PAPER

Sepsis in General Surgery

The 2005-2007 National Surgical Quality Improvement Program Perspective
Laura J. Moore, MD; Frederick A. Moore, MD; S. Rob Todd, MD; Stephen L. Jones, MD;
Krista L. Turner, MD; Barbara L. Bass, MD

Objective: To document the incidence, mortality rate,
and risk factors for sepsis and septic shock compared with
pulmonary embolism and myocardial infarction in the
general-surgery population.
Design: Retrospective review.
Setting: American College of Surgeons National Surgi-
cal Quality Improvement Program institutions.
Patients: General-surgery patients in the 2005-2007 Na-
tional Surgical Quality Improvement Program data set.
Main Outcome Measures: Incidence, mortality rate,
and risk factors for sepsis and septic shock.
Results: Of 363 897 general-surgery patients, sepsis oc-
curred in 8350 (2.3%), septic shock in 5977 (1.6%), pul-
monary embolism in 1078 (0.3%), and myocardial in-
farction in 615 (0.2%). Thirty-day mortality rates for each
of the groups were as follows: 5.4% for sepsis, 33.7% for
septic shock, 9.1% for pulmonary embolism, and 32.0%
for myocardial infarction. The septic-shock group had a
greater percentage of patients older than 60 years (no sep-
sis, 40.2%; sepsis, 51.7%; and septic shock, 70.3%;
P⬍ .001). The need for emergency surgery resulted in
more cases of sepsis (4.5%) and septic shock (4.9%) than
did elective surgery (sepsis, 2.0%; septic shock, 1.2%)
(P⬍ .001). The presence of any comorbidity increased
the risk of sepsis and septic shock 6-fold (odds ratio, 5.8;
95% confidence interval, 5.5-6.2) and increased the 30-
day mortality rate 22-fold (odds ratio, 21.8; 95% confi-
dence interval, 17.6-26.9).
Conclusions: The incidences of sepsis and septic shock
exceed those of pulmonary embolism and myocardial in-
farction. The risk factors for mortality include age older
than 60 years, the need for emergency surgery, and the
presence of any comorbidity. This study emphasizes the
need for early recognition of patients at risk via aggres-
sive screening and the rapid implementation of evidence-
based guidelines.
Arch Surg. 2010;145(7):695-700

Author Affiliations:
Department of Surgery, The
Methodist Hospital, Weill
Cornell Medical College,
Houston, Texas.
P
REVENTION OF PERIOPERA -
tive complications is a ma-
jor focus in the care of the
general-surgery patient. In
recent years, much atten-
tion has focused on the prevention of ve-
nous thromboembolism (postoperative
deep vein thrombosis and pulmonary em-
bolism [PE]), postoperative myocardial in-
farction (MI), and surgical site infections
CME available online at
www.jamaarchivescme.com
and questions on page 615
(SSIs). Through education and increased
awareness, there has been a significant re-
duction in the incidence of postoperative
venous thromboembolism. 1 Likewise,
preoperative cardiovascular evaluation
and risk assessment of elective general-
surgery patients have become standards
of care. The issue of SSIs has been ad-
dressed through national guidelines.2 Mini-
mizing the occurrence of these poten-
tially preventable complications improves
patient outcomes and reduces health care
costs.
Within our institution, we have iden-
tified surgical sepsis to be a potentially pre-
ventable cause of morbidity and mortal-
ity in our general-surgery patients. Severe
sepsis and septic shock are the leading
causes of multiple organ failure and mor-
tality in noncoronary intensive care units
(ICUs).3 It is estimated that in the United
States there are 751 000 cases per year of
sepsis, with an annual cost of $17 bil-
lion.4 By 2010, it is estimated that there
will be 934 000 cases per year.3 Unfortu-
nately, despite tremendous basic and clini-
cal research efforts, mortality from septic
shock remains unchanged at greater than

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Table 1. NSQIP Definitions of Sepsis and Septic Shock
Sepsis (SIRS and infection)
SIRS criteria (ⱖ2 must be present)
Temperature ⬎38°C or ⬍36°C
Heart rate ⬎90/min
Respiratory rate ⬎20/min or PaCO2 ⬍32 mm Hg
White blood cell count ⬎12 000/µL (12.0 ⫻ 109/L) or ⬍4000/µL
(4.0 ⫻ 109/L) or ⬎10% bands
Infection
Positive blood culture or
Purulence or positive culture from any site thought to be causative
Septic shock (sepsis and organ or circulatory dysfunction)
Organ dysfunction(s)
Oliguria
Acute alteration of mental status
Acute respiratory distress
Circulatory dysfunction(s)
Hypotension
Requirement of inotropic or vasopressor agents
Abbreviations: NSQIP, National Surgical Quality Improvement Program;
SIRS, systemic inflammatory response syndrome.
