CALS Instructor Update July 14, 2016 SEPSIS – 3.0 CALS Instructor Update July 14, 2016

Definitions It is difficult to define sepsis as it is a syndrome without a gold standard. There is no diagnostic test.

Definition vs Clinical Criteria Definition: What it is Clinical Criteria: How we operationalize the definition at the bedside

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) Sepsis SIRS as a result of infection 1991 the American College of Chest Physicians and the Society of Critical Care Medicine convened a conference in an attempt to provide a conceptual framework to define SIRS and sepsis Crit Care Med 1992;20:864-874

Definitions Severe Sepsis Septic shock Sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Hypoperfusion and perfusion abnormalities may include: lactic acidosis, oliguria or acute alteration in mental status. Septic shock A subset of severe sepsis with hypotension (BP < 90 or drop of > 40 from baseline), despite adequate fluid resuscitation Crit Care Med 1992;20:864-874

These definitions were revised in 2001 at and International Sepsis Definitions Conference based on new insights into the pathophysiology and availability of new data and diagnostic tests. These definitions have been incorporated into the latest Sepsis Guidelines published in January of 2013.

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)

Table 1 Continued. Criteria for sepsis

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 resuscitation

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 mortality

JAMA Feb 23, 2016

New Definition of Sepsis “Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection”

Organ Dysfunction Can be identified as an acute change in total SOFA score of ≥ 2

Sequential Organ Failure Assessment (SOFA) Score Not good for screening in Ed

MedCalc

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”

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.

qSOFA – for screening for Sepsis Need 2 out of 3

Remember qSOFA = HAT Hypotension (BPs < 100) Altered Mental Status (GCS ≤ 13) Tachypnea (RR > 22)

New Sepsis Definitions

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 2016 Subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone

Septic Shock Clinical Criteria Despite adequate fluid resuscitation, vasopressors needed to maintain MAP ≥ 65 And Lactate > 2

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.

Lactate What does and elevated lactate mean? Marker of cellular/metabolic stress … not necessarily tissue hypoperfusion Can also occur with liver disease, catecholamine Rx, other drugs (metformin) Independent predictor of mortality

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 role

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 severity

Sepsis – 3: What’s Out SIRS Severe Sepsis Routine sepsis

Sepsis – 3: What’s in Sepsis Septic Shock SOFA qSOFA