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Se psis: Ne w De finitio ns, Ne w Dire c tio n I mra na Ma lik, MD Asso c ia te Pro fe sso r De pa rtme nt o f Critic a l Ca re UT MD Ande rso n Ca nc e r Ce nte r Ho usto n, T e xa s, USA Disc lo sure No c o nflic ts o f inte re st
Se psis: Ne w De finitio ns, Ne w Dire c tio n
I mra na Ma lik, MD
Asso c ia te Pro fe sso r De pa rtme nt o f Critic a l Ca re UT MD Ande rso n Ca nc e r Ce nte r Ho usto n, T e xa s, USA
Disc lo sure
No c o nflic ts o f inte re st to re po rt re la te d to this ta lk
L e ar ning Obje c tive s
1. Disc uss the justific a tio n a nd c rite ria e sta b lishing the
ne w de finitio ns o f se psis a nd ho w the ir de ve lo pme nt impa c ts c ha ng e s a mo ng the a dult a nd pe dia tric po pula tio n
2. Co mpa re a nd c o ntra st the pre dic tive va lue fo r in
ho spita l mo rta lity b y using the SOF A sc o re , SI RS c rite ria , L ODS sc o re a nd the de ve lo pme nt o f the q SOF A sc o re in ide ntifying suspe c te d infe c tio n in pa tie nts o utside o f a c ritic a l c a re se tting
Outline
T
he Ne w De finitio n o f Se psis
Additio n o f q SOF
A
Stre ng ths & We a kne sse s o f T
he Ne w De finitio ns
Othe r c o nside ra tio ns
T he Ne w De finitio n o f Se psis
T
he Ne w De finitio n o f Se psis
Justific a tio n a nd Crite ria Re mo va l o f Se ve re Se psis Dia g no sis Use in Adult vs. Pe dia tric Po pula tio n
Pub lishe d in F
e b rua ry 2016
I
nte nde d to impro ve the c la rity o f the de finitio ns fo r
c linic a l c a re , e pide mio lo g y, q ua lity impro ve me nt a nd
re se a rc h
T
he ne w de finitio ns ha ve b e e n va lida te d re tro spe c tive ly in a dult pa tie nts, using la rg e da ta b a se s in the U.S. a nd E uro pe .
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
Justific a tio n
T
he de finitio ns o f se psis, se ptic sho c k, a nd o rg a n dysfunc tio n ha ve re ma ine d la rg e ly unc ha ng e d fo r o ve r 2 de c a de s
T
he re is impro ve d unde rsta nding o f se psis pa tho b io lo g y
Diffe re ntia ting se psis fro m unc o mplic a te d infe c tio n Upda ting de finitio ns o f se psis a nd se ptic sho c k Cre a ting a va lida te d c rite rio n sta nda rd dia g no stic te st Pro viding a mo re c o nsiste nt a nd re pro duc ib le pic ture o f se psis
inc ide nc e a nd o utc o me s
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
Crite ria
Se psis is “life thre ate ning o rg an dysfunc tio n c ause d
b y dysre g ulate d ho st re spo nse to infe c tio n”
Org a n Dysfunc tio n
T
he c linic a l dia g no sis o f se psis is b a se d o n the Se q ue ntia l Org a n F unc tio n Asse ssme nt sc o re (SOF A)
An a c ute c ha ng e in sc o re o f 2 o r g re a te r is dia g no stic I
de ntifie s pa tie nts with in-ho spita l mo rta lity o f >10%
And a 2-25 fo ld inc re a se d risk o f mo rta lity
c o mpa re d to pa tie nts with a SOF A sc o re o f <2.
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
SOF A Sc o re
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
Crite ria
Se psis is “life thre ate ning o rg an dysfunc tio n c ause d b y
dysre g ulate d ho st re spo nse to infe c tio n”
Org a n Dysfunc tio n T
he c linic a l dia g no sis o f se psis is b a se d o n the Se q ue ntia l Org a n F unc tio n Asse ssme nt sc o re (SOF A)
An a c ute c ha ng e in sc o re o f 2 o r g re a te r is dia g no stic Ide ntifie s pa tie nts with in-ho spita l mo rta lity o f >10% And a 2-25 fo ld inc re a se d risk o f mo rta lity c o mpa re d to
pa tie nts with a SOF A sc o re o f <2.
