CALS Instructor Update July 14 2016 Definitions Definition vs Clinical Criteria Definition What it is Clinical Criteria How we operationalize the definition at the bedside Definitions ACCPSCCM ID: 601730
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Slide1
SEPSIS – 3.0
CALS Instructor Update
July 14, 2016Slide2
DefinitionsSlide3
Definition
vs
Clinical Criteria
Definition
: What it is
Clinical Criteria: How we operationalize the definition at the bedsideSlide4
Definitions (ACCP/SCCM)
Systemic Inflammatory Response Syndrome
(SIRS)
: 2 or more of the following
Fever or hypothermia (T >100.4 or < 96.8)
Tachycardia ( HR > 90)
Tachypnea ( RR > 20 or PaCO2 < 32)
Leukocytosis, leukopenia or left shift (WBC > 12,000, < 4,000 or > 10% bands)SepsisSIRS as a result of infection
Crit
Care Med 1992;20:864-874Slide5
Definitions
Severe Sepsis
Sepsis associated with organ dysfunction,
hypoperfusion
, or hypotension.
Hypoperfusion
and perfusion abnormalities may include: lactic acidosis, oliguria or acute alteration in mental status.
Septic shockA subset of severe sepsis with hypotension (BP < 90 or drop of > 40 from baseline), despite adequate fluid resuscitation
Crit
Care Med 1992;20:864-874Slide6Slide7
Definitions – 2012 Surviving Sepsis Guideline
Sepsis:
The presence (probable or documented) of infection together with systemic manifestations of infection
(More than just SIRS plus infection)Slide8Slide9
Table 1 Continued. Criteria for sepsisSlide10
Definitions - 2012
Severe Sepsis:
Sepsis plus sepsis-induced organ dysfunction or tissue
hypoperfusion
Sepsis-induced hypotension: Systolic Blood pressure <90 mm Hg or MAP <70 mm Hg or SBP decrease > 40mm Hg
Septic Shock:
Sepsis induced hypotension persisting despite adequate fluid resuscitationSlide11Slide12
What is wrong with these definitions
Too sensitive
A bad cold could be classified as sepsis
Routine post op patients
Too much variability in the definition which can affect reported outcome such as mortalitySlide13Slide14
JAMA Feb 23, 2016Slide15
New Definition of Sepsis
“Sepsis is defined
as
life-threatening organ dysfunction caused by a
dysregulated
host response to infection
”Slide16
Organ Dysfunction
Can be identified as an acute change in total SOFA score of ≥ 2Slide17
Sequential Organ Failure Assessment (SOFA) Score
Not good for screening in EdSlide18
MedCalcSlide19
In lay terms
“
Sepsis is a life-threatening condition that arises when the body’s response to an infection injures it’s own tissues and organs”Slide20
Clinical criteria of Sepsis
Attempted to differentiate Sepsis from uncomplicated infections
Interrogated large clinical data sets of hospitalized patients with presumed infection correlating 21 different clinical and laboratory criteria with clinical outcomes
Mortality and ICU length of stay > 3 days
qSOFA
– simple bedside criteria to screen those with infection who are likely to have poor outcomes.Slide21
qSOFA – for screening for Sepsis
Need 2 out of 3Slide22Slide23
Remember qSOFA
= HAT
Hypotension (BPs < 100)
Altered Mental Status (GCS ≤ 13)
Tachypnea (RR > 22)Slide24
New Sepsis DefinitionsSlide25
Septic Shock Definitions
1991
Sepsis induced hypotension, persisting despite adequate fluid resuscitation, along with the presence of
hypoperfusion
abnormalities or organ dysfunction
2001
State of acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes
2016Subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than sepsis aloneSlide26
Septic Shock Clinical Criteria
Despite adequate fluid resuscitation, vasopressors needed to maintain MAP ≥ 65
And
Lactate > 2
Slide27
SIRS
SIRS has it’s place.
… though not for diagnosing sepsis
WBC, Temp are still useful in helping to form a provisional diagnosis of infection
SIRS is an appropriate – but not necessarily dysregulated host response toe infection.Slide28
Lactate
What does and elevated lactate mean?
Marker of cellular/metabolic stress
… not necessarily tissue hypoperfusion
C
an also occur with liver disease, catecholamine Rx, other drugs (metformin)
Independent predictor of mortalitySlide29
Why Lactate in Septic Shock Definition
Septic shock is more that hypotension alone
Wanted to reflect a sicker subset at higher risk for dying
Needed a readily available marker of cellular/metabolic abnormality
Lactate is the best current measure that fits this roleSlide30
Lactate + qSOFA
Lactate added only small improvement to the predictive value compared with
qSOFA
alone
May have some utility in intermediate risk patients (
qSOFA
= 1)
Not discouraging its use as a management tool or as a guide to therapeutic response nor and indicator of severitySlide31
Sepsis – 3:
What’s
Out
SIRS
Severe Sepsis
Routine sepsisSlide32
Sepsis – 3: What’s
in
Sepsis
Septic Shock
SOFA
qSOFASlide33