Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes
Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes
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DOI：
10.1186/s13054-016-1266-9
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发表时间：
2016-04-06
期刊：
影响因子：
15.1
通讯作者：
Klompas, Michael
中科院分区：
文献类型：
--
作者：
Rhee, Chanu;Kadri, Sameer S.;Klompas, Michael
背景资料：败血症是国家质量改进计划的重点，也是医疗保险和医疗补助服务中心最近的公开报告措施。然而，诊断败血症需要解释非特异性体征，因此可能是主观的。我们试图量化观察者间的变异性在诊断sepsis.Methods：我们分发了5例疑似或确诊感染和器官功能障碍的患者的样本执业重症监护。应答者将病例分类为全身炎症反应综合征、脓毒症、严重脓毒症、脓毒性休克或以上均无。观察者间变异性的计算使用Fleiss' kappa的五个级别的分类，并为回答二分为严重脓毒症/脓毒性休克与非严重脓毒症/脓毒性休克和任何脓毒症类别（脓毒症，严重脓毒症，或脓毒性休克）与非-sepsis.Results：94名医生完成了调查。大多数受访者（88%）被认为是重症监护专家;其他专业包括肺病学（39%）、麻醉学（19%）、外科学（9%）和急诊医学（9%）。受访者的执业时间中位数为8年，90%的人在学术医院执业。几乎所有受访者（83%）都对他们应用传统共识脓毒症定义的能力感到强烈或有点信心。然而，脓毒症诊断的总体评分者间一致性较差（Fleiss kappa 0.29）。当反应被二分为严重脓毒症/脓毒性休克与非严重脓毒症/脓毒性休克或任何脓毒症类别与非脓毒症时，一致性仍然很差（Fleiss kappa分别为0.23和0.18）。17%的受访者将5例病例中的1例归类为严重脓毒症/脓毒性休克，27.7%的受访者将2例归类为严重脓毒症/脓毒性休克，33.0%的受访者将3例归类为严重脓毒症/脓毒性休克，19.2%的受访者将4例归类为严重脓毒症/脓毒性休克，3.2%的受访者将5例归类为严重脓毒症/脓毒性休克。在对自己使用脓毒症定义的能力非常有信心的受访者中（n = 45），一致性并不好（Fleiss' kappa 0.28用于五类分类，Fleiss' kappa 0.21用于二分严重脓毒症/脓毒性休克分类）。在74%的回答中，病例被认为是非常或非常现实的;只有3%被认为是不现实的。结论：脓毒症的诊断是非常主观和可变的。需要客观的标准和标准化的方法来提高脓毒症研究、监测、基准和报告的一致性和可比性。
Background: Sepsis is the focus of national quality improvement programs and a recent public reporting measure from the Centers for Medicare and Medicaid Services. However, diagnosing sepsis requires interpreting nonspecific signs and can therefore be subjective. We sought to quantify interobserver variability in diagnosing sepsis.Methods: We distributed five case vignettes of patients with suspected or confirmed infection and organ dysfunction to a sample of practicing intensivists. Respondents classified cases as systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, or none of the above. Interobserver variability was calculated using Fleiss' kappa for thefive-level classification, and for answers dichotomized as severe sepsis/septic shock versus not-severe sepsis/septic shock and any sepsis category (sepsis, severe sepsis, or septic shock) versus not-sepsis.Results: Ninety-four physicians completed the survey. Most respondents (88 %) identified as critical care specialists; other specialties included pulmonology (39 %), anesthesia (19 %), surgery (9 %), and emergency medicine (9 %). Respondents had been in practice for a median of 8 years, and 90 % practiced at academic hospitals. Almost all respondents (83 %) felt strongly or somewhat confident in their ability to apply the traditional consensus sepsis definitions. However, overall interrater agreement in sepsis diagnoses was poor (Fleiss' kappa 0.29). When responses were dichotomized into severe sepsis/septic shock versus not-severe sepsis/septic shock or any sepsis category versus not-sepsis, agreement was still poor (Fleiss' kappa 0.23 and 0.18, respectively). Seventeen percent of respondents classified one of the five cases as severe sepsis/septic shock, 27.7 % rated two cases, 33.0 % respondents rated three cases, 19.2 % rated four cases, and 3.2 % rated all five cases as severe sepsis/septic shock. Among respondents who felt strongly confident in their ability to use sepsis definitions (n = 45), agreement was no better (Fleiss' kappa 0.28 for the five-category classification, and Fleiss' kappa 0.21 for the dichotomized severe sepsis/septic shock classification). Cases were felt to be extremely or very realistic in 74 % of responses; only 3 % were deemed unrealistic.Conclusions: Diagnosing sepsis is extremely subjective and variable. Objective criteria and standardized methodology are needed to enhance consistency and comparability in sepsis research, surveillance, benchmarking, and reporting.