50%.5 Early intervention and implementation of evidence-
based guidelines have been demonstrated to improve out-
comes in patients with sepsis.6,7 However, effective in-
tervention is contingent on the early identification of
sepsis.
In an attempt to improve the early identification of
sepsis, we have developed and instituted a sepsis
screening tool for use in our surgical ICU (SICU).8 The
use of this tool and implementation of early evidence-
based care through computerized clinical decision sup-
port resulted in a substantial decrease in the rate of
mortality from severe sepsis and septic shock.8 On the
basis of this experience, we believe that sepsis screening
could potentially prevent sepsis-associated morbidity
and mortality in the general-surgery population. Before
advocating mandatory sepsis screening programs in
general-surgery patients, we need to further character-
ize and understand sepsis in these patients. Further-
more, we need to document the relative incidence and
associated mortality of sepsis compared with the more
commonly addressed preventable causes of postopera-
tive mortality. The objective of this study was to docu-
ment the incidence, mortality, and risk factors for sep-
sis and septic shock compared with PE and MI in the
general-surgery population.
METHODS
This study is an analysis of prospectively collected data from
the American College of Surgeons National Surgical Quality Im-
provement Program (NSQIP) data set. The 2005-2007 NSQIP
data set contains prospectively gathered clinical data and out-
comes on 363 897 patients collected from 121 academic and
community-based hospitals. The NSQIP compiles data on
239 variables, including preoperative, intraoperative, and
30-day postoperative variables, for patients undergoing surgi-
cal procedures in inpatient and outpatient settings (a sample
of general-surgery cases using an 8-day cycle). All data are col-
lected by an institutional surgical clinical nurse reviewer, who
receives extensive training in the NSQIP methods and data col-
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lection. All variables that are gathered in the NSQIP are pre-
defined in the NSQIP data dictionary.
The 2005-2007 NSQIP Participant Use File was queried for
demographics, comorbidities, elective vs emergency case, and
30-day mortality in general-surgery patients. Patients having
severe sepsis and septic shock are classified in the NSQIP data
set as the septic-shock stratum, whereas patients having only
sepsis are classified as the sepsis stratum. Patients without either
sepsis or septic shock are classified as the no-sepsis stratum.
This strategy was adopted by NSQIP to avoid counting pa-
tients who had severe sepsis and septic shock twice. The NSQIP
data dictionary defines sepsis as the systemic inflammatory re-
sponse syndrome with a documented infection and defines sep-
tic shock as sepsis and documented organ and/or circulatory
dysfunction. The NSQIP definition of septic shock captures those
patients who are defined as having severe sepsis by the Ameri-
can College of Chest Physicians/Society of Critical Care Medi-
cine Consensus Conference Guidelines.9 Detailed descrip-
tions of the NSQIP definitions are presented in Table 1. From
the NSQIP data set, we were unable to determine the source of
the sepsis.
A PE is defined by the NSQIP as “lodging of a blood clot in
a pulmonary artery with subsequent obstruction of blood sup-
ply to the lung parenchyma.”10p31 The NSQIP data dictionary
defines a postoperative MI as “a new transmural acute myo-
cardial infarction occurring during surgery or within 30 days
as manifested by new Q-waves on ECG [electrocardiogram].”10p28
It also states, “The blood clots usually originate from the deep
leg veins or the pelvic venous system within 30 days of the op-
eration. PE documented if the patient has a ventilation-
perfusion scan interpreted as high probability of PE or a posi-
tive computed tomography spiral exam, pulmonary arteriogram,
or computed tomography angiogram. Treatment usually con-
sists of initiation of anticoagulation therapy or placement of
mechanical interruption (eg, Greenfield filter), for patients whom
anticoagulation is contraindicated or already instituted.”10p31
Patient body mass index (BMI) was calculated as weight in
kilograms divided by height in meters squared. Patient rec-
ords that were missing the weight or height were classified as
unknown BMI. The patients were then stratified by their BMI
following the 5 major categories of underweight, normal, over-
weight, obese, and severely obese (obese class III) as defined
by the World Health Organization BMI classification guide-
lines.11 The classification breakdown for BMI is as follows: less
than 18.50 is classified as underweight, between 18.50 and 24.99
as normal, between 25.00 and 29.99 as overweight, between
30.00 and 39.99 as obese, and 40.00 or higher as severely obese.
