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sepsis is not a

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Here are some of the key concerns: There is more to sepsis than just inflammation (SIRS is essentially a reflection of inflammation. it’s only fair that we should take a crack at them too.So the ED crowd have stolen a march on us following the recent publication of the Sepsis 3.”   . which may in fact be an adaptive response)   The inadequate sensitivity and specificity of the SIRS criteria lead to an unhelpful excess of false positives and negatives There is an inherent fallacy in the linear progression model of Infection -> Sepsis -> Severe sepsis -> Septic shock The definitions were assembled from expert opinion with no quality data to support them   Here are the new definitions as per the Sepsis 3 Consensus update: “Sepsis is life-threatening organ dysfunction as a result of a dysregulated host response due to known or suspected infection” “Septic shock is present when there is sepsis with a persistent hypotension requiring vasopressur supprt to maintain a MAP > 65mmHg AND a serum lactate > 2mmol/L DESPITE adequate volume resuscitation. as the Third International Consensus Definitions for Sepsis and Septic Shock (http://jama.aspx?articleid=2492881) was made up of a panel of 19 intensive care physicians (more about this a bit later). it has really helped to get the details out in the open. all along there has been an air of disquiet about this SIRS-based model of sepsis. And fair play to them for doing so.com/article.0 Consensus Definitions. However.jamanetwork. Since 1991 we have been defining sepsis using SIRS-based criteria: Suspected infection + 2 or more of 4 SIRS criteria = Sepsis Sepsis + organ dysfunction = Severe sepsis Sepsis + sBP <90mmHg = Septic shock   However.

You can read more about this in the accompanying JAMA articles here: Assessment of Clinical Criteria for SepsisFor the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) (http://jama.aspx?articleid=2492876)   The new definitions come with some specific criteria.jamanetwork.com/article.aspx?articleid=2492875) Developing a New Definition and Assessing New Clinical Criteria for Septic ShockFor the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) (http://jama.As much as possible the committee tried to construct these definitions using available evidence.com/article. Here’s how it works. He looks a bit sick.” . Sepsis requires a known or suspected infection (easy enough and arguably fairly subjective) with organ dysfunction and an element of life threat. I wonder does he have sepsis.” “Well he is tachypnoeic to 28bpm and he’s a bit confused so already his mortality risk in this setting is at lesat 10%.   The components of these two scores suggest organ dysfunction and their absolute values indicate the degree of mortality risk.jamanetwork. This is where they introduce the use of the SOFA and qSOFA scores. hmm.   “I think this patient has an infection.

“Jeepers. then he is in the higher risk group of SEPTIC SHOCK. it can only be calculated once work-up has been started in the ED or is being followed up on the ward or ICU. Realistically. The new sepsis and septic shock definitions still have a subjective I think this person has an infection component. Its validity has been derived and tested using a retrospective. as the SOFA score requires lab results. I’d better get cracking. It was deemed to add little to the purpose of the new definitions. figure out the source. get cultures off and antibiotics in and I think I might give ICU a call. as a diagnostic entity.”   So the label “SEPSIS” is not an illness as such. The SIRS-based sepsis definition spectrum is fairly subjective and largely based on expert opinion. Key features Severe sepsis. with a lactate >2mmol/L despite adequate volume resuscitation. Let’s break this new set of definitions down a bit. And if this patient is subsequently found to be hypotensive and needing a vasopressor.   And how do I decide whether to use the SOFA score or the qSOFA score? Well I could use either. while the insertion of the SOFA and qSOFA . It is a subset risk group of infected patients. The qSOFA only requires three clinical criteria and therefore can be applied by the bedside on the ward. This might kill him. at ED triage or even pre-hospital. It has yet to be prospectively validated or to be validated outside of North America. large population analysis which you can read in the two papers referenced above. no longer exists. he’s septic.

