Pharmacists: Discuss the rationale for modifications to the sepsis - PDF document

Pharmacists: Discuss the rationale for modifications to the sepsis definitions Describe the updated sepsis definitions (Sepsis‐3) Technicians: Define sepsis and septic shock Sarah Vest Cogle, PharmD, BCCCP Assistant Clinical Professor Auburn University Harrison School of Pharmacy AlSHP Fall Meeting September 30, 2016 I have no actual or potential conflict of interest Need to differentiate sepsis from infection in relation to this program Improved understanding of sepsis pathophysiology Previous definitions focused on SIRS criteria Variable definitions – inconsistent reporting Sepsis vs. severe sepsis Sepsis syndrome Septicemia Singer M, et al. JAMA . 2016;315(8):801‐810. Sepsis‐1 Sepsis‐2 Sepsis‐3 1991 2001 2016 Sepsis Systemic response to Presence of infection Life‐threatening organ infection with ≥2 SIRS with systemic dysfunction caused by a • Life‐threatening organ dysfunction criteria manifestations of dysregulated host Sepsis caused by a dysregulated host infection response to infection response to infection Severe Sepsis associated with Sepsis associated with *Severe sepsis removed sepsis hypotension, hypotension, hypoperfusion, or hypoperfusion, or organ organ dysfunction dysfunction (unchanged from 1991) • Subset of sepsis in which profound Septic Sepsis‐induced Acute circulatory failure Subset of sepsis in which circulatory, cellular, and metabolic shock hypotension persisting characterized by profound circulatory, Septic shock abnormalities are associated with despite adequate fluid persistent arterial cellular, and metabolic resuscitation, along hypotension unexplained abnormalities are a greater risk of mortality than with hypoperfusion by other causes associated with a greater with sepsis alone abnormalities or organ risk of mortality than dysfunction with sepsis alone Bone RC, et al. Chest . 1992;101:1644‐55. Singer M, et al. JAMA . 2016;315(8):801‐810. Levy MM, et al. Intensive Care Med . 2003;29:530‐538. Singer M, et al. JAMA . 2016;315(8):801‐810.

Suspected infection Monitor, re‐evaluate for No No No Sepsis still possible sepsis if indicated qSOFA ≥2 suspected ? Yes Yes qSOFA SOFA Yes Yes • quick Sequential [Sepsis‐related] • Sequential organ failure Assess for organ dysfunction Organ Failure Assessment assessment Yes Yes No No • Can be performed quickly • Can be more difficult to SOFA ≥2 without laboratory values calculate but laboratory qSOFA Variables: • Does NOT define sepsis parameters involved are • Respiratory rate (>22 BPM) Sepsi • • Score ≥2 associated with Mental status common s • Systolic blood pressure (<90 • Higher scores = increased increased length of ICU stay and mmHg) Despite adequate fluid resuscitation, No No mortality mortality 1) Vasopressors required to maintain SOFA Variables: • If ≥2 , elevate further for organ • Suspected infection + SOFA MAP ≥65 mmHg, AND • PaO 2 /FiO 2 ratio 2) Serum lactate >2 mmol/L dysfunction change from baseline ≥2 points • Glasgow Coma Score • Mean arterial pressure = sepsis Yes Yes • Administration of vasopressors • Serum creatinine or urine output Septic shock • Bilirubin • Platelet count Seymour CW, et al. JAMA . 2016;315(8):762‐774. Singer M, et al. JAMA . 2016;315(8):801‐810. Adapted from: Singer M, et al. JAMA . 2016;315(8):801‐810. A 58 year old female presents to the emergency department with altered mental status, shortness of breath and fever Surviving Sepsis Campaign response Ht: 67” Wt: 68 kg Screening for early identification and treatment of patients T: 102°F RR: 32 BPM HR: 134 BPM BP: 88/44 mmHg with sepsis (formerly called severe sepsis) should continue BUN 41 mg/dL SCr 2.1 mg/dL WBC 19.4 x 10 3 cells/m 3 Patients with sepsis should still be identified by the same Lactate: 4.9 mmol/L Chest X‐ray: infiltrate in right lower lobe organ dysfunction criteria Her blood pressure does not respond to a 2L crystalloid fluid Possibility for future use of qSOFA score to identify organ bolus and norepinephrine is initiated dysfunction How would you classify this patient based on Sepsis‐3 Impact on coding, CMS core measures remains definitions? to be fully seen a. Sepsis b. Severe sepsis c. Septic shock d. Septicemia Surviving Sepsis Campaign. Surviving Sepsis Campaign responds to Sepsis‐3. 2016 Mar 3. Available from: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC‐Statements‐Sepsis‐Definitions‐3‐2016.pdf A 58 year old female presents to the emergency department How would you classify this patient based on Sepsis‐3 with altered mental status, shortness of breath and fever definitions? Ht: 67” Wt: 68 kg a. Sepsis T: 102°F RR: 32 BPM HR: 134 BPM BP: 88/44 mmHg b. Severe sepsis WBC 19.4 x 10 3 cells/m 3 BUN 41 mg/dL SCr 2.1 mg/dL c. Septic shock Lactate: 4.9 mmol/L Chest X‐ray: infiltrate in right lower lobe d. Septicemia Her blood pressure does not respond to a 2L crystalloid fluid Suspected infection (likely pneumonia based on Chest X‐ray, bolus and norepinephrine is initiated fever, shortness of breath, elevated WBC) with evidence of How would you classify this patient based on Sepsis‐3 organ dysfunction that persists despite fluid resuscitation and definitions? elevated lactate (A and B are incorrect). Septicemia (answer a. Sepsis D) is incorrect as it is an antiquated term that is not included in the Sepsis‐3 definitions. Septic shock (answer C) is the only b. Severe sepsis correct answer based on this patient’s presentation. c. Septic shock d. Septicemia Singer M, et al. JAMA . 2016;315(8):801‐810.

Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest . 1992;101:1644‐55. Levy MM. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med . 2003;29:539‐538. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis‐3). JAMA . 2016;315(8):801‐810. Seymour CW, Liu VX, Iwashyna TJ. Assessment of clinical criteria for sepsis for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis‐3). JAMA . 2016;315(8):762‐774. Surviving Sepsis Campaign. Surviving Sepsis Campaign responds to Sepsis‐3. 2016 Mar 3. Available from: http://www.survivingsepsis.org/SiteCollectionDocuments/SSC‐ Statements‐Sepsis‐Definitions‐3‐2016.pdf