Slide 001

DR.JAKEER HUSSAINCritical care

SIRSSYSTEMIC INFLAMMATORY RESPONSE SYNDROM

Manifested by two or more of the following:

• Temperature > 38C or < 36C

• Heart rate > 90 beats/min

• Respiratory rate > 20 /min or PaCO2 < 32 mm Hg

• WBC > 12,000, < 4000, or > 10% immature (band) forms

Slide 002

SIRS- LACK SPECIFICITYSIRS criteria can be present in many hospitalised ptwho donot develop infection.

NON INFECTIOUS CONDITIONS WITH SIRS PANCREATITIS

VASCULITIS

AUTO IMMUNE DISORDERS

BURNS

SURGERY

THROMBOEMBOLISMSlide 002

SEPSISINFECTION

Inflammatory response to microorganisms or invasion of normally sterile tissues

SEPSIS

The systemic response to infection – i.e., confirmed or suspected infection plus ≥ 2 SIRS criteria

ACCP/SCCM Consensus Statement. Chest. 1992;

Slide 002

Why new definitionsDefinitions of sepsis and septic shock were last revised in 2001.Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis,

ECONOMIC BURDEN,, MORTALITY

suggesting the need for reexamination

Slide 002

Slide 002

SEPSIS 3

Sepsis is life-threatening organ dysfunction

caused

by a dys-regulated host response to infection

Slide 002

SEPSIS is life-threatening organ dysfunction caused by a dys-regulated host response to infection

• So … “sepsis” now = the old “severe sepsis

• As opposed to the “regulated host response”

that characterizes the non-septic response to infection

Slide 002

NEW DEFINATIONADVANTAGES

• Incorporates most up-to-date thinking on sepsis pathobiology

• Provides closest approximation possible to describing

“what sepsis is”

CONCERNS

• Of limited practical utility as they contain elements that cannot be clinically identified

• “organ dysfunction”

• “dysregulated host responseSlide 002

RISK FACTORS SEPSIS• ICU Admissions ( nosocomial infections)

• Bacteremia

• Advanced age ≥65 yrs

• Immunosuppresion ( comorbidies, drugs)

• DM, CANCER

• CAP ( approx 50% sepsis)

• Previous hospitalisationSlide 002

Slide 002

Slide 002

The Validity of SIRS challenged • SIRS criteria have been used to diagnose

sepsis for more than 20 years.

• “SIRS no longer has any legs ….. It sounded like a good idea in 1990 , but it has lost steam…..”

• Poor concurrent Validity

Slide 002

SOFA SCORE

Limitations of SOFA• The SOFA score identifies Pt septic both in & out of

ICU. But it involves the use of many lab tests and is a bit complex.

• Cumbersome due to multiple variables

• Not well known outside ICU setting

• Variables & cutoff values developed by consensus

• For patients not in the ICU, the performance of Quick SOFA score was similar to that of the SOFA score.

Slide 002

SOFA & LODS Superior in ICU

Slide 002

qSOFA similar to complex scores outside the ICU

Slide 002

Slide 002

Slide 002

Q SOFA• Poor man’s SOFA

• Quick and repeat bedside test

• No laboratory test required

• Outside ICU settings

• Emergency, WARDS.

Slide 002

To Summarize….

Slide 002

Slide 002

SEPTIC SHOCK

1991 & 2001 Septic Shock definitions1991Sepsis-induced hypotension, persisting despite adequate

fluid resuscitation, along with the presence of hypoperfusion

abnormalities or organ dysfunction

2001State of acute circulatory failure characterized by persistent

arterial hypotension unexplained by other causes

Neither definition proposed explicit criteriaSlide 002

Slide 002

Shankar-Hari M, Phillips GS, Levy ML et al.

Developing a New Definition and Assessing New Clinical Criteria for Septic Shock For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA 2016; 315: 775-787

SEPTIC SHOCK 2016SEPTIC SHOCK is a subset of sepsis

in which profound

circulatory, cellular and metabolic abnormalities

are associated with a

greater risk of mortality than with sepsis alone

(40% vs 10%)

Slide 002

Slide 002

Meta-analysis and systemic reviews from January 1, 1992- December 25,201544 septic shock studies166,479 patients

Clinical criteria for Septic shock

Three variables identified• Hypotension

• Elevated serum lactate level

• Sustained need for vasopressor therapy

Slide 002

Slide 002

Lactate > 2 mmol/L for predicting mortality in Septic Shock

• Sensitivity = 82.5 %

• Specificity = 22.4 %

• Mortality significantly higher in patients with fluid resistant hypotension requiring vasopressors & hyperlactatemia (42.3 %)

vs

Hyperlactatemia alone “or”

Fluid resistant hypotension requiring vasopressors

but Lactate level ≤ 2 mmol/L (30.1%)

Slide 002

WHY HYPOTENSION & HYPERLACTATEMIA

How it differs from old defination• Both serum lactate level and vasopressor-

dependent hypotension instead of either alone

• Lower serum lactate level cutoff of 2 mmol/L vs 4 mmol/L as currently used in the SSC definitions

Slide 002

ConclusionsDEFINITION

Septic shock is defined as a subset of sepsis in which

underlying circulatory, cellular and metabolic abnormalities are

associated with a greater risk of mortality than sepsis alone

CLINICAL CRITERIA

• Hypotension requiring use of vasopressors to maintain MAP

≥65 mmHg

• having a serum lactate >2 mmol/l

• Persisting despite adequate fluid resuscitation

Slide 002

Slide 002

FLOWCHART

Slide 002

Slide 002

X

X

20162002

Slide 002

Controversies and limitations• Most data extracted from US database

• q SOFA and SOFA can miss occult organ dysfunction

• Specific infections can cause local organ dysfunction without dysregulated systemic host response

• Non- availability of lactate measurements in resource poor settings

• Task force focused on adult patients

Slide 002

Some of the concerns raised …• ‘SOFA won’t be measured daily on every patient’

• ‘do I need to measure SOFA twice to measure change’

• ‘lactate should be in the sepsis criteria’

• ‘lactate should go from the septic shock criteria’

• ’80% of the world cannot measure lactate’

• ‘why not shock = hyperlactatemia OR hypotension?’

• ‘patients will die if we wait until qSOFA hits ≥2 before treating’

• ‘why don’t we just use qSOFA to diagnose sepsis?’

• ‘the coders won’t like it’

• ‘what about children?’ …

Slide 002

Treat the patient in front of you• NOT suggesting that infected patients shouldn’t be

actively managed until qSOFA≥2 or SOFA ≥2

• so treat infection, oliguria, hypoxaemia etc as indicated

• .. do not wait until criteria met

Slide 002

Slide 002

Slide 002

Slide 002

Slide 002

Slide 002

Slide 002

Slide 002

Slide 002

Slide 002