Se ptic Sho c k Pe rsiste nt hypo te nsio n re q uiring va so pre sso rs (MAP>65mm
HG)
Se rum la c ta te >2 mmo l/ L
de spite a de q ua te re susc ita tio n
T
he se c rite ria ide ntify pa tie nts with in-ho spita l mo rta lity >40%
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
Re mo va l o f Se ve re Se psis
T
he ne w te rm ‘ se psis’ invo lve s o rg a n dysfunc tio n
Se pa ra ting it fro m simple infe c tio n a nd se ptic sho c k ‘ Se ve re se psis’ b e c o me s supe rfluo us Gre a te r c o nc e rn fo r a nd tre a tme nt o f the pa tie nt
sho uld o c c ur with ‘ se psis’ witho ut ne e ding the a dditio na l a dje c tive
Adult vs. Pe dia tric Po pula tio n
Upda te d de finitio ns a re fo r a dult po pula tio ns o nly Pe dia tric pa tie nts c o mprise a c o mplic a te d sub se t o f
se psis pa tie nts
Due to a g e -de pe nde nt va ria tio ns in physio lo g ic
ra ng e s a nd re spo nse s
T
a sk F
de finitio ns in pe dia tric pa tie nts
Additio n o f q SOF A
Additio n o f q SOF
A
As a Sc re e ning T
As a Pre dic to r o f Mo rta lity
Additio n o f q SOF A – Sc re e ning T
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
AMS is de fine d a s Gla sg o w Co ma Sc a le <15 Sc o re is c o nside re d to b e po sitive if a t le a st 2 o f the c rite ria
a re me t
Do e s no t inc lude a me a sure me nt o f la c ta te o r a ny o the r la b
te sts
Additio n o f q SOF A – Sc re e ning T
T
he T a skfo rc e re c o mme nds use o f q SOF A to pro mpt c linic ia ns to :
F
urthe r inve stig a te fo r o rg a n dysfunc tio n
I
nitia te o r e sc a la te the ra py a s a ppro pria te
Co nside r re fe rra l to c ritic a l c a re o r inc re a se the
fre q ue nc y o f mo nito ring , if no t a lre a dy do ne
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
Additio n o f q SOF A –Pre dic tive Va lue
As a pre dic to r o f mo rta lity
Within the I
CU, SOF A is b e tte r tha n q SOF A
Outside the I
CU, q SOF A is simila r to SOF A
q SOF
A ide ntifie s a dult pa tie nts with infe c tio n who a re mo re like ly to ha ve po o r o utc o me s
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
Additio n o f q SOF A –Pre dic tive Va lue
In ICU Out of ICU
SOF A 74% 79% Cha ng e in SOF A 72% 79% SI RS 64% 76% q SOF A 66% 81% L ODS* 75%
ODS=L
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
Co nsiste nc y vs. Co mple xity Pre dic tio n vs. E
a rly Re c o g nitio n
Pra c tic a litie s o f Co ding fo r Se psis
Co nsiste nc y
Co nsiste nc y o f de finitio ns impro ve d se ve re se psis a nd se psis we re c o mmo nly use d
inte rc ha ng e a b ly
I
t ma y b e a b e tte r pre dic to r o f po o r o utc o me s
T
he c ha ng e ma y a id in the a sse ssme nt o f ne w the ra pie s.
Co mple xity
SOF
A sc o re c a n b e c o mple x
SOF
A sc o re is no t wide ly use d o utside c ritic a l c a re units.
