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SEPSIS NEW

DEFINITIONS

I MADE AGUS KRESNA SUCANDRA


OUTLINE

Objective
History
Old Definition
New Definition
Implication
OBJECTIVES

Understanding New Definition of SEPSIS


Related clinical assessment tools
Recognize the rationale the new definitions for
SEPSIS and SEPTIC SHOCK
Understand the relationship of the new sepsis
DEFINITION to BEDSIDE SCREENING and
TREATMENT
INTRODUCTION

(sipsi)
4th century BC : introduced by Hippocrates
the process of decay or decomposition of
organic matter
11th century AD : Ibn Sina (Avicenna)
introduced blood rot
19th century AD : sepsis
INTRO

Herrmann Boerhave (1668-1738) : toxic


substances in the air were the cause for
sepsis.

Justus von Liebig (early 19th century) :


contact between wounds and oxygen was
responsible for the development of sepsis.
INTRO

Ignaz Louis Joseph Robert Koch Hugo


Semmelweis Pasteur Lister (1843-1910) Schottmller
(1818-1865) (1822- (1827-1912) (1867-1936)
1895) Kochs
Puerperal Amputation postulate Sepsis
fever Bacteria sepsis modern
Steam definition
Clorine Carbolic sterilisation
acid
SEPSIS Burden

Mortality in the U.S increased from 154,159 in 2000 to


207,427 in 2007
hospitalizations with sepsis have overtaken those for
myocardial infarction
In the U.S., sepsis accounts for far more deaths than
the number of deaths from prostate cancer, breast
cancer and AIDS combined
The Agency for Healthcare Research and Quality lists
sepsis as the most expensive condition treated in U.S.
hospitals, costing more than $20 billion in 2011
increasing on average annually by 11.9%

http://world-sepsis-day.org/
Seymour et al. Am J Respir Crit Care Med 2012, 186(12):1264-1271.
Old Definition

The original definitions of sepsis and related


conditions are now more than 20 years old
Sepsis 1 (1991 2001) ACCP/SCCM
Sepsis 2 (2001 2015)
SCCM/ESICM/ACCP/ATS/SIS
Sepsis 3 (2015 - ) ESICM/SCCM
OLD and NEW

OLD
SEPTIC
SEVER SHOCK NEW
E
SEPSIS SEPSIS SEPTIC
SHOC
SIRS SEPSIS K

OLD DEFINITION

SIRS + infection : ???


poor discriminant validity
poor concurrent validity
SEPSIS = SIRS + INFECTION ?
The 3rd International
Consensus Definitions for
Sepsis and Septic Shock
(Sepsis-3)
NEW DEFINITION SCCM/ESICM
JAMA 2016;315(8):801-810.
IMPORTANCE

Definitions of sepsis and septic shock were last revised in


2001 15 years
Considerable advances have since been made into the
pathobiology (changes in organ function, morphology,
cell biology, biochemistry, immunology, and circulation),
management,
epidemiology of sepsis,
> suggesting the need for reexamination.
KEY FINDINGS FROM EVIDENCE
SYNTHESIS

Limitations of previous definitions included an excessive


focus on inflammation, the misleading model that sepsis
follows a continuum through severe sepsis to shock, and
inadequate specificity and sensitivity (SIRS) criteria.
Multiple definitions and terminologies are currently in use
for sepsis, septic shock, and organ dysfunction, leading to
discrepancies in reported incidence and observed mortality.
The task force concluded the term severe sepsis was
redundant
Why we need New Definition?

offer greater consistency for epidemiologic


studies and clinical trials, and
facilitate earlier recognition and more timely
management of patients with sepsis or at risk of
developing sepsis.
Key concept of SEPSIS

Sepsis is the primary cause of death from infection


urgent attention
SEPSIS : pathogen factors + host factors evolve over
time
SEPSIS vs infection : (1) abberant or dysregulated host
response, (2) organ dysfunction
Sepsis-induced organ dysfunction may be occult
life-threatening organ
dysfunction caused by a
dysregulated host
response to infection

SEPSIS
SEPSIS in lay term

life-threatening condition that arises when the


bodys response to an infection injures its
own tissues and organs
ORGAN DYSFUNCTION

Acute
change in total SOFA score 2 point
consequent to the infection

the baseline SOFA score can be assumed to


be zero in patients not known to have
preexisting organ dysfunction.

SOFA score 2 reflects an overall mortality


risk of approximately 10% in a general
hospital population with suspected infection.
subset of a sepsis in which
underlying circulatory and
cellular/metabolic abnormalities
are profound enough to


substantially increase mortality

SEPTIC SHOCK
SEPTIC SHOCK

persisting hypotension requiring vasopressors


to maintain MAP >65 mm Hg and having a
serum lactate level > 2 mmol/L (18 mg/dL)
despite adequate volume resuscitation.
This combination is associated with hospital
mortality rates > 40%.
Implication of the New
Definitions for Screening and
Management

STEP 1 : Screening and Management of Infection


STEP 2 : Screening for Organ Dysfunction and
Management of Sepsis
STEP 3 : Identification and Management of Initial
Hypotension
STEP 1 : Screening and
Management of Infection

Identification of infection
Sign and symptom
Obtaining blood and other cultures
Administering tailored antibiotics as
appropriate
Infection-related organ dysfunction
STEP 2 : Screening for Organ Dysfunction
and Management of Sepsis

Identified by the same organ dysfunction


criteria (including lactate level greater than 2
mmol/L)
Identified using the quick Sepsis-Related
Organ Failure Assessment (qSOFA)
Ensuring that the three-hour bundle elements
have been initiated continues to be a priority
(i.e. blood cultures)
STEP 3 : Identification and
Management of Initial
Hypotension

Px with infection and hypotension or a lactate level 4


mmol/L
providing 30 mL/kg crystalloid with reassessment of
volume responsiveness or tissue perfusion should be
implemented
The six-hour elements of care (6-hours bundles)
Repeat lactate level measurement if initial lactate level
2 mmol/L.
Quick SOFA (qSOFA)
Clarification for the
Practitioner

A tool for identifying patients at risk of sepsis with a higher


risk of hospital death or prolonged (ICU) stay SCREENING
TOOLS
Note that:
qSOFA does not define sepsis (but the presence of two
qSOFA criteria is a predictor of both increased mortality
and ICU stays of more than three days in non-ICU patients)
The new sepsis definitions recommend using a change in
baseline of the total SOFA score of two or more points
to represent organ dysfunction.
Controversies and
Limitations

Sepsis is a broad term applied to an


incompletely understood process.
There are no simple and unambiguous clinical
criteria or biological, imaging, or laboratory
features that uniquely identify a septic
patient.
Neither qSOFA nor SOFA is intended to be a
stand-alone definition of sepsis.
Prepare for Change!

As always, hospitals and every healthcare


components should prepare for major changes
that can alter fiscal considerations.
Hospitals should develop detailed plans and
educate their physician and nursing staff and
their coding departments to ensure that
their coders accurately capture the sense of
the new definitions.
Are we ready to new definition?
THANK YOU