Meet the New Sepsis (same as the old sepsis)

SIRS (>2) (old)

T <36 or >38
HR >90
RR >20
​WBC <4000 or >12000

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qSOFA (>2) (new)

RR > 22
​AMS
​SBP <100mmHG

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Septic shock (new):

• need pressor to maintain MAP >65
• lactate >2 after  resuscitation (original lactate not taken into account)
• (prognostic BUT does not change management)

Full SOFA score:
​

History of Sepsis:

• ​1980/90's: Sepsis definitions in medical literature
• 2001/2002: Sepsis 2 and Barcelona Declaration
• Multi-specialty (including EM) collaborative called Surviving Sepsis
• 2013: Surviving Sepsis Campaign Bundles become mandages measures
• 2016: Sepsis 3.0
  • 3 papers
    • consensus definitions
    • assessment of sepsis criteria
    • assessment of septic shock

Where did SOFA/qSOFA come from?

• retrospective review of 1.3 million EHR records from a single us region over 2 years
• confirmatory analysis using retrospective 700,000 national and international EHR records over 5 years (including pre-hospital, ED, wards, ICU data
• suspected infection:
  
  • abx -> culture within 24 hrs OR
    
  • culture -> abx within 72 hrs

Area under the curve (1 is a perfect correlation, 0.5 is as good as random):

• SIRS: 0.76 (0.75-0.77)
• SOFA: 0.79 (0.78-0.80)
• qSOFA: 0.82 (0.80-0.82)

Lactate:

• not an independent predictor of primary or secondary outcome
• trends point to qSOFA(1) + lactate (>2) = qSOFA (2)

New clinical Criteria for Septic Shock

• systematic review and meta-analysis of 44 studies (n=166479)
• expert consensus (Delphi process) to determine factors to analyze based on
• cohort studies to test variables identified

EM not involved in new guidelines

• declined to endorse new definitions after completed
• editorials in AEM and other EM lit point out that:
• • No CMS acceptance for quality measure changes
  • No ICD-10 changes
  • Minimal change in practice for EM other than qSOFA rather than SIRS

Recent EM Literature Using New Definitions

• qSOFA is ~80% sensitive (and a little better than CRB-65, so could use instead)

Take Away Points

• qSOFA appropriate as a screening tool and useful as adjunct to baseline risk for risk stratification for sepsis (GCS, RR, SBP)
• lactate further helps with risk stratification, but not an independent predictor of mortality or disposition
• sepsis is a quality measure