Patients were further categorized by ethnicity and age. Pa-
tients were classified based on their NSQIP-defined ethnicity.
After initial data explorations, it was clear that patients older
than 60 years formed a significant stratum of their own; thus,
we stratified patients according to their age by whether or not
they were older than 60 years at the time of the operation. Simi-
larly, patients were categorized by whether the procedure was
an emergency or elective. From the NSQIP data set, we were
unable to determine whether the sepsis occurred before or af-
ter the emergency surgical procedures.
In comparing the study groups, a ␹2 analysis was used for
categorical data. Generalized linear models were used to cal-
culate the adjusted relative risk between the presence of any
of the NSQIP-documented comorbidities and risk of develop-
ing sepsis, septic shock, or 30-day mortality after adjustment
for age, sex, ethnicity, BMI, and emergency case.12 P ⬍ .05 was
considered statistically significant. Stata statistical software, ver-
sion 10 (StataCorp LP, College Station, Texas), was used for
all statistical analyses. The review of data was approved by The
Methodist Hospital Research Institute.
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 Table 2. Demographic Characteristics of the Population a 9000 8350
(2.3%) Incidence
8000 Mortality
No. (%)
7000
5977
Septic (1.6%)
No Sepsis Sepsis Shock 6000

No. of Patients
Characteristics (n=349 570) (n=8350) (n=5977)
5000
Male sex 147 120 (42.1) 4248 (50.9) 3179 (53.2)
4000
Age, y
ⱕ19 5265 (1.5) 60 (0.7) 10 (0.2) 3000
2012
20-59 203 788 (58.3) 3975 (47.6) 1767 (29.6) (33.7%)
ⱖ60 140 517 (40.2) 4315 (51.7) 4200 (70.3) 2000 1078
(0.3%) 615
Ethnicity 1000 449
(5.4%) 98 (0.2%) 193
White 247 361 (70.8) 5982 (71.6) 4356 (72.9) (9.1%) (32.07%)
Asian or Pacific Islander 6472 (1.9) 140 (1.7) 101 (1.7) 0
Sepsis Septic Shock Pulmonary Myocardial
African American 33 548 (9.6) 1128 (13.5) 740 (12.4) Embolism Infarction
Hispanic 26 543 (7.6) 466 (5.6) 339 (5.7)
Group
American Indian 3230 (0.9) 47 (0.6) 34 (0.6)
Unknown 32 416 (9.3) 587 (7.0) 407 (6.8)
BMI b Figure. Incidence and mortality by group.
Underweight (⬍18.50) 8272 (2.4) 421 (5.0) 355 (5.9)
Normal (18.50-24.99) 95 022 (27.2) 2419 (29.0) 1744 (29.2)
Overweight (25.00-29.99) 102 841 (29.4) 2251 (27.0) 1565 (26.2) Table 3. Top 5 Operative Procedures for Sepsis
Obese (30.00-39.99) 90 532 (25.9) 2034 (24.4) 1357 (22.7) and Septic Shock
Severely obese (ⱖ40.00) 37 605 (10.8) 790 (9.5) 533 (8.9)
Unknown 15 298 (4.4) 435 (5.2) 423 (7.1)
Smoking 72 979 (20.9) 2179 (26.1) 1560 (26.1) Sepsis Septic Shock
Drinking 8875 (2.5) 335 (4.0) 301 (5.0) Partial removal of colon Partial removal of colon
Removal of small intestine Removal of small intestine
Abbreviation: BMI, body mass index (calculated as weight in kilograms Arterial bypass graft Arterial bypass graft
divided by the height in meters squared). Partial removal of pancreas Removal of colon
a Data are presented as number (percentage). Percentages may not total 100
Removal of colon Exploration of abdomen
because of rounding. P ⬍.001 for all characteristics.
b Data unavailable for 37 605 patients.