Other systemic illnesses can present with features suggestive of infection and lift SOFA and qSOFA scores by 2 or more points and culture tests may return negative results or the identified infection may be secondary rather than the main driver. pre-hospital. They (hopefully) exclude the infected who are well and/or likely-to-survive-regardless. neutrophilia. or septic shock. The qSOFA criteria and score were derived by retrospective analysis (associative) of a large dataset (that’s good) of hospitalised patients with presumed infection based on diagnositic coding (selection bias? diagnostic accuracy?). For the moment. there is   still no guarantee that they will be comparing the same thing. but we may not be able to be definitive. They are screening tools for the likelihood of a bad (death) outcome in someone with an infection. While the new definitions might make trial results and epidemiology easier to compare. we will still be left with treating the likelihood that this is sepsis. Limitations of Sepsis 3.0 There is no criterion standard test to confirm the diagnosis of sepsis. None of this has been tested in a paediatric population and there may be other subgroups missing or under-represented. scores result from a better understanding of sepsis pathophysiology and testing them against a large North American derivation and validation population. It is not a single disease entity. The expert committee who put these definitions together were intensivists from the ESICM and SCCM. There is a greater emphasis on life threat and host response dysregulation rather than simple physiological responses that may actually be adaptive (tachycardia. The new definitions identify a sicker cohort of patients than previously. The new sepsis definitions do not really provide a screening tool to diagnose sepsis and septic shock. No other craft group (ED. maybe fever). Sepsis is a non-homogenous amalgamation of triggering infections that set off a dysregulated host response and organ dysfunction. depending upon the make up of the triggering illnesses. They have not yet been prospectively validated nor tested outside of North America. etc) was involved until afterwards when the committee sought peer review. .

check out the following links: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) (http://jama. it performs no better in non-ICU populations (AUC 0.) For more picking apart of the Sepsis 3.org/2016/02/21/sepsis-redefined/) Merits 19 intensivists from around the world came to an agreed position on a complex issue and got buy in from 31 peer colleges and bodies.79 versus 0. including hearing from two of the lead authors. That said. Though there has been endorsement of the new definitions by 31 colleges and bodies. not everyone has climbed on board just yet (ACEP. free) . And it only took 18 months from start to finish.76). If you want to read more about the new sepsis definitions. this has yet to be prospectively validated. One of the biggest benefits has to be that it has multiple groups.jamanetwork. colleges and practicioners talking about sepsis and septic shock and this alone will hopefully result in improvements in associated mortality.   Mind though.81).org/pulmcrit/problems-sepsis-3-definition/) Jeremy Faust and Lauren Westafer’s FOAMCast – Sepsis: Redefined (https://foamcast.74 versus 0. SAEM.com/article. check out these sites: Josh Farkas’ PulmCrit – Top ten problems with the new sepsis definition (http://emcrit. The lead authors repeatedly admit that this is an evolving criterion set with scope for modification as better markers and ways to use them are identified and validated. Sepsis is not an illness Sepsis is a risk group of infected patients. The qSOFA however outperforms both SOFA and SIRS outside the ICU (AUC 0. There is no reference to Sepsis 3 on the ACEM or CICM websites by the date this article was posted.aspx?articleid=2492881) (Full text. Not a bad effort! SOFA performs better than the SIRS criteria at predicting mortality risk in ICU populations (AUC 0.0 Consensus Definitions.64).

com/sepsis-not- disease/&media=http://intensivecarenetwork.com/sepsis-not-disease/)  (https://plus. free) Salim Rezaie’s R.B.E.com/sharer.0 (http://emcrit.com/sepsis-3-0/) Josh Farkas’ PulmCrit – Top ten problems with the new sepsis definition (http://emcrit.com/sepsis-not- disease/)  (https://twitter.org/pulmcrit/problems-sepsis-3-definition/) Jeremy Faust and Lauren Westafer’s FOAMCast – Sepsis: Redefined (https://foamcast. EM – Sepsis 3.aspx?articleid=2492876) (Full text.com/shareArticle?url=http://intensivecarenetwork. Assessment of Clinical Criteria for SepsisFor the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) (http://jama.linkedin.org/podcasts/sepsis-3/) Scott Weingart’s EM Crit – Podcast 170: Cliff Deutschman with Additional Thoughts on Sepsis 3.com/wp-content/uploads/2016/04/Sepsis-3- banner.com/sepsis- not-disease/) .com/sepsis-not-disease/)  (http://pinterest.com/share?url=http://intensivecarenetwork.org/wee/wee-cliff-deutschman-additional-thoughts-sepsis-3-0/)   SHARE THIS  (http://www.E.google.0 (http://rebelem.org/2016/02/21/sepsis-redefined/) Scott Weingart’s EM Crit – Podcast 169: Sepsis 3.php?u=http://intensivecarenetwork.com/article.aspx?articleid=2492875) (Full text.com/pin/create/button/?url=http://intensivecarenetwork.com/share?url=http://intensivecarenetwork.com/sepsis-not-disease/)  (mailto:?subject=Sepsis is not a disease&body=http://intensivecarenetwork.jamanetwork.jamanetwork. free) Developing a New Definition and Assessing New Clinical Criteria for Septic ShockFor the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) (http://jama.com/sepsis-not- disease/)  (whatsapp://send?text=http://intensivecarenetwork.jpg&description=Sepsis is not a disease)  (https://www.facebook.0 with Merv Singer (http://emcrit.com/article.L.

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