Sepsis is a commonly used term of unclear definition and utility. A brief history:
Sepsis was formally defined in 1991 as dysregulated immune response to infection, characterized by the systemic inflammatory response syndrome and identifiable by its SIRS criteria.
Since sepsis had such a high mortality, the purpose of this definition was to support early recognition and treatment.
Over the next twenty years, clinical research focused on identifying diagnostic and treatment algorithms for sepsis, such as The Rivers Protocol and Early Goal Directed Therapy. Patients receiving this protocol lived longer, and this was quickly adopted as the standard of care. However, subsequent multicenter RCT's and meta analyses didn't show a mortality benefit (ProCESS, ARISE, ProMISE), suggesting that the success of the Rivers Protocol was related to the specifics of that one intensive care unit.
Recently, the definition of sepsis was updated by the Third International Consensus Definitions for Sepsis and Septic Shock in 2016, published in JAMA.
Here's a quick breakdown of that update:
-The SIRS criteria are abandoned- many patients meet SIRS but do not have systemic infection, and many patients have systemic infection but do not meet SIRS.
-"Severe Sepsis" is abandoned. Sepsis itself, with a 10% mortality, is already severe.
-The definition of sepsis is: "life-threatening organ dysfunction caused by a dysregulated host response to infection."
-"The task force recognized that no current clinical measures reflect the concept of a dysregulated host response."
-Sepsis is "predicated on infection as its trigger," but the task force "acknowledges the current challenges in the microbiological identification of infection."
-Organ dysfunction is best assessed by the SOFA score, which can be obtained through basic labs and PaO2. An increase by 2 or more points on SOFA incurs 10% mortality.
-qSOFA is NOT a definition of sepsis. It is a prompt to look for sepsis, a screening tool to identify patients who may progress to sepsis.
-qSOFA is intended as a quick bedside assessment, requiring only assessment of mental status (GCS <15 or not), blood pressure (systolic pressure less than 100), and respiratory rate (>22). A positive qSOFA increases the likelihood of progressing to sepsis.
-Insurers have not caught up with new definitions and still reimburse according to whether patients meet traditional sepsis criteria.
Bottom Line:
You need to rely on your best clinical judgment in identifying patients with severe infection to which the body's immune response is dysregulated. Since overwhelming infection is a common cause of death, you need to act quickly to prevent or treat poor tissue perfusion and multi-organ dysfunction. Treatment involves IV antibiotics and aggressive volume resuscitation, with consideration for pulmonary edema. It is also important to identify and resolve the source of infection quickly.
