- Septic shock: subset of sepsis with circulatory and cellular dysfunction associated with higher risk of mortality (identified by requirement of vasopressors to keep MAP ≥ 65 and persistence of lactate > 2 mmol/L despite adequate volume resuscitation)
- Veterinary definitions:
- Sepsis: Systemic inflammatory response to infection (= fulfilment of SIRS criteria + confirmed infection)
- Severe sepsis: Sepsis with organ dysfunction and/or hypoperfusion
- Septic shock: Sepsis with persistent arterial hypotension that is not responsive to fluid therapy (= vasopressor dependent)
For what is the use of qSOFA score recommended in humans? Is it useful in veterinary patients?
For humans recommended as screening tool for hospitalized patients (to identify sepsis)
Not correlated with presence of sepsis or mortality in overall veterinary patients (cut-offs not appropriate) but correlates with higher mortality in subset of patients with sepsis
Define MODS
Multiple organ dysfunction syndrome = presence of two or more dysfunctional organs in an acutely ill patient such that homeostasis cannot be maintained without intervention
What screening tools can be used to identify patients with sepsis
- SIRS criteria
- National Early Warning Score (NEWS) in humans - based on mentation, HR, SBP, T, SpO2, RR
- SOFA score and qSOFA score - not very useful as screening tool in veterinary medicine and controversial in humans (not recommended over SIRS or NEWS)
- Could use APPLEscore but not very practical as screening tool
How can CIRCI be identified
- No good test to identify it - treatment should be based on prolonged vasopressor requirement and not on tests
- Can measure cortisol difference after an ACTH stim (in septic dogs, delta cortisol < 3 ug/dL (83 nmol/L) following standard or low dose ACTH stimulation indicates a higher likelihood of being hypotensive / needing vasopressors and mortality)
List some biomarkers of sepsis / SIRS
- HMGB-1 (peaks ~72h after initiation of inflammation)
- TNF-alpha but peaks within 2h and quickly becomes undetectable
- IL-6 - could be associated with mortality
- Keratinocyte chemoattractant-like (KC-like)
- CCL2 (chemokine) - also predictor of death
- Cell-free DNA
- CRP (peaks ~36h after initiation of inflammation) - in dogs
- SAA
- Procalcitonin - could be associated with mortality
- These biomarkers are not specific for sepsis and usually not correlated with mortality
