Pharmacists: Discuss the rationale for modifications to the sepsis - - PDF document

Sarah Vest Cogle, PharmD, BCCCP Assistant Clinical Professor Auburn University Harrison School of Pharmacy AlSHP Fall Meeting September 30, 2016

Pharmacists:

Discuss the rationale for modifications to the sepsis definitions Describe the updated sepsis definitions (Sepsis‐3)

Technicians:

Define sepsis and septic shock

I have no actual or potential conflict of interest in relation to this program Need to differentiate sepsis from infection Improved understanding of sepsis pathophysiology

Previous definitions focused on SIRS criteria

Variable definitions – inconsistent reporting

Sepsis vs. severe sepsis Sepsis syndrome Septicemia

Singer M, et al. JAMA. 2016;315(8):801‐810. Singer M, et al. JAMA. 2016;315(8):801‐810.

• Life‐threatening organ dysfunction

caused by a dysregulated host response to infection

Sepsis

• Subset of sepsis in which profound

circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone

Septic shock

Sepsis‐1 Sepsis‐2 Sepsis‐3 1991 2001 2016 Sepsis Systemic response to infection with ≥2 SIRS criteria Presence of infection with systemic manifestations of infection Life‐threatening organ dysfunction caused by a dysregulated host response to infection *Severe sepsis removed Severe sepsis Sepsis associated with hypotension, hypoperfusion, or

• rgan dysfunction

Sepsis associated with hypotension, hypoperfusion, or organ dysfunction (unchanged from 1991) Septic shock Sepsis‐induced hypotension persisting despite adequate fluid resuscitation, along with hypoperfusion abnormalities or organ dysfunction Acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes Subset of sepsis in which profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone

Bone RC, et al. Chest. 1992;101:1644‐55. Levy MM, et al. Intensive Care Med. 2003;29:530‐538. Singer M, et al. JAMA. 2016;315(8):801‐810.

qSOFA SOFA

• quick Sequential [Sepsis‐related]

Organ Failure Assessment

• Can be performed quickly

without laboratory values

• Does NOT define sepsis
• Score ≥2 associated with

increased length of ICU stay and mortality

• If ≥2 , elevate further for organ

dysfunction

• Sequential organ failure

assessment

• Can be more difficult to

calculate but laboratory parameters involved are common

• Higher scores = increased

mortality

• Suspected infection + SOFA

change from baseline ≥2 points = sepsis

Seymour CW, et al. JAMA. 2016;315(8):762‐774. Singer M, et al. JAMA. 2016;315(8):801‐810.

Assess for organ dysfunction qSOFA ≥2 SOFA ≥2 Despite adequate fluid resuscitation, 1) Vasopressors required to maintain MAP ≥65 mmHg, AND 2) Serum lactate >2 mmol/L Septic shock Sepsi s Suspected infection No No Yes Yes Sepsis still suspected? Yes Yes No Monitor, re‐evaluate for possible sepsis if indicated Yes Yes No No No No Yes Yes qSOFA Variables:

• Respiratory rate (>22 BPM)
• Mental status
• Systolic blood pressure (<90

mmHg)

SOFA Variables:

• PaO2/FiO2 ratio
• Glasgow Coma Score
• Mean arterial pressure
• Administration of vasopressors
• Serum creatinine or urine output
• Bilirubin
• Platelet count

Adapted from: Singer M, et al. JAMA. 2016;315(8):801‐810.

Surviving Sepsis Campaign response

Screening for early identification and treatment of patients with sepsis (formerly called severe sepsis) should continue Patients with sepsis should still be identified by the same

• rgan dysfunction criteria

Possibility for future use of qSOFA score to identify organ dysfunction

Impact on coding, CMS core measures remains to be fully seen

Surviving Sepsis Campaign. Surviving Sepsis Campaign responds to Sepsis‐3. 2016 Mar 3. Available from: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC‐Statements‐Sepsis‐Definitions‐3‐2016.pdf

A 58 year old female presents to the emergency department with altered mental status, shortness of breath and fever

Ht: 67” Wt: 68 kg T: 102°F RR: 32 BPM HR: 134 BPM BP: 88/44 mmHg BUN 41 mg/dL SCr 2.1 mg/dL WBC 19.4 x 103 cells/m3 Lactate: 4.9 mmol/L Chest X‐ray: infiltrate in right lower lobe

Her blood pressure does not respond to a 2L crystalloid fluid bolus and norepinephrine is initiated How would you classify this patient based on Sepsis‐3 definitions?

• a. Sepsis
• b. Severe sepsis

c. Septic shock

• d. Septicemia

A 58 year old female presents to the emergency department with altered mental status, shortness of breath and fever

Ht: 67” Wt: 68 kg T: 102°F RR: 32 BPM HR: 134 BPM BP: 88/44 mmHg BUN 41 mg/dL SCr 2.1 mg/dL WBC 19.4 x 103 cells/m3 Lactate: 4.9 mmol/L Chest X‐ray: infiltrate in right lower lobe

Her blood pressure does not respond to a 2L crystalloid fluid bolus and norepinephrine is initiated How would you classify this patient based on Sepsis‐3 definitions?

• a. Sepsis
• b. Severe sepsis

c. Septic shock

• d. Septicemia

How would you classify this patient based on Sepsis‐3 definitions?

• a. Sepsis
• b. Severe sepsis

c. Septic shock

• d. Septicemia

Suspected infection (likely pneumonia based on Chest X‐ray, fever, shortness of breath, elevated WBC) with evidence of

• rgan dysfunction that persists despite fluid resuscitation and

elevated lactate (A and B are incorrect). Septicemia (answer D) is incorrect as it is an antiquated term that is not included in the Sepsis‐3 definitions. Septic shock (answer C) is the only correct answer based on this patient’s presentation.

Singer M, et al. JAMA. 2016;315(8):801‐810.

Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.

• Chest. 1992;101:1644‐55.

Levy MM. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med. 2003;29:539‐538. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis‐3). JAMA. 2016;315(8):801‐810. Seymour CW, Liu VX, Iwashyna TJ. Assessment of clinical criteria for sepsis for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis‐3). JAMA. 2016;315(8):762‐774. Surviving Sepsis Campaign. Surviving Sepsis Campaign responds to Sepsis‐3. 2016 Mar 3. Available from: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC‐ Statements‐Sepsis‐Definitions‐3‐2016.pdf