New Recommendations Aim to Redefine Definition and Enhance Diagnosis of Sepsis, Septic Shock
A task force of leading sepsis experts is putting forth important, new recommendations for physicians. The group’s recommendations not only advance new definitions for sepsis and septic shock, but also offer clinical guidance to help physicians more quickly identify patients with or at risk of developing sepsis.
The recommendations are published in the February 2016 issue of JAMA
and were recently highlighted for clinicians and media at the Society of Critical Care Medicine’s (SCCM) 45th Critical Care Congress in Orlando, Florida.
The task force of 19 leaders in the field of sepsis was convened by SCCM and the European Society of Intensive Care Medicine (ESICM). The group’s recommendations have been endorsed by more than 30 medical societies from six continents, spanning disciplines from critical care and emergency medicine to infectious disease and family practice.
Current attention around sepsis is warranted. It is the leading cause of death from infection and its reported incidence is on the rise. In the United States, sepsis accounted for more than 20 billion dollars in hospital costs in 2011.
The new recommendations define sepsis as life-threatening organ dysfunction due to a dysregulated host response to infection. Septic shock is defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality.
The new definitions for sepsis and septic shock – the first revisions since 2001 – reflect considerable advances made in the pathophysiology, management, and epidemiology of sepsis. They offer more specificity in describing the life-threatening conditions and are aimed at achieving greater clarity and consistency in how sepsis is diagnosed, reported, and treated.
“This is an incredibly exciting time in the field of sepsis,” said Craig M. Coopersmith, MD, FCCM, a task force member and immediate past president of SCCM. “Driven by a combination of data analysis on well over one million patients as well as expert consensus, these new definitions provide a real step forward.”
Absent from the new definitions is the term “severe sepsis” – a significant change from previous definitions. The task force has deemed this term redundant, as sepsis has a mortality rate of 10 percent or higher, making the condition already severe.
“We want to underscore that sepsis itself is potentially life-threatening,” Dr. Coopersmith said. “Mortality rates from sepsis are higher than heart attack, stroke, or trauma. Sepsis needs to be viewed with the same urgency as these other life-threatening conditions because we know early treatment can decrease mortality.”
The task force’s new sepsis definitions also draw attention to another important clinical consideration – organ dysfunction, which is the threshold that elevates uncomplicated infection to sepsis. The suggested method to assess for organ dysfunction is Sequential (Sepsis-Related) Organ Failure Assessment (SOFA).
“Physicians should be looking for organ dysfunction every time they suspect infection. Conversely, they need to be looking for infection whenever a patient presents with organ dysfunction,” Dr. Coopersmith said.
To facilitate diagnosis of sepsis, the task force has identified new clinical criteria that physicians can use in their offices, emergency departments, and hospital wards to quickly evaluate and assess patients for sepsis.
The new diagnostic tool is named quickSOFA, or qSOFA. It consists of three simple tests that clinicians can conduct at the bedside to identify patients at risk for sepsis. The qSOFA assessment directs physicians to look for these warning signs in patients:
- An alteration in mental status
- A decrease in systolic blood pressure of less than 100 mm Hg
- A respiration rate greater than 22 breaths/min
Data indicate that patients with two or more of these conditions are at a significantly greater risk of having a prolonged ICU stay (3 or more days) or to die in the hospital. For these patients, the task force recommends that clinicians investigate further for organ dysfunction, initiate or escalate therapy as appropriate, and to consider referral to critical care or increase the frequency of monitoring.
“This is a new concept that gives physicians an easy-to-use tool to screen for sepsis,” Dr. Coopersmith said. “It can be done quickly and without the use of a blood test.”
If a patient has two or three components of qSOFA, the patient should be examined for organ failure.
Septic shock differs from sepsis in that the complications are more severe and the risk of patient death is greater. The task force has identified two new clinical criteria that clinicians should use in diagnosing patients with septic shock. These include:
- Persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg
- Blood lactate >2 mmol/L despite adequate volume resuscitation
Data indicate mortality rates for patients with these two conditions are in excess of 40 percent, or four times greater than patients with sepsis.
The new recommendations represent an important step forward, but certainly not the last one in the evolving study of sepsis. The task force recommends that its report be designated “Sepsis-3,” recognizing the two earlier iterations to define sepsis (1991 and 2001) and signaling the need for future study.
“Our work in sepsis remains very much a work in progress,” Dr. Coopersmith said. “We’ve come a long way, but there is still much more to do to ensure patients are safe and healthcare providers are informed.”