Assessing New Clinical Criteria for Septic Shock

February 23, 2016

Assessing New Clinical Criteria for Septic Shock

  1. Patricia Kritek, MD

A multinational task force proposes new definitions for sepsis and presents a “quick” scoring system for non-ICU patients.

  1. Patricia Kritek, MD

The much anticipated new definitions of sepsis and septic shock have been published by the European Society of Intensive Care Medicine and Society of Critical Care Medicine Third International Consensus Task Force. A series of three articles describe the creation and validation of these definitions. For more than 2 decades, the cornerstone of sepsis identification included potential infection and presence of two of four systemic inflammatory response syndrome (SIRS) criteria. After 2 years of discussion, deliberation, and assessment, this Task Force defined sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and septic shock as “a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.” With inclusion of organ dysfunction in the definition of sepsis, the term “severe sepsis” was eliminated in this new iteration.

In an attempt to identify organ dysfunction more effectively, multiple models were retrospectively applied to a large cohort of patients with suspected infection from academic and community hospitals as well as prehospital, emergency department, ward, and intensive care unit (ICU) populations. Sequential Organ Failure Assessment (SOFA) scores were compared with the Logistic Organ Dysfunction System (LODS) and traditional SIRS criteria. SOFA scores are calculated based on PaO2/FiO2 (ratio of arterial oxygen partial pressure to fractional inspired oxygen), platelet count, bilirubin level, severity of hypotension, Glasgow coma score (GCS), and creatinine level/urine output. As SOFA and LODS performed comparably and SOFA is simpler, the Task Force recommended a threshold to diagnose sepsis as suspected infection plus a change in baseline SOFA score ≥2 points, with the assumption that most patients' baseline SOFA scores are 0. The clinical criteria to diagnose septic shock included vasopressor use to maintain mean arterial pressure >65 mm Hg and lactate level >2 mmol/L despite adequate fluid resuscitation.

To create a facile screening tool, the Task Force proposed a new 3-point metric called “quick SOFA” (qSOFA). The parameters included in qSOFA are altered mental status (GCS, ≤13), low systolic blood pressure (≤100 mmHg), and tachypnea (respiratory rate, ≥22 breaths per minute) in patients with suspected infection. Although this assessment strategy does not perform well in ICU populations, a qSOFA score of 2 or 3 accurately predicts poor outcomes in non-ICU patients.

Comment

These definitions definitely are a step forward from a SIRS-based paradigm; however, they have limitations outside of clinical trials. Calculating SOFA scores in time to make clinical decisions might not be realistic in some clinical environments and has the potential to drive excessive laboratory testing. The requirement of lactate testing to diagnose septic shock is limiting in low-resource settings. The most promising aspect of these new definitions is the inclusion of the qSOFA score as a means to identify potentially septic patients rapidly. That being said, prospective validation is needed before qSOFA is adopted into clinical practice.

Editor Disclosures at Time of Publication

  • Disclosures for Patricia Kritek, MD at time of publication Speaker’s Bureau American College of Chest Physicians (Critical Care Board Review Course)

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Reader Comments (1)

Farid Taymouri Physician, Rheumatology, HOSPITAL

THANK YOU VERY MUCH FOR THESE UPDATING GUIDELINES.

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