I
t ma ke s se psis a c ritic a l c a re de finitio n
E
ve n tho ug h mo st pa tie nts with se psis a re no t in c ritic a l c a re
E
a rly re c o g nitio n a nd tre a tme nt is a pro ve n stra te g y in re duc ing se psis-re la te d de a ths
T
he ne w de finitio n c o uld le a d to de la ys in dia g no sis a nd in initia tio n o f tre a tme nt
T
he re is no pro spe c tive da ta to suppo rt its use … ye t
Pre dic tio n vs. E
a rly Re c o g nitio n
Altho ug h SOF
A sc o re s c a rry pre dic tive va lue , it is no t a s va lua b le in e a rly re c o g nitio n, whic h o fte n o c c urs
CU
E
a rly re c o g nitio n re q uire s Sc re e ning fo r se psis
Using SI
RS c rite ria
Ra ise d E
a rly Wa rning sc o re s
Or using q SOF
A
No t pro spe c tive ly va lida te d… ye t
Pra c tic a litie s o f Co ding fo r Se psis
T
he T a sk F
se psis b a se d o n the ne w de finitio ns a nd I CD-10 c o de s
T
his ha s no t ye t b e e n tra nsla te d into pra c tic a l instruc tio ns fo r c linic a l c o de rs
Co de rs a re no t a b le to use SOF
A sc o re s a nd infe c tio n to c o de fo r se psis
Co ding fo r se psis will still de pe nd o n c linic ia ns
writing the dia g no sis in the no te s
Na tio na l inc e ntive s to impro ve se psis ma y b e a ffe c te d
So me c o untrie s ma y ha ve e xisting pro g ra ms a nd
inc e ntive s to impro ve se psis ma na g e me nt
Ac hie ve me nt o f a g re e d ta rg e ts ma y ha ve sig nific a nt
fina nc ia l implic a tio ns fo r ho spita ls
Ho spita ls sho uld e nsure tha t imple me nta tio n o f Se psis-3
do e s no t je o pa rdize a c hie ve me nt o f the ir ta rg e ts
T
his ma y ha ve a de trime nta l e ffe c t o n re so urc e s fo r se psis ma na g e me nt.
Cha ng e in se psis po pula tio n a nd impa c t o n
Se psis impro ve me nt pro je c ts sho uld c o nside r ho w
imple me nta tio n o f the ne w se psis de finitio ns ma y a ffe c t the ir o utc o me s
Cha ng e s in o utc o me s ma y b e re la te d to a c ha ng e in
se psis po pula tio n ra the r tha n impro ve me nts in c a re .
T
he ne w de finitio ns he lp se pa ra te Simple Infe c tion fro m
Se psis fro m Se ptic shoc k
T
he ne w de finitio ns a re de sig ne d to pic k o ut pa tie nts who fa re d b a dly o r “re a lly sic k pa tie nts with infe c tio n”.
T
he te rm “se ve re se psis” is no lo ng e r b e use d.
SOF
A sc o re is a b e tte r pre dic to r o f mo rta lity in I CU tha n q SOF A o r SI RS
q SOF
A a nd SI RS a re e q uiva le nt to SOF A a s pre dic to rs o f mo rta lilty o utside the I CU, a nd fa r e a sie r to c o mpute
SOF
A sc o re he lps de fine o rg a n dysfunc tio n in a c o nsiste nt a nd re pro duc ib le ma nne r
T
he se de finitio ns a nd q SOF A a re no t pro spe c tive ly va lida te d ye t
T
he de finitio ns a re no t va lid in Pe dia tric pa tie nts ye t
T
he de finitio ns ma y a ffe c t na tio na l inc e ntive s re la te d to se psis impro ve me nt pro je c ts in te rms o f c o mpa riso n o f
Sing e r M, e t. a l. JAMA 2016; 315 (8): 801-810
I
t is impo rta nt to ma inta in the fo c us o n ide ntifying infe c tio n e a rly a nd sta rting tre a tme nt b e fo re o rg a n dysfunc tio n o c c urs
A pro spe c tive ly va lida te d sc re e ning to o l tha t is b e tte r
tha n SI RS is no t ye t a va ila b le
T
he sc re e ning a nd dia g no stic to o ls we use fo r se psis must pro vide va lua b le info rma tio n in
Re so urc e -po o r a s we ll a s re so urc e -ric h se tting s Adult a s we ll a s Pe dia tric po pula tio ns
L e a rning Asse ssme nt Que stio ns
A is the ne w de finitio n o f se psis.
rue
a lse
(Answe r B is the c o rre c t a nswe r b e c a use q SOF A is a sc re e ning to o l no t the de finitio n o f se psis.)
he ne w de finitio n fo r se ptic sho c k ide ntifie s pa tie nts with a n in ho spita l mo rta lity o f ___.
A. >10% B. >20% C. >30% D. >40%
(Answe r D is the c o rre c t.)