Hello!
I believe most of you must have read the new definitions of sepsis and septic shock published in the "JAMA" latest issue. A new definition in which the SOFA score becomes a diagnostic tool and not just a prognosis-assesment one.
The score in itself is quite easy to use but when it comes to the GCS, what should one do? Most of ICU patients or those with septic shock are sedated. How can we evaluate the GCS then, should we always use the last GCS measured before sedation, or should we assign a random medium number in such cases??
Many thanks for your insight.
http://jama.jamanetwork.com/article.aspx?articleid=2492856
My understanding of the article is to rapidly identify sepsis on this three variable composite score.."The final qSOFA model included Glasgow Coma Scale (GCS)
score of 13 or less, systolic blood pressure of 100mmHg or less,
and respiratory rate of 22/min or more (1 point each; score
range, 0-3)" which works perfect for me on new patients presenting to the ED. However, those patients who are already in the ICU, I would think any significant change in the GCS or in a modified GCS score would raise the suspicion for possible sepsis. I have seen some ICUs use a modified GCS for intubated patients since the speech factor can not be adequately assessed when intubated. Hope that helps.
Indeed, there is a modified GCS score to use in patients intubated: EVtM. But what about patients under hypnotics, even the other parameters can't be properly assesed??
A sedation free period should be there every day
for ICU patients in Traumatic brain injury patients and a protocol should be established for assesment of GCS.If a time period of sedation free trail is introduced it will helpful.
To answer the question above, the new consensus divide patients in 2 groups, which are out of ICU group and in ICU group.
For out of ICU, quick SOFA (qSOFA) was introduced. GCS is part of qSOFA. The 2 score out of 3 qSOFA with a source of infection make the diagnosis of sepsis.
For those patients who admitted in ICU, 2 types of scoring were used, which are SOFA or LODS scoring for in sepsis diagnosis. qSOFA cannot be applied in ICU because the vital sign of patient who admitted to ICU was usually augmented/masked by sedation, inotrop or ventiation.
Measuring GCS in the sedated population can lead to incorrect SOFA scoring, even in those patients receiving a daily drug "holiday". The lingering effects of sedatives can decrease perceived/measured mentation. So, my answer is, that there is no easy way to address this precisely. We try to assess prior to sedation, when able, then continue with this score until off sedation for an adequate period of time to clear sedative effects.
The GCS component of SOFA score showed only moderate accuracy. In contrast to the other organ systems, almost half of the CNSscores were based on assumption rather than on actual timely evaluation.
Article Reliability and accuracy of Sequential Organ Failure Assessm...
Article Accuracy of Sequential Organ Failure Assessment (SOFA) scori...
Agree with Dr C Meldrum, have to wait for sedatives to clear off from the body before assessing GCS in ICU patients and use the last GCS before sedation as guide. Its a tricky situation assessing GCS in patients on sedation in ICU.
I would like to share finding of qSOFA via this meta analysis. QSOFA performance may be affected depend on different geographical region of the world.
https://www.nature.com/articles/s41598-018-35144-6
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