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Definiciones Sepsis y Shock Septico 2016 PDF
Definiciones Sepsis y Shock Septico 2016 PDF
CME Quiz at
PROCESS A task force (n = 19) with expertise in sepsis pathobiology, clinical trials, and
jamanetworkcme.com and
epidemiology was convened by the Society of Critical Care Medicine and the European CME Questions page 816
Society of Intensive Care Medicine. Definitions and clinical criteria were generated through
meetings, Delphi processes, analysis of electronic health record databases, and voting,
followed by circulation to international professional societies, requesting peer review and
endorsement (by 31 societies listed in the Acknowledgment).
(Reprinted) 801
Clinical Review & Education Special Communication Consensus Definitions for Sepsis and Septic Shock
S
epsis, a syndrome of physiologic, pathologic, and bio-
chemical abnormalities induced by infection, is a major Box 1. SIRS (Systemic Inflammatory Response Syndrome)
public health concern, accounting for more than $20 bil- Two or more of:
lion (5.2%) of total US hospital costs in 2011.1 The reported inci- Temperature >38°C or <36°C
dence of sepsis is increasing,2,3 likely reflecting aging populations Heart rate >90/min
with more comorbidities, greater recognition,4 and, in some coun-
Respiratory rate >20/min or PaCO2 <32 mm Hg (4.3 kPa)
tries, reimbursement-favorable coding.5 Although the true inci-
White blood cell count >12 000/mm3 or <4000/mm3
dence is unknown, conservative estimates indicate that sepsis is a
or >10% immature bands
leading cause of mortality and critical illness worldwide.6,7 Further-
more, there is increasing awareness that patients who survive sep- From Bone et al.9
802 JAMA February 23, 2016 Volume 315, Number 8 (Reprinted) jama.com
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Clinical Review & Education Special Communication Consensus Definitions for Sepsis and Septic Shock
Score
System 0 1 2 3 4
Respiration
PaO2/FIO2, mm Hg ≥400 (53.3) <400 (53.3) <300 (40) <200 (26.7) with <100 (13.3) with
(kPa) respiratory support respiratory support
Coagulation
Platelets, ×103/μL ≥150 <150 <100 <50 <20
Liver
Bilirubin, mg/dL <1.2 (20) 1.2-1.9 (20-32) 2.0-5.9 (33-101) 6.0-11.9 (102-204) >12.0 (204)
(μmol/L)
Cardiovascular MAP ≥70 mm Hg MAP <70 mm Hg Dopamine <5 or Dopamine 5.1-15 Dopamine >15 or
dobutamine (any dose)b or epinephrine ≤0.1 epinephrine >0.1
or norepinephrine ≤0.1b or norepinephrine >0.1b
Central nervous system
Glasgow Coma Scale 15 13-14 10-12 6-9 <6
scorec
Renal
Creatinine, mg/dL <1.2 (110) 1.2-1.9 (110-170) 2.0-3.4 (171-299) 3.5-4.9 (300-440) >5.0 (440)
(μmol/L)
Urine output, mL/d <500 <200
b
Abbreviations: FIO2, fraction of inspired oxygen; MAP, mean arterial pressure; Catecholamine doses are given as μg/kg/min for at least 1 hour.
PaO2, partial pressure of oxygen. c
Glasgow Coma Scale scores range from 3-15; higher score indicates better
a
Adapted from Vincent et al.27 neurological function.
tion is consistent with the view that cellular defects underlie physi-
A Need for Sepsis Definitions for the Public ologic and biochemical abnormalities within specific organ sys-
and for Health Care Practitioners tems. Under this terminology, “severe sepsis” becomes superfluous.
Sepsis should generally warrant greater levels of monitoring and in-
Despite its worldwide importance,6,7 public awareness of sepsis is tervention, including possible admission to critical care or high-
poor.29 Furthermore, the various manifestations of sepsis make di- dependency facilities.
