Whatis Sepsis - SFAI
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What is Sepsis? New and Old Definitions, How Do They Match Reality? Magnus Brink M.D. Ph.D. Departement of Infectious Diseases Sahlgrenska University Hospital Gothenburg, Sweden
Transcript of Whatis Sepsis - SFAI
What is Sepsis?New and Old Definitions, How Do They Match Reality?
Magnus Brink M.D. Ph.D.
Departement of Infectious Diseases
Sahlgrenska University Hospital
Gothenburg, Sweden
Vadhar sepsis och fotbollgemensamt?
ση̃ψιζrot, foul smell
Hippokrates(460-370 f.kr.)
“A local lesion, heated by humor afflux, makes the whole body become feverish. One can die because of this, especially on odd numbered days”
Hippocrates
Robert Koch (1843-1910)
Louis Pasteur (1822-1895)
Germ theory
penicillin 1928
Alexander Flemming (1881-1951)
multiorgan failure
39°“The time has come to close the book on infectious diseases. We have basically wipedout infection in the United States.”
the Surgeon General of the United States of America,William Stewart, 1967
ANTI-
BIOTIC
multiorgan failure
HOST THEORY39°
Exterminate the Beast
Dr. Roger C. Bone, 1941–1997Specialist in Pulmonary Medicine
Published some 1,000 scientific articles and wrote or edited 56 books.
bacteremia ≠ sepsis
positive blood-culture
sepsis
International Classification of Diseases
≥ 2 of• BT > 38° or < 36• WBC > 12 or < 4 • HR > 90• RR > 20 or PaCO2 < 4 kPa
Infection+
SIRS
Sepsis with organ dysfunction, hypoperfusion(lactacidosis, oliguria, altered mental status),
or hypotension (SBP < 90 mmHg or SBP >40 mmHg below baseline)
Severe sepsis with hypotension despite adequate fluid resuscitation
SEPSIS
SEVERESEPSIS
SEPTICSHOCK
SIRSSystemic Inflammatory Response Syndrome
Sepsis-1
1992
≥ 2 of• BT > 38° or < 36• WBC > 12 or < 4 • HR > 90• RR > 20 or PaCO2 < 4 kPa
Sepsis with organ dysfunction
Severe sepsis with hypotension (SBT < 90 mmHg or MAP < 60 mmHg or > 40 mmHg below baseline despite adequate fluid resuscitation)
“Because of the limitations of SIRSdiscussed above, we included a list of
possible signs of systemic inflammationin response to infection (Table 1)”.
SEPSIS
SEVERESEPSIS
SEPTICSHOCK
SIRSSystemic Inflammatory Response Syndrome
Sepsis-2
2001
PIRO(predisposition,
infection, response, organ dysfunction)
SIRS= Systemic Inflammatory Response Syndrome
>2 av: ● Temp > 38° el. <36° ● LPK >12 el. <4
● HF >90/min ● AF >20/min el. PaCO2 <4kPa
SEPSISmisstänkt el. verifierad infektion
+ SIRS
SEPTISK
CHOCK
SVÅR SEPSISSEPSIS + endera
hypotension/
hypoperfusion/organdysfunktion
Hypotension= SBT<90 MAP<70
Hypoperfusion=
P-laktat > 3 mmol
el. BE <-5 mmol/l
Organdysfunktion=
● oliguri <0,5 ml/kg/tim
el. krea >45 mmol/l
● PaO2/FiO2 <33 (27)
SaO2 ≈ 86% (78%)
● TPK <100,
INR >1,5
● RLS
● Bil >70
Septisk hypotensionsom inte svarar
på adekvat
mängd
vätska
tillsammans med
hypoperfusion
o/el. organ-
dysfunktion
12 % of patients in ICU with infection and organ failure did not have SIRS Kaukonen 2015
Of all patients with SIRS in EDonly 38 % had infection Liao 2014
> 2 av: ● Temp > 38° el. <36° ● LPK >12 el. <4
● HF >90/min ● AF >20/min el. PaCO2 <4kPa
GÅR DET ATT FÅ ORDNING PÅ ELÄNDET?
SEPSIS-3
DEFINITIONER
ANGER VAD VI UTIFRÅN VÅR NUVARANDE
KUNSKAPSHORISONT ANSER ATT SEPSIS ÄR
SVAR PÅ FRÅGAN:VAD ÄR SEPSIS?
DIAGNOSTISKA KRITERIER
ANGER KRITERIER FÖR ATT FASTSTÄLLA SEPSISDIAGNOS HOS ENSKILDA PATIENTER
SVAR PÅ FRÅGAN:VEM HAR (HAFT)
SEPSIS?
SCREENING
VERKTYG FÖR TIDIG KLINISK
IDENTIFIERING AV PATIENTER SOM KAN HA SEPSIS
SVAR PÅ FRÅGAN:VEM KAN HA
SEPSIS?
Sepsis 3: tre nivåer
SIRS
SEPSIS
SEPTIC
SHOCK
SEVERE SEPSISSEPSIS
Sepsis-3
2016
definition SEPSIS
life-threatening organ dysfunction caused by a dysregulated host
response to infection.
INFEKTIONDYSREGULATEDHOST RESPONSE
ORGANDYSFUNCTION
LIFE-THREATENING
Sepsis is life threatening
organ dysfunction caused
by a dysregulated host
response to infection.
