Trying to grasp the updated definitions of sepsis

Last month, latest definitions of sepsis and septic shock (Sepsis-3) were released and published. Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) is the results of a consensus of experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Over the years, the definition of sepsis and treatment strategies have undergone quite a few changes and evolutions as we proceed to expand our understanding of the complex biology of sepsis and the physiological effects of sepsis on the body. We proceed to adapt this information to clinical practice. Despite advances in our understanding of the biology of sepsis, it continues to be a condition related to high morbidity and mortality worldwide. Despite continued advances in pharmacological therapy and organ support devices (i.e. mechanical ventilation, renal substitute therapy, etc.), early identification and treatment of patients with sepsis stays the cornerstone of improving survival. The latest definitions simplify the classification of sepsis and supply tools to discover those with suspected infection who’re vulnerable to developing sepsis complications, using Sequential Organ Failure Assessment (Sepsis-related) (SOFA) and qSOFA results.

The latest definitions and risk scores shift the main target from inflammation to organ dysfunction related to a dysregulated host response, or sepsis. In fact, Sepsis-3 defines sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al. 2016).” The article also provides a colloquial definition describing sepsis as “a life-threatening condition that occurs when the body’s response to infection damages its own tissues and organs” (Singer et al. 2016). This provides helpful terminology when talking to families a few complex and complex condition.

Before the Sepsis-3 vaccine was released, physicians typically distinguished 4 different degrees of sepsis: (SIRS in response to a confirmed infectious process), (sepsis and organ dysfunction as manifested by hypotension or ischemia of a number of organs), and (sepsis with persistent hypotension or ischemia despite adequate fluid substitute).

There has been much controversy over the SIRS criteria through the years because they’re considered to have poor specificity and sensitivity in predicting the event of sepsis. The SIRS criteria—fever, tachycardia, tachypnea, leukopenia/leukocytosis—are present in many conditions, each in chronic medical illnesses and in acute reactions to infection. A patient with acute bacterial pharyngitis with dehydration as a consequence of poor fluid intake and tachycardia as a consequence of dehydration and fever will be treated as an outpatient and have a really low risk of developing septic shock despite meeting the SIRS criteria. Furthermore, the “levels” of sepsis suggest that there’s a continuum or spectrum through which a patient with sepsis moves over the course of their illness, which is just not the case.

In short, the brand new definitions described above give attention to defining sepsis as a life-threatening organ dysfunction brought on by a dysregulated host response to infection. Sequential Organ Failure Assessment (Sepsis-related) (SOFA) is presented as a tool to discover organ dysfunction and the danger of a patient with infection developing sepsis. SIRS has been eliminated from the sepsis lexicon, as has severe sepsis, which has been deemed unnecessary. So now we’ve got:

1. Life-threatening organ dysfunction brought on by a deranged host response to infection. Organ dysfunction is measured by changes within the Sequential (sepsis-related) Organ Failure Assessment (SOFA) rating of two or more points. In a patient with an unknown baseline, the initial rating is zero.
2. a subset of sepsis cases requiring using vasoconstrictor drugs to take care of blood pressure (MAP) >65 and serum lactate >2 mmol/L within the absence of hypovolemia (i.e. after the patient has received appropriate fluid resuscitation).

The SOFA rating (Vincent et al. 1996) provides a clinical technique of identifying organ dysfunction; these criteria discover infected patients who’re more than likely to develop sepsis. Organ dysfunction is identified as an acute change within the SOFA rating greater than or equal to 2. These clinical variables include the PaO2/FiO2 ratio, platelet count, bilirubin, MAP with and without vasoactive agents, Glasgow Coma Scale, creatinine, and urine output.

Criteria (Quick SOFA) is an extra tool featured in Sepsis-3. The clinical variables of qSOFA are:

• Respiratory rate > 22
• Changed mentality (GCS < 15)
• Systolic blood pressure ≤ 100

The presence of two of those criteria (qSOFA) in a patient with a known infection should prompt further evaluation for organ dysfunction. This tool will be utilized by the bedside nurse.

While these definitions won’t change how we treat patients with sepsis or presumed sepsis, they supply clearer terminology in addition to a bedside tool for assessing patients with infection, potentially allowing us to each discover patients in danger more quickly and treat them earlier. The presence of qSOFA criteria in a patient with infection should prompt further assessment of the patient and possibly measurement of more specific SOFA criteria to evaluate for organ dysfunction. As a nurse, awareness and understanding of the newest sepsis terminology improves the care of our patients and allows for higher communication of patient information to colleagues in a consistent manner. Nurses are in a key position on the bedside to observe and discover patients within the early stages of clinical decline and have the potential to positively impact patient outcomes by facilitating early interventions and treatment of the patient with sepsis.

With this information, we are able to improve our communication. In the past, we might need said, “I am very concerned about Mr. X. He has been admitted to the unit for treatment of a urinary tract infection. I have a feeling that his condition is getting worse; he looks like he may have sepsis.” Now, with the brand new definitions, we are able to say, “I am very concerned about Mr. X. He has been admitted to the unit for treatment of a urinary tract infection. Since his admission, his clinical condition has deteriorated; his qSOFA score is two, his respiratory rate is 30, and his systolic blood pressure is 80. When he arrived in the emergency department, his SOFA score was one because of a creatinine of 1.5. Now, his urine output is down to 15 mL/hour and his MAP is 60. I think we need to order more labs and have someone reassess him for possible transfer to the ICU.” As nurses, we regularly know when something is changing and our patient’s clinical condition is heading within the unsuitable direction. Familiarizing ourselves with these tools provides us with more objective data to present and support our concerns.

It has been several weeks because the release of Sepsis-3. Reviewing medical commentary, one can find mixed opinions on the brand new definitions and utility of the SOFA and qSOFA scores. It is true that qSOFA and SOFA will not be diagnostic of sepsis or septic shock; SOFA is a predictor of mortality; but they supply objective data points that will be easily measured within the hospital setting. Our goal of early identification and early treatment to cut back the general morbidity and mortality related to sepsis stays unchanged. Sepsis is a fancy disease; along with the overt symptoms, complex biochemical, genetic, and endogenous aspects are involved within the pathobiology of sepsis. Some pathways are well understood, while others are only on the border of understanding.

Personally, I’m pleased with the brand new definitions and ease of the diagnostic terms for sepsis and septic shock. I stay up for improved dialogue and communication using the SOFA criteria. As with any change in medicine, there is often a lag between publication and implementation. In my hospital, especially within the ICU, there has definitely been quite a lot of buzz and support for the brand new terminology. I might love to listen to how other hospitals and facilities have responded to Sepsis-3!

Megan Doble, Registered Nurse, Registered Nurse, Registered Nurse

Bibliography:
Singer M, Deutschman CS, Seymour C, et al. Third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
Vincent JL, Moreno R, Takala J, et al.; Sepsis-related Problems Working Group of the European Society of Intensive Care Medicine. The Sepsis-related Organ Failure Assessment (SOFA) scale for describing organ dysfunction/failure. Intensive Care Med. 1996;22(7):707-710.