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In this episode I’ll:
1. Discuss an article about using the qSOFA score in adult emergency department patients.
2. Answer the drug information question “Can leucovorin be substituted for folic acid as cofactor therapy in the treatment of methanol toxicity?”
3. Share a resource that brings some humor to the world of Free Open Access Medical Education (#FOAMed).
Article
Lead author: Adam J. Singer
Published online in Annals of Emergency Medicine January 2017
Background
The Quick Sequential Organ Failure Assessment (qSOFA) score has been advocated for use by the Third International Sepsis Consensus Definitions Task Force to identify patients with suspected infection who are at greater risk for a poor outcome outside the intensive care unit (ICU).
qSOFA is scored from 0 to 3 with 1 point each being given for respiratory rate ≥22 breaths/min, systolic blood pressure ≤100 mm Hg, and altered mental status.
The authors of this study sought to determine the association between qSOFA scores and outcomes in adult emergency department (ED) patients with and without suspected infection.
Methods
This study was a single-site, retrospective review of adult ED patients. Over 22,500 patients were included in the review. Receipt of IV antibiotics was used as a surrogate measure of suspected infection.
Results
A qSOFA score of zero was associated with 0.6% mortality, 5% ICU admission, and 5 day length of hospital stay.
A qSOFA score of one was associated with 3% mortality, 11% ICU admission, and 6 day length of hospital stay.
A qSOFA score of two was associated with 13% mortality, 21% ICU admission, and 9 day length of hospital stay.
A qSOFA score of three was associated with 25% mortality, 27% ICU admission, and 10 day length of hospital stay.
Conclusion
The authors concluded:
qSOFA scores were associated with inpatient mortality, admission, ICU admission, and hospital length of stay in adult ED patients likely to be admitted both with and without suspected infection and may be useful in predicting outcomes.
Discussion
There has been some controversy regarding the validation of qSOFA compared to other measures like SIRS criteria. One area that I think qSOFA may play a role based on this study is helping ED pharmacists prioritize which patients get their focus. Having spent a good portion of my career in a 45-bed ED there are always more patient needs than any one pharmacist has time for. The qSOFA appears to be a specific test that can identify patients that may benefit from a close review of current pharmacotherapy interventions.
Drug information question
Q: Can leucovorin be substituted for folic acid as cofactor therapy in the treatment of methanol toxicity?
A: Yes.
Formic acid is a toxic by-product of methanol ingestion. Both folic acid and folinic acid (leucovorin) act as cofactors and enhance the metabolism of formate. Folinic acid is a metabolically active form of folic acid that does not require the enzymatic conversion.
If one of these cofactors is unavailable, the other may be substituted at an equivalent dose (often 50 mg IV q 6 hrs). Otherwise, folinic acid is preferred since it is already in the active form and pharmacies are more likely to have a sufficient supply of IV folinic acid compared to folic acid.
Resource
The resource for this episode is one that brings some humor to the world of Free Open Access Medical Education (#FOAMed). The twitter account @thanksfoamed is a parody account using humor to highlight, among other things, the oversimplification of “medical education” provided in 140 characters on twitter. Here are some example tweets:
Should emergency physicians abandon Oxygen? #FOAMed #MedEd https://t.co/bBhusCBCLC
— thanks, FOAMed (@thanksFOAMed) February 1, 2017
Anyone using Ketamine for this? https://t.co/2ryyGmRHQQ — thanks, FOAMed (@thanksFOAMed) January 16, 2017
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
I found the qSOFA score interesting; I wonder if regulatory agencies would use this score for bench marking or a a measure of performance. Just with some quick math in head, most of our ICU pts come in with a score of 2 and have an average hospital stay of 7 days. Could we report that to show an improvement in standard of care? Just curious.
Interesting…I think it would be more likely to be used as a measure of acuity perhaps since it identifies patients at risk for mortality? Or perhaps actual mortality could be benchmarked against predicted based on qSOFA scores.
I am very wary of these quality measures since so many of them have been poorly implemented without regard to downstream consequences – especially pneumonia measures.