SEPSIS NEW

DEFINITIONS
I MADE AGUS KRESNA SUCANDRA
OUTLINE

 Objective
 History
 Old Definition
 New Definition
 Implication
OBJECTIVES

 Understanding New Definition of SEPSIS

 Related clinical assessment tools
 Recognize the rationale the new definitions for SEPSIS and SEPTIC
SHOCK
 Understand the relationship of the new sepsis DEFINITION to
BEDSIDE SCREENING and TREATMENT
INTRODUCTION

 σήψις (sipsi)
 4th century BC : introduced by Hippocrates
 the process of decay or decomposition of organic matter
 11th century AD : Ibn Sina (Avicenna) introduced “blood rot”
 19th century AD : sepsis
INTRO

 Herrmann Boerhave (1668-1738) : toxic substances in the air were the

cause for sepsis.

 Justus von Liebig (early 19th century) : contact between wounds and
oxygen was responsible for the development of sepsis.
 INTRO

Ignaz Louis Pasteur Joseph Lister Robert Koch Hugo

Semmelweis (1822-1895) (1827-1912) (1843-1910) Schottmüller
(1818-1865) (1867-1936)
Bacteria Amputation Koch’s
Puerperal fever sepsis postulate Sepsis modern
definition
Clorine Carbolic acid Steam
sterilisation
SEPSIS Burden

 Mortality in the U.S increased from 154,159 in 2000 to 207,427 in

2007
 hospitalizations with sepsis have overtaken those for myocardial
infarction
 In the U.S., sepsis accounts for far more deaths than the number of
deaths from prostate cancer, breast cancer and AIDS combined
 The Agency for Healthcare Research and Quality lists sepsis as the
most expensive condition treated in U.S. hospitals, costing more
than $20 billion in 2011 increasing on average annually by 11.9%

http://world-sepsis-day.org/
Seymour et al. Am J Respir Crit Care Med 2012, 186(12):1264-1271.
“Old Definition”

 The original definitions of sepsis and related conditions are now more
than 20 years old
 Sepsis 1 (1991 – 2001) ACCP/SCCM
 Sepsis 2 (2001 – 2015) SCCM/ESICM/ACCP/ATS/SIS
 Sepsis 3 (2015 - ) ESICM/SCCM
“OLD and NEW”

OLD
SEPTIC
SEVERE SHOCK NEW
SEPSIS
SEPSIS SEPTIC
SEPSIS SHOCK
SIRS




“OLD” DEFINITION

 SIRS + infection : ???

 poor discriminant validity
 poor concurrent validity
SEPSIS = SIRS + INFECTION ?
 The 3rd International
Consensus Definitions for
Sepsis and Septic Shock
(Sepsis-3)
NEW DEFINITION SCCM/ESICM

JAMA 2016;315(8):801-810.
IMPORTANCE

 Definitions of sepsis and septic shock were last revised in

2001  15 years
 Considerable advances have since been made into the
 pathobiology (changes in organ function, morphology,
cell biology, biochemistry, immunology, and circulation),
 management,
 epidemiology of sepsis,
—> suggesting the need for reexamination.
KEY FINDINGS FROM EVIDENCE SYNTHESIS

 Limitations of previous definitions included an excessive

focus on inflammation, the misleading model that sepsis
follows a continuum through severe sepsis to shock, and
inadequate specificity and sensitivity (SIRS) criteria.
 Multiple definitions and terminologies are currently in
use for sepsis, septic shock, and organ dysfunction, leading
to discrepancies in reported incidence and observed
mortality.
 The task force concluded the term severe sepsis was
redundant
Why we need New Definition?

 offer greater consistency for epidemiologic studies and

clinical trials, and
 facilitate earlier recognition and more timely management
of patients with sepsis or at risk of developing sepsis.
Key concept of SEPSIS

 Sepsis is the primary cause of death from infection  urgent

attention
 SEPSIS : pathogen factors + host factors  evolve over time
 SEPSIS vs infection : (1) abberant or dysregulated host response, (2)
organ dysfunction
 Sepsis-induced organ dysfunction may be occult
 life-threatening organ
dysfunction caused by a
dysregulated host
response to infection

SEPSIS
SEPSIS in lay term

 life-threatening condition that arises when the body’s response to an

infection injures its own tissues and organs
ORGAN DYSFUNCTION

 Acute change in total SOFA score ≥ 2 point consequent to the

infection

 the baseline SOFA score can be assumed to be zero in patients

not known to have preexisting organ dysfunction.

 SOFA score ≥ 2 reflects an overall mortality risk of

approximately 10% in a general hospital population with
suspected infection.
 subset of a sepsis in which
underlying circulatory and
cellular/metabolic
abnormalities are profound
enough to substantially
increase mortality

SEPTIC SHOCK
SEPTIC SHOCK

 persisting hypotension requiring vasopressors to maintain MAP >65

mm Hg and having a serum lactate level > 2 mmol/L (18 mg/dL)
despite adequate volume resuscitation.
 This combination is associated with hospital mortality rates > 40%.
 Implication of the New Definitions
for Screening and Management

 STEP 1 : Screening and Management of Infection

 STEP 2 : Screening for Organ Dysfunction and Management of Sepsis
 STEP 3 : Identification and Management of Initial Hypotension
STEP 1 : Screening and Management of Infection

 Identification of infection
 Sign and symptom
 Obtaining blood and other cultures
 Administering tailored antibiotics as appropriate
 Infection-related organ dysfunction
STEP 2 : Screening for Organ Dysfunction and
Management of Sepsis

 Identified by the same organ dysfunction criteria (including lactate

level greater than 2 mmol/L)
 Identified using the “quick Sepsis-Related Organ Failure Assessment”
(qSOFA)
 Ensuring that the three-hour bundle elements have been initiated
continues to be a priority (i.e. blood cultures)
 STEP 3 : Identification and Management of
Initial Hypotension

 Px with infection and hypotension or a lactate level ≥ 4 mmol/L

 providing 30 mL/kg crystalloid with reassessment of volume
responsiveness or tissue perfusion should be implemented
 The six-hour elements of care (6-hours bundles)
 Repeat lactate level measurement if initial lactate level ≥ 2 mmol/L.
 Quick SOFA (qSOFA) Clarification for
the Practitioner

 A tool for identifying patients at risk of sepsis with a higher risk of

hospital death or prolonged (ICU) stay  SCREENING TOOLS
 Note that:
 qSOFA does not define sepsis (but the presence of two qSOFA
criteria is a predictor of both increased mortality and ICU stays of
more than three days in non-ICU patients)
 The new sepsis definitions recommend using a change in baseline of
the total SOFA score of two or more points to represent organ
dysfunction.
Controversies and Limitations

 Sepsis is a broad term applied to an incompletely understood

process.
 There are no simple and unambiguous clinical criteria or biological,
imaging, or laboratory features that uniquely identify a septic patient.
 Neither qSOFA nor SOFA is intended to be a stand-alone definition of
sepsis.
Prepare for Change!

 As always, hospitals and every healthcare components should

prepare for major changes that can alter fiscal considerations.
 Hospitals should develop detailed plans and educate their physician
and nursing staff and their coding departments to ensure that their
coders accurately capture the sense of the new definitions.
Are we ready to new
definition?
THANK YOU