agnosis difficult, even for experienced clinicians. Thus, the public
needs an understandable definition of sepsis, whereas health care Clinical Criteria to Identify Patients With Sepsis
practitioners require improved clinical prompts and diagnostic ap- The task force recognized that no current clinical measures reflect
proaches to facilitate earlier identification and an accurate quanti- the concept of a dysregulated host response. However, as noted
fication of the burden of sepsis. by the 2001 task force, many bedside examination findings and
routine laboratory test results are indicative of inflammation or
organ dysfunction.10 The task force therefore evaluated which
clinical criteria best identified infected patients most likely to
Results/Recommendations
have sepsis. This objective was achieved by interrogating large
Definition of Sepsis data sets of hospitalized patients with presumed infection,
Sepsis is defined as life-threatening organ dysfunction caused by a assessing agreement among existing scores of inflammation
dysregulated host response to infection (Box 3). This new defini- (SIRS) 9 or organ dysfunction (eg, SOFA, 27,28 Logistic Organ
tion emphasizes the primacy of the nonhomeostatic host response Dysfunction System30) (construct validity), and delineating their
to infection, the potential lethality that is considerably in excess of correlation with subsequent outcomes (predictive validity). In
a straightforward infection, and the need for urgent recognition. As addition, multivariable regression was used to explore the perfor-
described later, even a modest degree of organ dysfunction when mance of 21 bedside and laboratory criteria proposed by the 2001
infection is first suspected is associated with an in-hospital mortal- task force.10
ity in excess of 10%. Recognition of this condition thus merits a Full details are found in the accompanying article by Seymour
prompt and appropriate response. et al.12 In brief, electronic health record data of 1.3 million encoun-
Nonspecific SIRS criteria such as pyrexia or neutrophilia will con- ters at 12 community and academic hospitals within the Univer-
tinue to aid in the general diagnosis of infection. These findings sity of Pittsburgh Medical Center health system in southwestern
complement features of specific infections (eg, rash, lung consoli- Pennsylvania were studied. There were 148 907 patients with
dation, dysuria, peritonitis) that focus attention toward the likely ana- suspected infection, identified as those who had body fluids
tomical source and infecting organism. However, SIRS may simply sampled for culture and received antibiotics. Two outcomes—
reflect an appropriate host response that is frequently adaptive. Sep- hospital mortality and mortality, ICU stay of 3 days or longer, or
sis involves organ dysfunction, indicating a pathobiology more com- both—were used to assess predictive validity both overall and
plex than infection plus an accompanying inflammatory response across deciles of baseline risk as determined by age, sex, and
alone. The task force emphasis on life-threatening organ dysfunc- comorbidity. For infected patients both inside and outside of the
804 JAMA February 23, 2016 Volume 315, Number 8 (Reprinted) jama.com
Consensus Definitions for Sepsis and Septic Shock Special Communication Clinical Review & Education
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Clinical Review & Education Special Communication Consensus Definitions for Sepsis and Septic Shock
806 JAMA February 23, 2016 Volume 315, Number 8 (Reprinted) jama.com
Consensus Definitions for Sepsis and Septic Shock Special Communication Clinical Review & Education
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Clinical Review & Education Special Communication Consensus Definitions for Sepsis and Septic Shock
Sepsis
B SOFA Variables
PaO2/FiO2 ratio
Despite adequate fluid resuscitation, Glasgow Coma Scale score
1. vasopressors required to maintain Mean arterial pressure
No
MAP ≥65 mm Hg
AND Administration of vasopressors
2. serum lactate level >2 mmol/L? with type and dose rate of infusion
Serum creatinine or urine output
Yes Bilirubin
Septic shock Platelet count
The baseline Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score should be assumed to be zero unless the patient is known to have preexisting
(acute or chronic) organ dysfunction before the onset of infection. qSOFA indicates quick SOFA; MAP, mean arterial pressure.
808 JAMA February 23, 2016 Volume 315, Number 8 (Reprinted) jama.com
Consensus Definitions for Sepsis and Septic Shock Special Communication Clinical Review & Education
ARTICLE INFORMATION Acquisition, analysis, or interpretation of data: All his time spent in these roles. Dr Hotchkiss reports
Author Affiliations: Bloomsbury Institute of authors. consulting on sepsis for GlaxoSmithKline, Merck,
Intensive Care Medicine, University College Drafting of the manuscript: Singer, Deutschman, and Bristol-Meyers Squibb and reports that his
London, London, United Kingdom (Singer); Seymour, Shankar-Hari, Angus. institution received grant support from Bristol-
Hofstra–Northwell School of Medicine, Feinstein Critical revision of the manuscript for important Meyers Squibb and GlaxoSmithKline, as well as the
Institute for Medical Research, New Hyde Park, intellectual content: All authors. NIH, for research on sepsis. Dr Marshall reports
New York (Deutschman); Department of Critical Statistical analysis: Shankar-Hari, Seymour. serving on the data and safety monitoring board
Care and Emergency Medicine, University of Obtained funding: Deutschman, Chiche, (DSMB) of AKPA Pharma and Spectral Medical
Pittsburgh School of Medicine, Pittsburgh, Coopersmith. Steering Committee and receiving payment for
Pennsylvania (Seymour); Department of Critical Administrative, technical, or material support: speaking from Toray Ltd and Uni-Labs. Dr Martin
Care Medicine, Guy’s and St Thomas’ NHS Singer, Deutschman, Chiche, Coopersmith, reports serving on the board for SCCM and Project
Foundation Trust, London, United Kingdom Levy, Angus. Help, serving on the DSMB for Cumberland
(Shankar-Hari); Department of Critical Care Study supervision: Singer, Deutschman. Pharmaceuticals and Vanderbilt University, serving
Medicine, University of Versailles, France (Annane); Drs Singer and Deutschman are joint first authors. on the medical advisory board for Grifols and
Center for Sepsis Control and Care, University Conflict of Interest Disclosures: All authors have Pulsion Medical Systems, and grants to his
Hospital, Jena, Germany (Bauer); Australian and completed and submitted the ICMJE Form for institution from NIH, the Food and Drug
New Zealand Intensive Care Research Centre, Disclosure of Potential Conflicts of Interest. Administration, Abbott, and Baxter. Dr Opal reports
School of Public Health and Preventive Medicine, Dr Singer reports serving on the advisory boards of grants from GlaxoSmithKline, Atoxbio, Asahi-Kasei,
Monash University, Melbourne, and Austin Hospital, InflaRx, Bayer, Biotest, and Merck and that his Ferring, Cardeas, and Arsanis outside the submitted
Melbourne, Victoria, Australia (Bellomo); Vanderbilt institution has received grants from the European work; personal fees from Arsanis, Aridis, Bioaegis,
Institute for Clinical and Translational Research, Commission, UK National Institute of Health Cyon, and Battelle; and serving on the DSMB for
Vanderbilt University, Nashville, Tennessee Research, Immunexpress, DSTL, and Wellcome Achaogen, Spectral Diagnostics, and Paratek. No
(Bernard); Réanimation Médicale-Hôpital Cochin, Trust. Dr Deutschman reports holding patents on other disclosures were reported.