groups (no sepsis, 0.6%; sepsis, 4.0%; and septic

RESULTS
The 2005-2007 NSQIP data set contains information on
363 897 general-surgery patients. Of these, 349 570
(96.1%) had no sepsis, 8350 (2.3%) had sepsis, and 5977
(1.6%) had septic shock. Pulmonary embolism oc-
curred in 1078 patients (0.3%) and MI in 615 (0.2%).
The demographic breakdown for the entire population
is listed in Table 2. The septic-shock group had a greater
percentage of patients older than 60 years (no sep-
sis, 40.2%; sepsis, 51.7%; and septic shock, 70.3%;
P⬍.001). The incidence of sepsis and septic shock in elec-
tive cases was 2.0% and 1.2%, respectively, compared with
4.5% and 4.9%, respectively, for sepsis and septic shock
in emergency cases (P ⬍ .001). The sepsis and septic-
shock groups had a higher incidence of patients with 1
or more NSQIP comorbidities (no sepsis, 69.0%; sep-
sis,90.2%; and septic shock, 96.4%; P ⬍.001). The pres-
ence of any of the NSQIP-documented comorbidities in-
creased the odds of developing sepsis and septic shock
by 6-fold (odds ratio [OR], 5.8; 95% confidence interval
[CI], 5.5-6.2). In addition, the presence of any comor-
bidity when compared with patients without comorbidi-
ties increased the risk of 30-day mortality 22-fold
(OR,21.8; 95% CI, 17.6-26.9). Thirty-day mortality rates
for each of the groups were as follows: no sepsis, 1.1%;
sepsis, 5.4%; and septic shock, 33.7% (vs 9.1% for PE and
32.0% for MI). The incidence and mortality rates for the
groups are depicted in the Figure. The 30-day mortal-
ity of sepsis and septic shock within the elective case
shock,30.0%; P ⬍ .001) and the emergency-case groups
(no sepsis,4.9%; sepsis,9.4%; and septic shock,39.3%;
P ⬍ .001) were different, but patients with septic shock
in elective and emergency cases had a similar high mor-
tality rate. The development of sepsis increased the risk
of 30-day mortality 4-fold (OR,3.9; 95% CI, 3.5-4.3). The
development of septic shock increased the risk of 30-
day mortality 33-fold (OR,32.9; 95% CI, 30.9-35.1). The
operative procedures most commonly associated with
sepsis and septic shock are listed in Table 3.
COMMENT
Minimizing mortality by preventing postoperative com-
plications is a key component of surgical care. In recent
years there has been an increasing focus on minimizing
the risk of perioperative complications, including ve-
nous thromboembolism, perioperative cardiac events, and
SSIs. Multiple professional organizations have pub-
lished guidelines addressing these issues.2,13,14 There is
no question that the implementation of these guidelines
has reduced the occurrence of these perioperative ad-
verse events and subsequent mortality. However, the find-
ings of this study demonstrate that sepsis continues to
be a common and serious complication in general-
surgery patients and occurs much more frequently than
PE and MI. Of note, septic shock occurs 10 times more
frequently than MI and has the same mortality rate; thus,
it kills 10 times more people. These findings are consis-
tent with other studies15-17 demonstrating that sepsis con-

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 tinues to be a major cause of morbidity and mortality in
surgical patients.
Surgical site infections are defined as infections oc-
curring up to 30 days after surgery and affecting either
the incision or deep tissue at the operative site.18 Surgi-
cal site infections are the second most common nosoco-
mial infection in hospitalized patients, occurring in at least
2% of those undergoing surgical procedures.19 The Cen-
ters for Disease Control and Prevention have estab-
lished guidelines to address the issue of SSI.2 These guide-
lines focus on a bundle approach, ie, optimization of
patient factors, antisepsis in the operating room, admin-
istration of prophylactic antibiotics, and postoperative
incision care.2 Although these initiatives can decrease the
occurrence of SSI, they fail to address the systemic role
of sepsis, of which SSIs are only a low-risk subset of po-
tential causes. In particular, these guidelines fall short
of addressing the issue of postoperative surveillance for
the development of sepsis.
