Make new friends but keep the old…
Using two previous datasets on early ED shock resuscitation, they found 470 patients who met the old definition (see below*) of septic shock. Only 200/470 (42.5%) met the new, more stringent Sepsis-3 definition (see below**) of septic shock. Patients meeting the new Sepsis-3 definition had greater severity of illness. However, of the patients who only met the old definition, there was still a high incidence of organ dysfunction and 14% mortality. The authors concluded, “These findings suggest that a large number of patients, who were previously considered ‘septic shock,’ may be missed using the new definition…” From my perspective, anyone who meets either definition gets maximally aggressive ED care and ICU admission, so I don’t think the new definition will significantly alter my practice.
Learn the new Sepsis-3 definition of septic shock, but realize that the old definition still identifies a group of very ill individuals with high mortality.
The Impact of the Sepsis-3 Septic Shock Definition on Previously Defined Septic Shock Patients. Crit Care Med. 2017 May 24. doi: 10.1097/CCM.0000000000002512. [Epub ahead of print]
Peer Reviewed by Thomas Davis.
In 1991, the ACP and SCCM developed definitions for sepsis:
- “systemic inflammatory response syndrome” (calculate SIRS)
- “sepsis,” when SIRS results from an infection
- “severe sepsis,” when associated with organ dysfunction, hypoperfusion, or hypotension
- “septic shock,” when sepsis-induced hypotension persists after adequate fluid resuscitation, along with the presence of perfusion abnormalities or organ dysfunction.
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) divides sepsis into two distinct categories: sepsis and septic shock.
- “Sepsis” is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection”.
- SIRS was deemed unhelpful, and Sequential Organ Failure Assessment (SOFA) score and the quick SOFA (qSOFA) score were recommended for prognostic purposes instead.
- “Severe sepsis” was eliminated.
- The definition of “septic shock” was altered to “a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality,” clinically identified by “vasopressor requirement to maintain a mean arterial pressure (MAP) of more than 65 mm Hg and serum lactate level more than 2 mmol/L in the absence of hypovolemia” and identifies a subset of patients with a hospital mortality rate of more than 40%.