Evidence based medicine SEPSIS 3 GUIDELINES Diagnosis of ...

Evidence based medicine �C SEPSIS 3 GUIDELINES

Diagnosis of sepsis and septic shock �C The Sepsis �C 3 Guidelines

Source: Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus

Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016 Feb 23;315(8):801�C10. Summary prepared by Ajay K. Mishra,

Assistant Professor, Dept. of Medicine, Christian Medical College, Vellore.

in six organ systems. [Table 1]3 Organ dysfunction is

identified as an acute change in SOFA score by 2

points. The baseline SOFA score can be assumed to be

zero in patients not known to have pre-existing organ

dysfunction. This scoring facilitates the recognition of

even a mild organ dysfunction in the back ground of

Introduction

Definitions for SIRS (systemic Inflammatory Response

Syndrome), sepsis, and sepsis related organ failure

were established with a consensus guideline in 1992

and was revisited in 2001. The task force recognized

the need of incorporation of the recent advances in

pathogenesis into the definitions. They pointed out that

though SIRS was useful in establishing a diagnosis of

sepsis it was nonspecific and not sensitive either.1 This

was confirmed with a study which showed 1 out of 8

patients admitted to an ICU with infection and organ

failure did not have the required minimum 2 criteria for

SIRS. 2 The task force also identified that the present

guideline failed to stage and prognosticate sepsis based

on its severity.

Key points

Objective: The task force aimed to 1] differentiate

sepsis from uncomplicated infection and 2] to update

definitions of sepsis and septic shock based on the

recent understanding of its pathobiology

The process: The European Society of Intensive Care

Medicine and the Society of Critical Care Medicine

convened a task force of 19 specialists from different

fields in January2014. The clinical criteria were

developed over a period of one year.

Findings:

Sepsis is defined as life-threatening

organ dysfunction caused by a

dysregulated host response to infection.

?

Organ dysfunction is identified as an acute

change in SOFA score by 2 points.

?

A qSOFA score of > 2 in the back ground

of suspected infection can predict

prolonged ICU stay or death.

?

Septic shock - Presence of the triad of

variables �Chypotension (MAP 2mmol/L (18 mg/dL).

?

The SIRS criteria is inadequate for

identifying patients with organ dysfunction.

infection, which is associated with 10% increase in inhospital mortality.3

The SOFA score also helps in prognosticating

patient outcome and predicting mortality. A higher

SOFA score is associated with an increased probability

of mortality.

Sepsis is defined as life-threatening organ dysfunction

caused by a dysregulated host response to infection.3

As sepsis induced organ dysfunction can be occult, any

unexplained organ dysfunction should suffice to raise

the possibility of underlying infection to sepsis. The

previous SIRS criteria (Table 3) failed to indicate a

dysregulated, life-threatening response to infection in

more than 10% of patients. The Sequential Organ

Failure Assessment (SOFA) and the Quick SOFA (q

SOFA) scores were developed in this context.

Quick SOFA (qSOFA): is a clinical model that

includes 3 clinical variables (Table 2) that provides a

simple bedside method of identifying adult patients

with suspected infection who are likely to have poor

outcome. A qSOFA score of > 2 in the back ground of

suspected infection can predict prolonged ICU stay or

death. As suggested by the task force qSOFA can be

used when the clinician suspects organ dysfunction

SOFA score: Sequential Organ Failure Assessment

(SOFA) score provides a simple and objective system

in ICU settings for organ failure scoring; to calculate

both the number and the severity of organ dysfunction

CMI 14:3

?

44

July 2016

Evidence based medicine �C SEPSIS 3 GUIDELINES

secondary to sepsis which is not reflected by the SIRS

criteria. The new guidelines recommend the usage of

qSOFA score rather than the previously popularized

SIRS criteria (Table 3).

The qSOFA score is less robust than a SOFA

score of 2 or greater in the ICU. However, since it does

not require laboratory tests and can be assessed quickly

and repeatedly at the bedside, it has its advantages over

the SOFA scoring system in a peripheral hospital with

limited resources. The task force suggests that qSOFA

criteria can be used to prompt clinicians to further

investigate for organ dysfunction, to initiate or escalate

therapy as appropriate, and to consider referral to

critical care or increase the frequency of monitoring, if

such actions have not already been undertaken.3

However, as compared to the SIRS criteria, qSOFA has

not yet been studied or compared.2

Table 1. Sequential Organ Failure Assessment Score (SOFA score)

Score

System

1. Respiration

PaO2/F102

mm Hg (kPa)

2. Coagulation

Platelets, x103/?L

3. Liver

Bilirubin,

mg/dL (?mol/L)

4. Cardiovascular

0

1

2

3

4

>400 (53.3)

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