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Definition: Sepsis-3
Prof. Dr. Frank M. Brunkhorst
Jena University Hospital
Early Goal Directed Therapy (EGDT)
1
Sepsis-1:
The “old” sepsis definitions
Early Goal Directed Therapy (EGDT)
Sepsis - 1
“SEPSIS-1”
“SEPSIS-2”
Early Goal Directed Therapy (EGDT)
Sepsis - 1
PANCREATITIS
BACTEREMIA
POST-PUMP SYNDROME
INFECTION SIRS
FUNGEMIA TRAUMA
SEPSIS
PARASITEMIA
BURNS
VIREMIA
OTHER OTHER
781,725
118,676
??? over-reported
??? under-reported
300,270 213,124
Hospitalizations for which certain infection codes were listed as a primary diagnosis, 2003–2011.
N ENGL J MED 2014; 370:1673-1676
Early Goal Directed Therapy (EGDT)
Sepsis - 1
Mortality
increased linearly
with each
additional SIRS
criterion without
any transitional
increase in risk at
a threshold of two
SIRS criteria.
2
Sepsis-3:
The new sepsis definitions
Early Goal Directed Therapy (EGDT)
Sepsis - 3
SEPSIS-3
Early Goal Directed Therapy (EGDT)
Sepsis - 3
Relationship of Organ Dysfunction, Sepsis and Infection
PANCREATITIS
TRAUMA
BACTEREMIA
BURNS
VIREMIA
OTHER OTHER
“Tradition is
not holding
the ashes but
passing on the
flame ."
Thomas Morus
07. 02. 1478 - London,
† 06. 07. 1535 - London,
englischer Staatsmann, humanistischer
Autor, Heiliger der Römisch-
Katholischen Kirche (Gedenktag 22. Juni)
und Patron der Regierenden
Early Goal Directed Therapy (EGDT)
Sepsis - 3
http://qsofa.org/
Early Goal Directed Therapy (EGDT)
Sepsis - 3
Importance
The 3rd International Consensus Definitions Task
Force defined sepsis as “life-threatening organ
dysfunction due to a dysregulated host response
to infection.”
JAMA. 2016;315(8):762-774
Early Goal Directed Therapy (EGDT)
Sepsis - 3
JAMA. 2016;315(8):762-774
Early Goal Directed Therapy (EGDT)
Sepsis - 3
JAMA. 2016;315(8):762-774
Early Goal Directed Therapy (EGDT)
Sepsis - 3
JAMA. 2016;315(8):762-774
Early Goal Directed Therapy (EGDT)
Sepsis - 3
245 627 873 803 588 397 251 135 174 329 377 925 774 552 488 283 354
N 261 996 2,454 2,857 1,364 N 458 778 862 692 467 310 170 102 N 604 696 682 868 549 287 164 N 173 1,195 3,175 3,389
o o o o
JAMA. 2016;315(8):762-774
. SIRS . SOFA . LODS . qSOFA
27,560 9,690 3,326 1,047 418 163 90 41 31 29,789 4,429 4,426 1,088 442 211 118 122
N 20,130 22,357 15,852 6,777 1,406 N 16,067 5,013 1,992 625 238 111 72 20 N 15,085 7,878 1,600 788 366 128 52
N 31,010 24,393 9,327 1,792
o o o o
. SIRS . SOFA . LODS . qSOFA
Early Goal Directed Therapy (EGDT)
Sepsis - 3
Results 4
Relative to qSOFA scores lower than 2, encounters with qSOFA
scores of 2 or higher had a 3- to 14-fold increase in hospital
mortality across baseline risk deciles.
Findings were similar in external data sets and for the
secondary outcome.
qSOFA mortality (%)
0 ~1
1 ~3
2 ~8-10
3 >20
JAMA. 2016;315(8):762-774
Early Goal Directed Therapy (EGDT)
Sepsis - 3
JAMA. 2016;315(8):762-774
Early Goal Directed Therapy (EGDT)
Sepsis - 3
• A. qSOFA Variablen B. SOFA Variablen
Patient mit Atemfrequenz • PaO2/FiO2 Ratio
V.a. Infektion • Bewusstsein • Glasgow Coma Scale
• Systolischer Blutdruck • Mittlerer art. Blutdruck
• Gabe von Vasopressoren
Nein Nein
• mit Präparat und Infusionsrate
Klinik überwachen;
qSOFA 2? Weiterhin V.a.
Reevaluation für mögliche
• Serum-Kreatinin u. Urinvolumen
Siehe A Sepsis Sepsis falls klinisch indiziert
• Bilirubin
• Thrombozyten
Ja
Ja
Organdysfunktion
erfassen
Septischer Schock
Nein
Ja
Klinik überwachen;
SOFA 2? Reevaluation für mögliche
Siehe B Sepsis falls klinisch indiziert Trotz adäquater Volumengabe:
1. Vasopressorengabe erforderlich um bei
Ja Ja persistierender Hypotonie einen mittleren
Sepsis arteriellen Druck 65 mmHg aufrecht zu
erhalten
Nein Und
2. Serumlaktat 2 mmol/l (18 mg/dl)
JAMA. 2016;315(8):762-774
Early Goal Directed Therapy (EGDT)
Sepsis - 3
Early Goal Directed Therapy (EGDT)
Sepsis - 3
qSOFA, SIRS, and Early Warning Scores for Detecting Clinical
Deterioration in Infected Patients Outside the ICU
CONCLUSIONS:
qSOFA is better than CRB-65 for identification of a high risk of mortality and requirement of
ICU admission.
Chen XY et al. Crit Care. 2016 Jun 1;20(1):167. doi: 10.1186/s13054-016-1351-0.
Early Goal Directed Therapy (EGDT)
Sepsis - 3
Predictive value of qSOFA, SIRS in patients with
suspected infection in a resource limited setting in
Gabun
1-specificity sensitivity
AUROC 0.83
Huson MAM et al.Travel Med Infect Dis 2016 (ePub)
Early Goal Directed Therapy (EGDT)
Summary qSofa
Conclusions
SEPSIS-3 offers (we hope) objectivity, reproducibility and
generalizability for research, for coding, for epidemiology ..
definitions don’t change patient management - clinicians do!
qSOFA may be a useful bedside prompt to highlight at-risk
patients
- needs prospective validation
- embedded within NEWS (standard-of-care EWS in UK)
NOT the final word - it’s an iterative process ..
- Sepsis-4 will improve on Sepsis-3
.. but I do hope it is progress!!!
Early Goal Directed Therapy (EGDT)
http://www.zks.uniklinikum-jena.de/