Holy Smokes! Batman, the SOFA and the Latest Sepsis Definitions

HOLY SMOKES!-2

We can be a confused bunch when it comes to sepsis.  We have seen definitions, debates and controversies as to how we treat and what we treat.  Today a new definition was unleashed on the world and you can read the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) here for free at JAMA.

But does this make things clearer?  We will let you decide, but let’s recap what we now define as sepsis:

1. Life-threatening organ dysfunction due to a dysregulated host response to infection.

So the SIRS criteria are now out.  The SIRS criteria have been criticised for their lack of specificity and inadequate representation of the patient with sepsis.  As a heterogenous population of patients, the SIRS criteria may be present in some, and not in others.  SIRS criteria can also present in patients who do not have sepsis, so it is understandable why we have moved away from them.  Although not necessarily the most catchy definition, it does clarify what it is we are seeking to diagnose and treat.

2. It’s all about septic SOFAs

The organ dysfunction identified above is identified and quantified by a change in the SOFA score by more than 2 points.  To recap the SOFA score (Sequential organ failure assessment) is a physiological score based on:

  • BP and pressor use
  • Platelet count
  • Bilirubin
  • GCS
  • Creatinine
  • PaO2/FiO2 ration
  • Mechanical ventilation

If, as a result of infection, there is an increase of 2 points then we have an overall mortality rate of 10%.  We now no longer need to use the term severe sepsis and we can forget that concept, for the time being.

3. Enter the sepsis qSOFA

As Nat shows above, the qSOFA is a quick bedside test that focuses on BP, Mental state and respiratory rate as means to identify the septic patient.

  • Blood pressure (<100 systolic)
  • Altered mental state
  • Tachypnoea (RR>22)

If two or more of the above are present then it predicts a poor outcome in those patients who are not in the intensive care unit.

qSOFA-2

4.  Septic shock

‘[A] subset of sepsis where underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality’

These patients are those who need vasopressors to achieve a MAP of 65 or above and those whose lactate concentration is
greater than 2mmol/L despite adequate fluid resuscitation.

What does this mean?

  • Severe sepsis no longer exists
  • Organ dysfunction and dysregulation in the presence of an infection defines sepsis
  • qSOFA is quick, easy and identifies at risk patients
  • Septic shock = vasopressors and lactate rise
  • For the layperson, this all means that sepsis is ‘a life-threatening condition that arises when the body’s response to infection injures its own tissue’

 

There is a great review on the ESCIM website here, and our friends over at FOAMcast are all over this already. They’ve put together this great table to help you understand what’s different (credit to @FOAMpodcast).

Sepsis Definitions: Old vs. 3.0 — @FOAMpodcast

Sepsis Definitions: Old vs. 3.0 — @FOAMpodcast

Sounds great!

Well, maybe, but it’s not the whole story. Criticism has already been voiced by our South American colleagues, who did not endorse the guidelines for a number of reasons concerning the applicability of the SOFA score in lower and middle income countries – read the full statement from the Latin American Sepsis Institute here.

There have also been concerns about the performance of this score versus other early warning scores…

…So it looks like the Sepsis Story is:

TBC

 

Cheers!

Rich & Nat

@richcarden @_NMay

 

Further reading.

A: FOAMcast with our friends @jeremyfaust  & @LWestafer and have a great podcast on the new sepsis definitions http://foamcast.org/2016/02/21/sepsis-redefined/

Also check out their links and references below (we’ve copied them across here as they are so good):

  1. Levy MM, Fink MP, Marshall JC. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Critical care medicine. 31(4):1250-6. 2003.
  2.  Singer M, Deutschman CS, Seymour CW, et al: The Sepsis Definitions Task Force The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
    AMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
  3.  Seymour CW, Liu V, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016;315(8):762-774. doi:10.1001/jama.2016.0288.
  4. Shankar-Hari M, Phillips G, Levy ML, et al.Developing a New Definition and Assessing New Clinical Criteria for Septic ShockFor the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) (JAMA, Feb 22, 2016).
  5. Kaukonen KM, Bailey M, Bellomo R. Systemic Inflammatory Response Syndrome Criteria for Severe Sepsis. The New England journal of medicine. 373(9):881. 2015.

B: Check out our friends in Leicester on the EM3 site who had the first post out on the new definitions. http://em3.org.uk/latest/22/2/2016/sepsis-2016

C: Salim Rezzaie, one of our many Texan #FOAMite colleagues at REBEL EM on the new guidelines.

D: Listen to Scott Weingart with Merv Singer on a deeper interpretation of the new definitions on a great blog post entitled Sepsis 3.0 and the back story that explains how and why we should consider this progress. Also check out Cliff Deutschman on an EMCRIT wee as follow up.

We are also awaiting more from colleagues such as @EMCRIT and colleagues in the #FOAMed world.

 

Before you go please don’t forget to…

17 Comments

  1. Cannulator

    In the setting of infection.
    I think this is the one bit that is being under acknowledged since this change.
    I’m sure we could find someone with BAT symptoms not in the setting of suspected infection.

    The diversity for practitioner inclduing primary and prehospital care means that this caveat is worth harping on.
    I have seen the events of clincians treating normal and acceptable and self compensating response to infection in unvulnerable patients as sepsis ( bags of fluid, legs up etc) using the over sensitive SIRS criteria, so hoepfully this will calm a few down as well.

    Reply
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  3. Derek Louey

    I take it that part of this re-definition is to improve the sensitivity and specificity of identifying at-risk septic patients for both research and operational purposes. But I agree with LASI that it seems to fulfil the former better than the latter. There are some practical concerns about its administration particularly in resource-poor environments.

    Wealthy healthcare systems will always have the privilege of having easy access to sophisticated diagnostic tools and resources to make precise therapeutic decisions whilst the rest of the world just has to make do.

    Reply
  4. Roslan

    AUC for SOFA and SIRS almost similar (0.78 vs 0.79)! outside icu setting in detecting ‘bad’ sepsis..

    Reply
    1. Derek Louey

      Roslan,

      Good point. It seems the accuracy of SIRs criteria for predicting outcomes is only diminished in an First-world ICU cohort. Elsewhere it performs similarly to SOFA in either ICU or non-ICU patients.

      But what defines an ICU cohort in a hospital without one?

      Reply
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