Descartes University, Cochin Institute, Paris, France materials not related to this work and receiving Funding/Support: This work was supported in part
(Chiche); Critical Care Center, Emory University travel/accommodations and related expenses for by a grant from the Society of Critical Care Medicine
School of Medicine, Atlanta, Georgia participation in meetings paid by the Centers for (SCCM) and the European Society of Intensive Care
(Coopersmith); Washington University School of Disease Control and Prevention, World Federation Medicine (ESICM).
Medicine, St Louis, Missouri (Hotchkiss); Infectious of Societies of Intensive and Critical Care, Role of the Funder/Sponsor: These funding bodies
Disease Section, Division of Pulmonary and Critical Pennsylvania Assembly of Critical Care Medicine/PA appointed cochairs but otherwise had no role in the
Care Medicine, Brown University School of Chapter, Society of Critical Care Medicine design and conduct of the work; the collection,
Medicine, Providence, Rhode Island (Levy, Opal); (SCCM)/Penn State–Hershey Medical Center, management, analysis, and interpretation of the
Department of Surgery, University of Toronto, Society of Critical Care Medicine, Northern Ireland data; preparation of the manuscript; or decision to
Toronto, Ontario, Canada (Marshall); Emory Society of Critical Care Medicine, International submit the manuscript for publication. As other
University School of Medicine and Grady Memorial Sepsis Forum, Department of Anesthesiology, national and international societies, they were
Hospital, Atlanta, Georgia (Martin); Trauma, Stanford University, Acute Dialysis Quality Initiative, asked for comment and endorsement.
Emergency & Critical Care Program, Sunnybrook and European Society of Intensive Care Medicine
Health Sciences Centre, Toronto, Ontario, Canada (ESICM). Dr Seymour reports receiving personal Disclaimer: Dr Angus, JAMA Associate Editor, had
(Rubenfeld); Interdepartmental Division of Critical fees from Beckman Coulter and a National no role in the evaluation of or decision to publish
Care, University of Toronto (Rubenfeld); Institutes of Health (NIH) grant awarded to his this article.
Department of Infectious Diseases, Academisch institution. Dr Bauer reports support for travel to Endorsing Societies: Academy of Medical Royal
Medisch Centrum, Amsterdam, the Netherlands meetings for the study from ESICM, payment for Colleges (UK); American Association of Critical Care
(van der Poll); Department of Intensive Care, speaking from CSL Behring, grants to his institution Nurses; American Thoracic Society (endorsed
Erasme University Hospital, Brussels, Belgium from Jena University Hospital, and patents held by August 25, 2015); Australian–New Zealand
(Vincent); Department of Critical Care Medicine, Jena University Hospital. Dr Bernard reports grants Intensive Care Society (ANZICS); Asia Pacific
University of Pittsburgh and UPMC Health System, from AstraZeneca for activities outside the Association of Critical Care Medicine; Brasilian
Pittsburgh, Pennsylvania (Angus); Associate Editor, submitted work. Dr Chiche reports consulting for Society of Critical Care; Central American and
JAMA (Angus). Nestlé and Abbott and honoraria for speaking from Caribbean Intensive Therapy Consortium; Chinese
Author Contributions: Drs Singer and Deutschman GE Healthcare and Nestlé. Dr Coopersmith reports Society of Critical Care Medicine; Chinese Society of
had full access to all of the data in the study and receiving grants from the NIH for work not related Critical Care Medicine–China Medical Association;
take responsibility for the integrity of the data and to this article. Dr Coopersmith also reports bring Critical Care Society of South Africa; Emirates
the accuracy of the data analysis. president-elect and president of SCCM when the Intensive Care Society; European Respiratory
Study concept and design: All authors. task force was meeting and the article was being Society; European Resuscitation Council; European
drafted. A stipend was paid to Emory University for Society of Clinical Microbiology and Infectious
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Clinical Review & Education Special Communication Consensus Definitions for Sepsis and Septic Shock
810 JAMA February 23, 2016 Volume 315, Number 8 (Reprinted) jama.com