Within our institution, we have identified sepsis to be
a major cause of morbidity and mortality in our general-
surgery patients. As a result, our multidisciplinary sep-
sis research team has developed a sepsis-management pro-
tocol that uses computerized clinical decision support to
ensure timely and consistent implementation of the evi-
dence-based guidelines for the management of sepsis.20
Through our initial experience with implementation of
our computerized clinical decision support sepsis-
management protocol, we encountered the unantici-
pated problem of untimely and inaccurate recognition
of sepsis by bedside physicians. The need for routine, ac-
curate screening of all SICU patients for sepsis quickly
became apparent. In an attempt to increase the early iden-
tification of sepsis, we developed a sepsis screening tool
in our SICU.8 This tool is based on graded derange-
ments in 4 variables that define the systemic inflamma-
tory response syndrome: heart rate, white blood cell count,
temperature, and respiratory rate. The ranges for these
4 variables are based on the Acute Physiology and Chronic
Health Evaluation II scoring system.21 Our initial expe-
rience with this tool in our SICU showed promising re-
sults. The tool yielded a sensitivity of 96.5%, a specific-
ity of 96.7%, a positive predictive value of 80.2%, and a
negative predictive value of 99.5%. In addition, sepsis-
related mortality decreased from 35.1% to 23.3%.8 On
the basis of this experience, we have expanded use of the
tool to our surgical ward and are currently evaluating its
applicability in the non-ICU setting.
Although implementing mandatory sepsis screening
on the inpatient surgical floor is likely to improve the early
recognition of sepsis and allow for implementation of ap-
propriate evidence-based care, implementing a system-
wide screening protocol would require a significant
amount of health care resources. By identifying risk fac-
tors for the development of sepsis and septic shock in
general-surgery patients, we can better allocate the avail-
able resources and focus screening on those patients most
likely to develop sepsis and/or septic shock. Previously
identified risk factors for early death from sepsis delin-
eated by a French ICU group include low blood pH, shock,
preexisting liver or cardiac insufficiency, and hypother-
mia.22 In addition, a recent epidemiologic study23 of pa-
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tients with septic shock from ventilator-associated pneu-
monia identified advanced age, lymphocytopenia, high
blood glucose levels, and increased clinical pulmonary
infection scores as independent predictors of the devel-
opment of septic shock. The findings of advanced age and
preexisting liver or cardiac insufficiency from these stud-
ies are consistent with our findings.
Our analysis of the NSQIP data set identified 3 major
risk factors for the development of sepsis and septic
shock and mortality from sepsis and septic shock: age
older than 60 years, the need for emergency surgery,
and the presence of any comorbidity. The association
between age, the presence of comorbid conditions, and
the need for emergency surgery and development of
sepsis or septic shock has been demonstrated in larger
epidemiologic studies.4,5,24 However, these studies were
retrospective analyses of International Classification of
Diseases, Ninth Revision (ICD-9)25 discharge data from
state databases. These findings suggest that those pa-
tients with any of these 3 factors warrant a high index of
suspicion for the development of sepsis and that this
patient population would most likely benefit from man-
datory sepsis screening.
A healthy respect for these risk factors, in addition to
early sepsis identification by screening, has influenced
our surgical management of this patient population. A
distinct window of early intervention exists in which the
septic source must be eliminated and physiologic de-
rangements corrected. For the postoperative patient whose
sepsis has a nonsurgical source, such as pneumonia or a
urinary tract infection, this goal can be accomplished in
an ICU setting in a straightforward manner. In the set-
ting of abdominal surgical sepsis, however, this issue be-
comes more complicated. This patient often requires emer-
gency exploration for source control but loses valuable
resuscitation time on the operating room table with on-
going heat, intravenous volume, and blood loss. In this
context, our practice has focused more on damage-
control surgery in the setting of septic shock. We have
used this concept for patients with de novo intra-
abdominal sepsis and patients with postoperative ab-
dominal complications requiring surgery. Of note, this
surgery is performed for only those patients with signifi-
cant physiologic derangements and predefined risk fac-
tors. We continue to further delineate these risk factors
and physiologic cutoffs for truncated laparotomy with
the goal of decreasing the morbidity and mortality of sur-
gical sepsis even further. By incorporating damage-
control surgery into our established sepsis resuscitation
protocol, we are maximizing the paradigm of early goal-
directed sepsis management for our surgical patients.
