I’ve written a couple of blogs on sepsis for the C & C in November. Some of the red shifters including Shelly, Jude, Shane, Rowan and I (and probably others) have done some research this year so let’s collaborate and discuss the current practice, and what’s applicable to us in Christchurch.
I’m posting this summary as a starting point for hopefully interesting discussions, and stimulate curiosity for those haven’t looked into this hot topic yet.
Sepsis and septic shock is a complicated beast as is not a single disease but it is a syndrome involving every cells and organ of our body. Due to its complicated nature, defining sepsis has been and still is highly debatable (some even claims we should get rid of the term sepsis altogether!). Vague definition and the poor level of understanding of the disease has resulted in conflicting epidemiological findings and debatable treatment guidelines.
St John CPG is consistent with the international guidelines (Surviving Sepsis Campaign 2012 – SSC Guidelines) and I think it is cleverly worded to give us the best definition and the treatment guidelines. I think it’s clever because it gives us the level of autonomy that may not be seen in other EMS, while still gives us enough guidance to be consistent with the current recommendations. However, the relatively high level of autonomy can result in varied management, and I’m sure the risk/benefit analysis is consistently reviewed by our clinical department.
As many of you are aware, it’s been a major effort in trying to redefine sepsis and septic shock early this year “Sepsis 3.0 (Singer et al., 2016) “, and the SSC guidelines are also due for an update later this year.
The new definition by Sepsis 3.0 are;
Sepsis is life-threatening organ dysfunction due to a dysregulated host response to infection.
Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.
* The term SIRS and severe sepsis has been taken out.
You should also check out the SSC ‘s Response to Sepsis 3.0
Assessment of sepsis and septic shock
There is no such a thing (at this stage) as sepsis assessment tool, as sepsis has not been defined as a single disease as mentioned earlier.
So, the following tools are not used to assess and diagnose sepsis or septic shock, but it is a literally a tool to add to your arsenal of your clinical assessment skills.
Temp >38 C or
RR >20/min or PaCO2
WCC >12 or >10% immature band forms
Hypotension: SBP less than or equal to 100 mmHg
Altered mental status (any GCS less than 15)
Tachypnoea: RR greater than or equal to 22
Patients with 2 or more of the above criteria have a great chance of dying.
* However, once again, this is not a screening tool, and you won’t make the clinical decision based just on qSOFA.
The Sepsis 3.0 group claims the SIRS criteria (that we currently use) being too non-specific and should not be used. Instead, they recommend the use of qSOFA as it is more specific when assessing high mortality as a result of sepsis/septic shock.
However, this statement has caused a lot of debate and confusion as although SIRS may not be specific, it is highly selective. Also, the loss of the SIRS criteria to rule in infection may be harmful to the non-expert, and this includes paramedics*.
But wait, there’s more!
qSOFA has failed a validation study published last month!
(This stuffed up part of my essay…)
Churpek, M. M., Snyder, A., Han, X., Sokol, S., Pettit, N., Howell, M. D., & Edelson, D. P. (2016). qSOFA, SIRS, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients Outside the ICU. American Journal of Respiratory and Critical Care Medicine. https://doi.org/10.1164/rccm.201604-0854OC
This study found National Early Warning Score (NEWS), designed and validated to identify patients at the risk of deterioration, being more selective and specific compared to SIRS criteria or qSOFA.
Check out the PulmCrit blog for more details
“Bad news for sepsis 3.0”
Well, I’m trying my best to keep it brief….
I’ll post the treatment guidelines and what applies to us on the next blog.
Comments, especially from those have done some study this year would be greatly appreciated!
Dellinger, R. P., Jaeschke, R., Osborn, T. M., Nunnally, M. E., Townsend, S. R., Reinhart, K., … Douglas, I. S. (2013). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Medicine, 39(2), 165–228. http://doi.org/10.1007/s00134-012-2769-8
Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., … Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA: Journal of the American Medical Association, 315(8), 801–810. http://doi.org/10.1001/jama.2016.0287