SLIDE 1
Sarah Vest Cogle, PharmD, BCCCP Assistant Clinical Professor Auburn - - PowerPoint PPT Presentation
Sarah Vest Cogle, PharmD, BCCCP Assistant Clinical Professor Auburn - - PowerPoint PPT Presentation
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
SLIDE 2
SLIDE 3
I have no actual or potential conflict of interest in relation to this program
SLIDE 4
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.
SLIDE 5
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
SLIDE 6
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.
SLIDE 7
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.
SLIDE 8
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.
SLIDE 9
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
SLIDE 10
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
SLIDE 11
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
SLIDE 12
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.
SLIDE 13
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.