We identified some limitations involved with work-
ing with the NSQIP data set. The first limitation is the
NSQIP definitions for sepsis and septic shock. The Ameri-
can College of Chest Physicians/Society of Critical Care
Medicine consensus conference definitions of sepsis, se-
vere sepsis, and septic shock9 were developed in an at-
tempt to standardize patient classification. However, the
NSQIP definitions deviate from these consensus confer-
ence standards. Within the NSQIP data dictionary there
is no definition for severe sepsis. Instead, patients with
severe sepsis are classified into the septic-shock cat-
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 egory in the NSQIP. This misclassification of patients
makes it difficult to compare NSQIP patients with those
from other data sets. However, this phenomenon is con-
sistent with our experience: it is sometimes difficult to
differentiate severe sepsis and septic shock. The second
limitation is related to lack of data regarding cause of
death. Although the NSQIP reports mortality, there is not
a defined category for cause of death. This makes it im-
possible to determine whether patients in the data set died
as a result of sepsis or septic shock or from another cause.
That is true of other large data sets: it is difficult to know
the ultimate cause of mortality in patients with multiple
organ failure.
This study demonstrates that the incidence of sepsis
and septic shock far exceeds that of MI and PE in general-
surgery patients. In addition, case mortality rates in pa-
tients with sepsis and septic shock exceed those of MI
and PE combined by nearly 10-fold. Therefore, our level
of vigilance in identifying sepsis and septic shock needs
to mimic, if not surpass, our vigilance for identifying MI
and PE. By identifying 3 major risk factors for the devel-
opment of and death from sepsis and septic shock in gen-
eral-surgery patients, we can heighten our awareness for
sepsis and septic shock in these at-risk populations. The
implementation of mandatory sepsis screening for these
high-risk populations has resulted in decreased sepsis-
related mortality within our institution. Further evalu-
ation of the role of sepsis screening programs in other
settings is critical and could significantly reduce sepsis-
related mortality in general-surgery patients.
Accepted for Publication: March 11, 2010.
Correspondence: Laura J. Moore, MD, Department of Sur-
gery, The Methodist Hospital, Weill Cornell Medical Col-
lege, 6550 Fannin St, Smith Tower 1661, Houston, TX
77030 (ljmoore@tmhs.org).
Author Contributions: Drs L. J. Moore, F. A. Moore,
Todd, and Jones had full access to all the data in the study
and take responsibility for the integrity of the data and
the accuracy of the data analysis. Study concept and de-
sign: L. J. Moore, F. A. Moore, Jones, and Turner. Acqui-
sition of data: Jones, Turner, and Bass. Analysis and in-
terpretation of data: L. J. Moore, F. A. Moore, Todd, Jones,
and Turner. Drafting of the manuscript: L. J. Moore, F. A.
Moore, and Jones. Critical revision of the manuscript for
important intellectual content: L. J. Moore, F. A. Moore,
Todd, Jones, Turner, and Bass. Statistical analysis: Jones.
Administrative, technical, and material support: Todd, Jones,
Turner, and Bass. Study supervision: L. J. Moore, F. A.
Moore, and Turner.
Financial Disclosure: None reported.
Funding/Support: This study was supported by The Meth-
odist Hospital Research Institute, Houston, Texas.
Disclaimer: The American College of Surgeons National
Surgical Quality Improvement Program and the hospi-
tals participating in the National Surgical Quality Improve-
ment Program are the source of the data used herein; they
have not verified and are not responsible for the statisti-
cal validity of the data analysis or the conclusions derived
by the authors.
Previous Presentation: This paper was presented at the
117th Scientific Session of the Western Surgical Asso-
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ciation; November 11, 2009; San Antonio, Texas; and is
published after peer review and revision. The discus-
sions that follow this article are based on the originally
submitted manuscript and not the revised manuscript.
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WWW.ARCHSURG.COM
 22. Brun-Buisson C, Doyon F, Carlet J, et al; French ICU Group for Severe Sepsis. 3. You documented 3 risk factors for higher mortality: age
Incidence, risk factors, and outcome of severe sepsis and septic shock in adults: older than 60, any comorbidity, and the need for emergency
a multicenter, prospective study in intensive care units. JAMA. 1995;274(12): surgery. None of these seem to be of the nature or sort that
968-974.
we as clinicians can affect. And perhaps the emergency sur-
23. Aydogdu M, Gursel G. Predictive factors for septic shock in patients with ventilator-
associated pneumonia. South Med J. 2008;101(12):1222-1226.
gery was in fact done to treat sepsis or a closed-space infec-
24. Vogel TR, Dombrovskiy VY, Lowry SF. Trends in postoperative sepsis: are we tion. So what then should we do with this information of risk
improving outcomes? Surg Infect (Larchmt). 2009;10(1):71-78. factors?
