GOODBYE SIRS, HELLO qSOFA: Sepsis, A New Definition

By Dave Hoffman, DO

sepsis

We’re back after a long hiatus and are here to inform you that SIRS is OUT. FOAM is atwitter with the newest edition of Sepsis , SEPSIS-3.

SEPSIS-3

In the February 2016 edition of JAMA, “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)”, was released. In this article, a taskforce of specialists came together to tackle and update the definition of sepsis, an outdated definition which was last modified in 2001.

Their new definition of sepsis is:

A life-threatening acute organ dysfunction caused by a dysregulated host response to infection.

In their article, they advocate eliminating SIRS from the definition because of its many inaccuracies. They instead sponsor using qSOFA (Quick Sequential [Sepsis-related] Organ Failure Assessment). qSOFA is based on only 3 criteria, altered mentation, respiratory rate, and systolic blood pressure.

Below is the article’s recommendation:

Recommendations  Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.

BOTTOM LINE

1) The new focus of the 2016 consensus was less on screening for a very strict definition of sepsis and more on identifying which patients with infections may have a poor outcome — mortality or ICU stay of ≥3 days.

2) SIRS is OUT, qSOFA is IN

(SIRS=sensitivity->who might be septic) (qSOFA and SOFA=specificity->who needs ICU)

3) qSOFA:

  • New/Worsened Altered Mentation
  • RR >22
  • Systolic BP <100

2 points or more=10% mortality.

4) ACEP has not officially endorsed this article and critique exists. See the FOAM weblinks below for a deeper dive.

 

RESOURCES

There are some great resources out there , if you’re interested in diving a little deeper go to…

The original article

http://jama.jamanetwork.com/article.aspx?articleid=2492881

Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.

 

There is also a great 2 minute video:

http://jama.jamanetwork.com/multimediaPlayer.aspx?mediaid=12511362

 

Other videos by the authors:

http://jama.jamanetwork.com/multimediaPlayer.aspx?mediaid=12478968

http://jama.jamanetwork.com/multimediaPlayer.aspx?mediaid=12478966

 

MDCalc:

http://www.mdcalc.com/sequential-organ-failure-assessment-sofa-score/

http://www.mdcalc.com/qsofa-quick-sofa-score-for-sepsis-identification/

 

FOAM:

Below are some great FOAM resources that discuss SEPSIS-3 and also critique its role in the ED.

http://foamcast.org/2016/02/21/sepsis-redefined/

http://first10em.com/2016/02/25/sepsis-3-0/

http://rebelem.com/sepsis-3-0/

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