Understanding Sepsis: Criteria, Definitions, Pathogenesis, and Treatment, Study notes of Pathophysiology

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S E P S I S :

UPDATE GUIDELINE 2016:

WHAT’S DIFFERENCES THAN

GUIDELINE 2001?

Erwin Budi Cahyono

 Definitions  Epidemiology  Pathophysiology  Treatment  Future directions

Older Definitions

SEPSIS :

 Evidence of SIRS accompanied by known or suspected infection. Severe SEPSIS :  Sepsis accompanied by hypoperfusion or organ dysfunction.  Cardiovascular :  SBP<90 mmhg/MAP<70 for at least 1 hr despite adequate volume resuscitation or the use of vasopressors to achieve the same goals.  Renal :  Urine output <0.5 ml/kg/hr or Acute Renal Failure.  Pulmonary :  PaO2/FiO2 <250 if other organ dysfuncton is present or <200 if the lungs is the only dysfunctional organ.

Older Definitions

Severe SEPSIS (contd) :  Gastrointestinal :  Hepatic dysfunction (hyperbilirubinemia,Elevated transaminases  CNS :  Alteration in Mental status (delirium)  Hematologic :  Platelet count of <80,000/mm3 or decreased by 50% over 3 days/DIC  Metabolic :  PH<7.30 or base deficit >5.0 mmol/L  Plasma lactate >1.5 upper limit of normal. Septic Shock :  Severe Sepsis with persistent hypoperfusion or hypotension despite adequate fluid resuscitation

Sepsis 1

• Introduced the term “systemic inflammatory response syndrome” (SIRS).
• SIRS is considered to be present when patients have more than one of the following clinical findings: - Body temperature higher than 38 °C or lower than 36 °C - Heart rate higher than 90/min - Hyperventilation evidenced by respiratory rate higher than 20/min or PaCO2lower than 32 mmHg - White blood cell count higher than 12,000 cells/ μl or lower than 4,000/ μl

Sepsis 1

• Sepsis
  • SIRS plus infection
• Severe sepsis
  • sepsis associated with organ dysfunction, hypoperfusion or hypotension
• Septic shock
  • sepsis with arterial hypotension despite “adequate” fluid resuscitation

Sepsis 2

• Unchanged concepts of sepsis, severe sepsis, and septic shock
• Original SIRS overly sensitive and nonspecific - > increased complexity of scoring system.

Expanded SIRS criteria

Sepsis

• Sepsis clinical criteria: organ dysfunction is defined as an increase of 2 points or more in the Sequential Organ Failure Assessment (SOFA) score - for patients with infections, an increase of 2 SOFA points gives an overall mortality rate of 10%
• Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside with qSOFA (“HAT”); i.e. 2 or more of: - H ypotension: SBP less than or equal to 100 mmHg - A ltered mental status (any GCS less than 15) - T achypnoea: RR greater than or equal to 22

Septic Shock

• Septic shock is ‘a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.’
• Septic shock clinical criteria: Sepsis and (despite adequate volume resuscitation) both of: - Persistent hypotension requiring vasopressors to maintain MAP greater than or equal to 65 mm Hg, and - Lactate greater than or equal to 2 mmol/L
• With these criteria, hospital mortality is in excess of 40%

Epidemiology

 Current estimates suggest that over 750,000 cases of Sepsis are diagnosed annually, resulting in more than 200,000 deaths.  The incidence rate for Sepsis has been increasing over the past two decades, driving an increase in the number of deaths despite a decline in case-fatality rates.  Sepsis is the tenth leading cause of death in the United States and accounts for more than 17 billion dollars in direct healthcare expenditures.  Risk factors include age > 65 years, male, non- whites.  A primary site of infection cannot be established in 10% of patients with severe Sepsis/SIRS.

Epidemiology:

Epidemiology : Causative organism

Pathophysiology of Sepsis