What’s New in the Patient Safety World
February 2017
Yes, the New Sepsis Criteria Fit the Bill
In our March 2016 What's New in the Patient Safety World column “Finally…A More Rationale Definition for Sepsis” we welcomed a new consensus definition for sepsis that did away with the SIRS criteria (Singer 2016). For many years we had been on our soapbox about the games played where the patient with pneumonia happily pushing his IV pole up and down the hallway who meets a couple SIRS criteria gets coded as "sepsis", which of course gets a significantly higher reimbursement than pneumonia. The coding games largely skewed the mortality statistics for both “pneumonia” and “sepsis”. So it was with great enthusiasm that we welcomed the new definition that excluded the SIRS criteria.
But the usefulness of this new definition still needed
validation in clinical settings. That validation has now come from 2 studies in
several settings. Both studies looked at the ability of the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score and
the quick SOFA (qSOFA) to predict mortality (see our
March 2016 What's New in the Patient Safety World column “Finally…A
More Rationale Definition for Sepsis” for details of the new definitions). One validation study was done
retrospectively in the ICU setting, the other prospectively in the emergency
department setting.
Freund and colleagues found that among patients presenting to the emergency department with suspected infection, the use of qSOFA resulted in greater prognostic accuracy for in-hospital mortality than did either SIRS or severe sepsis (Freund 2017). These findings provide support for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria as a predictive tool, at least in the emergency department setting. The qSOFA in that setting was as good as the full SOFA in predicting mortality. Those patients with a qSOFA score of 2 or more had an in-hospital mortality rate of 24% whereas those with qSOFA scores <2 had a 3% mortality. Moreover, the addition of serum lactate did not further enhance the predictive value.
The SOFA score also
does well at predicting mortality in ICU patients with sepsis but the shorter qSOFA may not fare as well in ICU patients. Raith and colleagues found that among adults with suspected
infection admitted to an ICU, an increase in SOFA score of 2 or more had
greater prognostic accuracy for in-hospital mortality than SIRS criteria or the
qSOFA score (Raith 2017). In that study another more complex tool,
the Logistic Organ Dysfunction System, also predicted ICU patient mortality
better than the qSOFA. These findings suggest that
SIRS criteria and qSOFA have limited utility for
predicting mortality in an ICU setting. Note, though, that the qSOFA fared as well or better than Logistic Organ
Dysfunction System or the full SOFA in sepsis patients not in the ICU.
In the editorial accompanying these two studies, Lamontagne and colleagues (Lamontagne 2017) stress that early identification of sepsis is still key and that, until future rapid diagnostic tests for sepsis are developed, the qSOFA is a simple tool that appears to be useful.
The Surviving Sepsis Campaign promptly responded to the new definition(s) in March 2016, noting that the implementation of the new definitions and related coding changes would take time for hospitals but reiterating that the new definitions do not change the primary focus of early sepsis identification and initiation of timely treatment (response March 2016).
Howell and colleagues also recently provided a summary of the updated guidelines for managing sepsis (Howell 2017). The highlights include:
- Administer broad-spectrum intravenous antimicrobials for all likely pathogens within 1 hour after sepsis recognition.
- Obtain anatomic source control as rapidly as is practical.
- Assess patients daily for deescalation of antimicrobials and narrow therapy based on cultures and/or clinical improvement (antibiotic stewardship).
- Fluid resuscitation: For patients with sepsis-induced hypoperfusion, provide 30 mL/kg of intravenous crystalloid within 3 hours with additional fluid based on frequent reassessment, preferentially using dynamic variables to assess fluid responsiveness.
- For patients with septic shock requiring vasopressors, use norepinephrine as a first-choice vasopressor and target a mean arterial pressure of 65 mm Hg.
There were also recommendations regarding mechanical ventilation parameters for patients with sepsis-related ARDS and a general statement that hospitals and health systems should implement formal programs to improve sepsis care that include sepsis screening. The full updated guideline will be in the March 2017 issue of Critical Care Medicine and is now available online (Rhodes 2017).
Time is of the essence in management of sepsis. We still
need to focus on early recognition, timely antibiotics and adequate fluid
resuscitation to reduce morbidity and mortality from “sepsis”. It does appear
that the new definitions are steps in the right direction and will help us
better manage sepsis going forward.
Our other columns on sepsis:
- March 15, 2011 “Early Warnings for Sepsis”
- April 1, 2014 “Expensive Aspects of Sepsis Protocol Debunked”
- September 8, 2015 “TREWScore
for Early Recognition of Sepsis”
- October 2015 “Even
Earlier Recognition of Severe Sepsis”
- February 2, 2016 “Success
Against Sepsis”
- March 2016 “Finally…A
More Rationale Definition for Sepsis”
References:
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315(8): 801-810
http://jama.jamanetwork.com/article.aspx?articleid=2492881
Freund Y, Lemachatti N, Krastinova E, et al. for the . Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality among Patients with Suspected Infection Presenting to the Emergency Department.
http://jamanetwork.com/journals/jama/article-abstract/2598268
Raith EP, Udy AA, Bailey M, et al. Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality among Adults with Suspected Infection Admitted to the Intensive Care Unit. JAMA 2017; 317(3): 290-300
http://jamanetwork.com/journals/jama/article-abstract/2598267
Lamontagne F, Harrison DA, Rowan KM. qSOFA for Identifying Sepsis among Patients with Infection. JAMA 2017; 317(3): 267-268
http://jamanetwork.com/journals/jama/article-abstract/2598244
Surviving Sepsis Campaign website.
http://www.survivingsepsis.org/Pages/default.aspx
Surviving Sepsis Campaign. Surviving Sepsis Campaign Responds to Sepsis-3. March 1, 2016
http://www.survivingsepsis.org/SiteCollectionDocuments/SSC-Statements-Sepsis-Definitions-3-2016.pdf
Howell MD, Davis AM. Management of Sepsis and Septic Shock. JAMA 2017; Published online January 19, 2017.
http://jamanetwork.com/journals/jama/fullarticle/2598892
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine 2017; 45(3): 1-67 Published-Ahead-of-Print Post Author Corrections: January 17, 2017
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