In this episode I’ll:
1. Discuss an article about identifying patients at risk of death from sepsis outside of the ICU.
2. Answer the drug information question: What are the new definitions and clinical criteria for sepsis and septic shock?
3. Share a resource for understanding the new definitions and clinical criteria for sepsis.
Subscribe on iTunes, Android, or Stitcher
This episode focuses on sepsis definitions, clinical criteria, and identification. For information on the treatment of sepsis check out episode 42.
Article
Assessment of Clinical Criteria for Sepsis
Lead author: Christopher W. Seymour
Published in JAMA February 2016
Background
Sepsis is now defined by The Third International Consensus Definitions Task Force as: “life-threatening organ dysfunction due to a dysregulated host response to infection.”
The performance of clinical criteria to identify sepsis according to this definition is unknown.
Methods
A derivation, validation and confirmatory cohort were used to identify new clinical criteria and compare them to existing criteria to identify septic patients at risk of higher mortality.
The derivation and validation cohorts were composed of a group of 148,907 patients with suspected infection at 12 community and academic hospitals in the UPMC health care system in southwestern Pennsylvania.
The confirmatory cohort was composed of 4 different data sets totaling 706,399 patients from out-of-hospital and hospital encounters at 165 hospitals.
The existing clinical criteria evaluated were the Sequential Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, and Logistic Organ Dysfunction System (LODS) score. In addition a new model derived using multivariable logistic regression was evaluated: The Quick Sequential Organ Failure Assessment (qSOFA) score.
The qSOFA score evaluates 3 clinical criteria and assigns 1 point for each positive criteria:
1. Systolic BP < 100 mmHG
2. Respiratory rate >/= 22 per min
3. Altered mentation (defined as Glasgow Coma Scale (GCS) score of 13 or less)
Results
The Sequential Organ Failure Assessment (SOFA) score or Logistic Organ Dysfunction System (LODS) score were the best predictors of mortality in ICU patients. However the new Quick Sequential Organ Failure Assessment (qSOFA) score had a predictive validity that was statistically greater than SOFA or SIRS for patients outside of the ICU. Compared to patients with a qSOFA score less than 2, those with a score of 2 or greater had a 3 to 14 fold increase in mortality.
Conclusion
The authors concluded that use of the SOFA score was supported in ICU patients, and that use of the qSOFA score was supported in non-ICU patients.
Discussion
This new qSOFA score has significant implications for the identification of septic patients outside of the ICU who are at increased risk of mortality. One of the significant problems with the current system of using SIRS criteria to evaluate non-ICU patients at risk of mortality from sepsis is the high number of false-negatives. The number of false-negatives was not assessed in the study. Looking at the data from the validation cohort, about 33% of non-ICU patients had a positive SIRS score, but less than 20% of non-ICU patients had a positive qSOFA score.
I’d love to see research that examines whether this new qSOFA score can decrease the burden of “alert fatigue” when it comes to systems that are used to identify non-ICU patients at risk of mortality from sepsis.
Drug information question
Q: What are the new definitions and clinical criteria for sepsis and septic shock?
A: According to The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), endorsed by the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM)
Definitions:
Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection
Septic shock: Sepsis with circulatory and cellular/metabolic abnormalities profound enough to substantially increase mortality
Clinical Criteria:
Sepsis: Suspected or documented infection and an acute increase of ≥ 2 SOFA points (a proxy for organ dysfunction)
Septic Shock: Sepsis and vasopressor therapy needed to elevate MAP ≥ 65 mmg Hg and lactate > 2 mmol/L (18 mg/dL) after adequate fluid resuscitation
Resource
The February 23rd edition of JAMA is titled “Evolving issues in critical care and sepsis”. Several important sepsis research and opinion articles have been published in this episode. JAMA has assembled podcasts, video interviews, and related links to help clinicians digest this new information here. In addition to these resources, a qSOFA calculator can be found at qsofa.org.
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.
Leave a Reply