This is Sepsis!
Ok, Plato I get your point, but is this
guy septic?
DIAGNOSTIC CRITERIA for SEPSIS
INFECTIONDYSREGULATEDHOST RESPONSE
ORGANDYSFUNCTION
LIFE-THREATENING
INFECTIONDYSREGULATEDHOST RESPONSE
ORGANDYSFUNCTION
LIFE-THREATENING
DIAGNOSTIC CRITERIA for SEPSIS
0-24
Diagnostic criteriera for SEPSIS
infection
+an acuet increase
of≥ 2 SOFA-points
definition SEPTIC SHOCK
a subset of sepsis in which underlying
circulatory and cellular metabolism
abnormalities are profound enough
to substantially increase mortality
Persisting hypotension requiring
vasopressors to maintain MAP 65 mmHg
and having a serum lactate level
>2 mmol/L (18mg/dL) despite adequate
volume resuscitation
Diagnostic criteriera for
SEPTIC SHOCK
≈ 1 milion patients with infection
Singer 2016
Diagnostic criteria
for SEPSIS
42,3% 30,1%
Singer 2016
Diagnostic criteria for SEPTIC SHOCK
mortality rates
SEPSIS-3
mortality risk
alla with INFECTION 5%
SEPSIS 10%
SEPTIC SHOCK 40%
quick SOFA
confirmed/suspected infection + qSOFA > 2
WARNING! It can be sepsis!
RR
> 22
SBP
< 100GSC
< 15
Nya koder
R65.2 Sepsis
R65.21 Septic chock
SEPSIS-2
How Do They Match Reality?
SEPSIS-1
SEPSIS-3
Sepsis 2 vs. 3
in the ICU
Shankar-Hari, BJA, 2017
Sepsis 2 vs. 3
in the ICU
Shankar-Hari, BJA, 2017
Shock Sepsis-3
Shock Sepsis-2
2. Fewer patients in the ICU with septic chock criteria,
but higher case fatality rate
1. Same number of patients the ICU with sepsisas previously with severe sepsis, unchanged case fatality rate
What shall we expect in the ICU when
changing from Sepsis-2 to Sepsis-3
SEPSIS
SEPTICSHOCK
SEPTICSHOCK
• Sepsis: same incidence, same CFR
• Septic shock: lower incidence, higher CFR
SEPSIS-2 → SEPSIS-3
SEPSISSEPSISSEPTIC
SHOCK
SEPTICSHOCK
SEPSIS SEPTIC SHOCK:Lower incidence, higher CFR
SEPSIS:Higher incidence, higher CFR
BUT, HOW ARE WE CODING?
SEPSIS OR SEPTIC SHOCK
Sepsis på Svenska IVA 2017–2018
Svenska intensivvårdsregistret
ICU
hospitalwards
Sepsis in one Swedish Centre
Ljungström 2017
Men hur skall vi ha det?
SILFMagnus BrinkJonas Cronqvist
SWESEMLisa KurlandMantas Okas
SFAIAnneli FagerbergMiklos Lipcsey
SIRJohan PeterssonPär Lindgren
SEPSIS-3 i Sverige
Definition:Livshotande organdysfunktion som
orsakas av ett stört systemiskt svar på infektion
Diagnostiska kriterier:infektionsutlöst akut ökning≥ 2 SOFA-poäng
Screening utanför IVA:infektion med≥ 2 qSOFA
ICD-10: R65.2
Definition:En undergrupp av sepsis där bakom-liggande cirkulatoriska och cellulära / metabola störningar är tillräckligt uttalade för att avsevärt öka dödligheten
Diagnostiska kriterier:Kvarstående hypotension som kräver vasopressor för att upprätthålla MAP ≥65 mmHg tillsammans med laktat >2 mmol/L trots adekvat vätske-rescusitering
ICD-10: R65.21
SEPSIS SEPTISK CHOCK
✔ ✔
✔
✔
✗
✗ ✗
National Early Warning Score 2 (NEWS-2)
KoderDe föreslagna koderna (R65.2, R65.21) kan bara användas I USA
Lösning: Återanvändning av de gamla sepsiskoderna:
R65.1 Sepsis
R57.2 Septisk chock
Inga fastställda tidsgränser
Maximalt tidsintervall för SOFA-poäng?
Vårt beslut: max 36 timmar
The main SOFA-problem outside ICU
Grading of respiratorydysfunction
PaO2/FiO2PaO2: partial pressure of O2 i arterial bloodFiO2: O2-fraction i inspired gas (0,21-1,0)
Simplification Aproximation
Breathing room air (FiO2=0,21)
SpO2 92-95% – 1 SOFA-pointSpO2 < 92% – 2 SOFA-points
Clinical care
Sepsis CriteriaWhat Reality Shall They Match?
Researchbasic
clinical
Epidemiologyand
surveillance
Quality improvement
and audit
an exercise in pragmatism
How has Sepsis-3 been received?
Parts of SEPSIS-3 that were not so good
Process
• Some key specialities (e.g. Emergency Medicine) were not involved
• Underrepresentation from resource poor settings
Content
• Suggested codes (R 65.2, R 65.21) not universally accept by WHO
• No timeframe for SOFA-scoring
• SOFA is not an optimal tool for grading of organ failure outside ICU
• The calibration of SOFA (≥2 for sepsis) can be questioned
EXTRA
Sepsis-3
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