Sepsis can be a difficult condition to diagnose thanks in part to non-specific criteria; the definitions of sepsis and septic shock were last revised in 2001. This February, the Journal of the American Medical Association (JAMA) published “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” to evaluate and update these definitions. (The definitions can be accessed at http://jama.jamanetwork.com/article.aspx?articleid=2492881.)
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ACEP Now: Vol 35 – No 07 – July 2016But how accurate are these definitions, and are they useful in clinical EM practice? ACEP Now medical editor-in-chief Dr. Kevin Klauer recently had a conversation with physicians who work with septic patients and are involved with sepsis survival care to get their opinions.
Moderator:
Kevin Klauer, DO, EJD, FACEP, chief medical officer–emergency medicine and chief risk officer for TeamHealth, executive director of the TeamHealth Patient Safety Organization, and medical editor-in-chief for ACEP Now
Participants:
Tiffany Osborn, MD, MPH, FACEP, serves on Centers for Disease Control and Prevention’s National Sepsis Task Force; member of National Quality Measures Technical Expert Panel for ACEP’s Clinical Emergency Data Registry and the ACEP EQUAL Network Sepsis Initiative; and representative for Surviving Sepsis Campaign
Donald M. Yealy, MD, FACEP, chair at Department of Emergency Medicine for the University of Pittsburgh/University of Pittsburgh Physicians; senior medical director, for Health Services Division of UPMC; and professor of emergency medicine for Clinical and Translational Sciences at University of Pittsburgh School of Medicine
John J. Rogers, MD, CPE, FACS, FACEP, vice president for ACEP; and co-ED medical director for Coliseum Northside Hospital, Macon, Georgia
Todd L. Slesinger, MD, FACEP, FCCM, FCCP, FAAEM, founding program director for the Emergency Medicine Residency at Aventura Hospital and Medical Center in Florida; and associate professor of emergency medicine and critical care at Florida International UniversityKK: We know that there were new sepsis definitions launched and published in February. What was the primary reason for drafting these new definitions?
DY: A group of experts primarily in critical care medicine from Europe and the United States had noted that it had been over a decade since the working definitions of sepsis in place had been evaluated. The experts found strengths and weaknesses with the previous definitions. It began not as a scheduled but as a not-surprising relook at a set of conditions.
KK: I appreciate that extra detail. Was there some critical event that happened, perhaps with the ProCESS [Protocolized Care for Early Septic Shock] trial? Do you think there was really something critical that happened that forced people to take a look and reevaluate?
2 Responses to “A Marriage of Old Data and New Concepts: New Sepsis Definitions Raise Concerns about Accuracy, Usefulness in Emergency Medicine”
July 26, 2016
Lawrence LynnWe were encouraged that sepsis science was trying to move toward evidenced based crteria from the guessed SIRS of the past. The use of the guessed SIRS criteria in clinical trials was not scientific and was producing runaway inflation of the sepsis diagnosis, inflating the perceived benefit of intervention and rendering any positive benefit of RCT (in comparison with a control population) nonreproducible. SIRS had to be abandoned as the standard definition used in sepsis research.
However the needs of clinical medicine in a vacuum of objective data are different than the needs of scientists in that same vacuum. It is therefore not surprising that ER physcians have been disappointed with qSOFA which was derived from an effort to improve the scientific study of sepsis.
The problem is that there was no determination of when, on the timeline of the different dynamic relational patterns of common sepsis phenotypes, qSOFA criteria are met.
To illustrate this, consider the case of Rory Staunton. He was alert, non hypotensive, yet he had tachypnea, over 50% bands (evolving neutrophilic failure), a low platelet count (although not down to 100) and evidence of infection. Later (perhaps too late) he had hypotension and mental status changes.
When we called for a new sepsis definition we expected that the data from large trials would be reviewed to determine the dynamic relational patterns of the common sepsis phenotypes and then EARLY markers components of the patterns selected as a screening definition with the addition of the time patterns in the scientific definition. Alas, in the statistical search for correlates, time was, once again, overlooked. ER docs never overlook time as the essence of the word “emergency” is time.
The problem with setting up late criteria is the risk of a false sense of security. Altered mental state and hypotension are proven markers of all sepsis phenotypes but so is death. All three are often late findings and markers of diagnostic delay.
July 31, 2016
Mike GertzThe recommendations by the surviving sepsis campaign have always been to only screen patients who are “seriously ill appearing.” As a specialty, we know what that means. The problem is that we are trying to screen everyone with a lot of resultant noise. In the end, sepsis is like pornography, difficult to define but we all know it when we see it.