Clinical question: What are the best criteria to identify sepsis and septic shock?
Bottom line: An international task force of experts has updated the definitions of sepsis and septic shock and created a new bedside scoring tool to identify patients with suspected infection who may be at high risk for poor outcomes. Based on the Sequential Organ Failure Assessment (SOFA) score, the new quickSOFA states that meeting 2 of 3 clinical criteria (respiratory rate of 22 per minute or greater, systolic blood pressure of 100 mg Hg or less, and altered mental status) identifies patients at high risk of poor outcomes from sepsis. This score will need to be validated further in multiple health care settings before it can be widely accepted in clinical practice. (LOE = 5)
References: 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, et al. Assessment of clinical criteria for sepsis (Sepsis-3). JAMA 2016;315(8):762-774.
Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock (Sepsis-3). JAMA 2016;315(8):775-787.
Study design: Other
Funding source: Foundation
Setting: Inpatient (ward only)
Synopsis: Systemic inflammatory response syndrome (SIRS) criteria are present in many hospitalized patients, even those without infections or life-threatening illnesses. The use of these criteria to identify sepsis may lead to misdiagnosis. Funded by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, an international task force consisting of 19 critical care, infectious disease, surgical, and pulmonary specialists convened to update the definitions of sepsis and septic shock and identify clinical criteria that can be used to recognize patients at high risk for mortality. Researchers conducted a systematic review and meta-analysis of observational studies followed by a Delphi consensus process to determine appropriate criteria for identifying septic shock. Furthermore, they validated and confirmed the ability of different clinical criteria, including the SIRS criteria and the SOFA score, to predict poor outcomes in patients with suspected infection.
Per the task force's recommendations, sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis in which there is an increased risk of mortality due to profound circulatory and cellular metabolism abnormalities. Sepsis can be identified by an increase in the SOFA score of 2 points or more. This is associated with an in-hospital mortality exceeding 10%. Septic shock can be identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and a serum lactate level greater than 18 mg/dL (> 2 mmol/L) after adequate fluid resuscitation. This combination of clinical criteria is associated with a hospital mortality rate of 40%.
Using a derivation and validation cohort of approximately 75,000 patients, the group also developed a new bedside clinical measure termed quickSOFA, or qSOFA, which consists of a respiratory rate of 22 per minute or greater, altered mental status, and systolic blood pressure of 100 mm Hg or less. Patients with suspected infection who are not in the intensive care unit and have at least 2 of these 3 criteria are at higher risk of poor outcomes from sepsis (area under receiver operating characteristics curve = 0.81).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.