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

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

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

4. 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:

5. 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:

6. 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.

7. 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)

9. Table 1 Continued. Criteria for sepsis

10. Definitions
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

12. 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

14. JAMA Feb 23, 2016

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

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

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

18. MedCalc

19. 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”

20. 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.

21. qSOFA – for screening for Sepsis
Need 2 out of 3

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

24. New Sepsis Definitions

25. 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

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

27. 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.

28. 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

29. 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

30. 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

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

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