Saturday, August 23, 2008

Emergency Medicine Digest

A new pneumonia severity assessment tool? SMART-COP

Existing severity assessment tools, such as the pneumonia severity index (PSI) and CURB-65 (tool based on confusion, urea level, respiratory rate, blood pressure, and age >or=65 years), predict 30-day mortality in community-acquired pneumonia (CAP) and have limited ability to predict which patients will require intensive respiratory or vasopressor support (IRVS).

Researchers developed a new stratification tool, called SMART-COP, to determine which patients are likely to require intensive respiratory or vasopressor support (IRVS).
Using data from a prospective, multicenter, observational study, researchers of the Australian CAP Study (ACAPS) performed multivariate analysis of clinical features from 882 episodes of CAP in 862 patients to identify features that were significantly associated with receipt of IRVS.

In this ACAPS, 10.3% of patients received IRVS, and the 30-day mortality rate was 5.7%.

The features statistically significantly associated with receipt of IRVS were

S = low systolic blood pressure (2 points)
M = multilobar chest radiography involvement (1 point)
A = low albumin level (1 point)
R = high respiratory rate (1 point)
T = Tachycardia (1 point)

C = confusion (1 point)
O = poor oxygenation (2 points), and
P = low arterial pH (2 points)

A SMART-COP score of >or=3 points identified 92% of patients who received IRVS, including 84% of the 38 patients (42%) who received IRVS and were initially admitted to general wards and later transferred to the intensive care unit

Sensitivities of PSI and CURB-65 for identifying the need for IRVS were 74% and 39%, respectively.

The Infectious Diseases Society of America’s CAP treatment guidelines recommend using the PSI to risk-stratify patients. The simple-to-use SMART-COP score seems to be more sensitive than the PSI for identifying patients who might need intensive care. With further validation, SMART-COP could prove to be better than the PSI.

My comments: It is possible to perform a validation study of SMART-COP in our patient community in Hospital USM. However, our liver function test lab results often come back late as we have to send them to the centre lab. We need to get a simple bedside test or point-of-care kit to perform serum albumin on the spot in emergency department. A validation study of SMART-COP and also comparison of SMART-COP versus PSI or/and CURB-65 can be performed.

Click here for the pneumonia severity index calculator.

Click here for a pdf copy of the CURB-65 chart.

Charles PGP et al. SMART-COP: A tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008 Aug 1; 47:375.

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