25. World Health Organization. International Classification of Diseases, Ninth Revi- 4. Since NSQIP is meant to be a quality improvement/
sion (ICD-9). Geneva, Switzerland: World Health Organization; 1977. quality assurance analysis, can you provide any information on
the quality of care for those patients who developed sepsis or
septic shock? Were they effectively treated? Did they receive
DISCUSSION
the correct and timely antibiotics? Was there timely surgical
management of closed-space infections?
Gregory J. Jurkovich, MD, Seattle, Washington: Drs Moore
I appreciate the effort gone into the analysis of the NSQIP
and colleagues have shown us compelling data from the Ameri-
database and the recognition of the limitations that can and do
can College of Surgeon’s NSQIP demonstrating that sepsis and
occur with any and all administrative databases. This is an-
septic shock are a significant problem in the surgical patient. This
other example of the power of large numbers, as it gives us good
likely comes as no surprise to any surgeon in this audience. What
insight into the magnitude of the problem of sepsis in the sur-
may be more surprising is the severity of the problem. Overall,
gical patient.
nearly 4% of the 363 000 patients analyzed over this 3-year time
Dr Todd: As for your first question, is there a magic bullet?
frame were diagnosed with sepsis or septic shock. This is
Unfortunately, no, but we have developed a sepsis screening
20-fold higher than the 0.2% incidence of pulmonary embolus
tool based on the systemic inflammatory response syndrome
and 15-fold higher than the 0.3% incidence of MI. While these
criteria and the Acute Physiology and Chronic Health Evalu-
data do not necessarily support the contention made in the title
ation II cut points, which is quite effective in our SICU. Our
that sepsis and septic shock are preventable, this frequency alone
SICU patients are screened every 12 hours using this tool. If
supports the argument for better screening, intervention, and treat-
they attain a score greater than or equal to 4, a secondary screen
ment tools. This is particularly so, given that the mortality from
is performed by either a midlevel provider or a surgical resi-
sepsis is 5% and for septic shock a remarkable 33%.
dent. The purpose of this evaluation is to validate the pres-
The authors have suggested they have the answer: a better
ence of an infectious source or not. In evaluating this tool sta-
screening tool for the early diagnosis and more rapid effective
tistically, it has a sensitivity and specificity of more than 90%.
interventions in the treatment of sepsis. But what is this screen-
We are currently evaluating this tool on our surgical wards and
ing tool? Dr Todd, I fear you have left the audience hanging,
assessing its validity.
like a chad, or like an anxious schoolgirl waiting for the text
Your second question addressed the timing of the sepsis (pre-
message, or well — the correct analogy clearly escapes me, but
operative or postoperative). In NSQIP, there is no preopera-
what I am trying to ask is, “Where’s the beef?” Is a magical
tive variable for sepsis, so all of these counts of sepsis are post-
screening tool for the early recognition of impending sepsis really
operative.
available? Is it some propriety formula you plan on market-
What are the sources of sepsis? Unfortunately, that is not
ing? Or is it an embarrassment that you have had to resort to
available in NSQIP.
something so simplistic in your ICU that you hesitate to dis-
Regarding the risk factors we identified as significant, you
cuss it publicly? Like paying attention to an elevated white blood
are correct, we cannot adjust these (their age, their need for an
cell count and fever? Less someone misconstrue my com-
emergency procedure, or their comorbidities). Our objective
ments, I am simply teasing the authors, as they have teased us,
here was to identify a high-risk group for screening in our hos-
and asking them to provide us more information.
pital. We have a 1000-bed hospital and realistically cannot af-
I have the following 4 queries for the authors:
ford to screen every patient every 12 hours. These variables
1. When did sepsis or septic shock occur in these pa- should provide us a narrower scope for focusing our limited
tients? Was it always a postoperative problem, or could it have resources.
been a presenting symptom or diagnosis? This has significant Unfortunately, you are correct; the answer is no. One of the
implications for its recognition and interventions. biggest struggles with the Surviving Sepsis Campaign Guide-
2. What was the cause of sepsis? At the very least, can you lines is that clinicians have a difficult time actually interven-
provide us the origin by body regions, such as lungs, gastro- ing and providing the needed therapies in a timely fashion.
intestinal, renal, or soft tissue? Again, this carries significant
implications for diagnosis and treatment. Financial Disclosure: None reported.

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