From The LGH Physician Advisor Team
One of the interesting yet frustrating parts of our job is the constant evolution of treatment and diagnostic criteria. We all need to keep our practice current and stay abreast of changes in our field.
In 2001 the international Sepsis Definition Taskforce emphasized Systemic Inflammatory Response (SIRS) as the primary factor in determining sepsis. This led to the old diagnosis as SIRS in the setting of infection. Since inflammatory changes are quite common and non-specific, this led to an overdiagnosis of sepsis and made study of the condition difficult.
Just last month, the international Sepsis Definition Taskforce updated the definition, focusing on “life-threatening organ dysfunction” in response to infection. This was published in JAMA in February.
To help support the diagnosis of organ dysfunction, the taskforce has opted to focus on a scoring system called “Sepsis-related Organ Failure Assessment Score,” or “SOFA” score. This is not how many points your team scores while you drink beer on the sofa. It is a somewhat cumbersome scoring system that looks at the degree of various organ system dysfunction, such as respiratory, cardiovascular, CNS and renal.
The good news is that you do not need to calculate a formal SOFA (though this may become more routine for our critical care colleagues). You can apply clinically relevant abnormalities in common vital signs, physical exam findings and labs.
Keep it simple:
Sepsis = Infection (proven or suspected) with life-threatening organ dysfunction evidenced by 2 or more systems (or SOFA score >=2):
- Lungs: RR>22 (sustained), respiratory distress, new acute respiratory failure (RA sat< 88 or PaO2 < 60mmHg)
- CNS: Acute Encephalopathy with documented departure from baseline (documenting baseline will be key to support this, especially if the patient has baseline cognitive impairment)
Circulatory: Hypotension with SBP < 100
- Kidney: Cr > 1.5x baseline
You need a little LUCCK
to survive sepsis.
To count, you need to suspect that these abnormalities are due to the infection and not something else.
Other updates to sepsis:
“Severe Sepsis” no longer exists as a term.
“Septic Shock” is similar to the old definition, except it includes Lactate > 2 and MAP < 65 +/- pressors AFTER adequate (2+ L) isotonic fluid resuscitation.