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Third International Consensus
Definition for Sepsis and Septic
Shock
http://jama.jamanetwork.com
/multimediaPlayer.aspx?med
iaid=12511362
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Old definitions
• Sepsis : infection + SIRS
• Severe sepsis : sepsis + sepsis -induced organ
dysfunction or tissue hypoperfusion
• Septic shock : sepsis -induced hypotension
persisting despite adequate fluid resusciation
Survivin Sepsis Campaign: Internetional Guidelines for Management ofSevere Sepsis and Septic Shock: 2012. CCM.2013;41(2):580-637
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Sepsis
According to the new definitions, sepsis is now
defined as life-threatening organ dysfunction
caused by a dysregulated host response to
infection clinically characterized by an acute
change of 2 points or greater in the SOFA score
JAMA 2016;325(8):757-759
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Elimination of mention of SIRS in
the diagnosis of sepsis
http://westjem.com/wp-content/uploads/2013/04/wjem-14-168-g001.jpg
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Elimination of mention of SIRS in
the diagnosis of sepsis
The presence of SIRS is nearly ubiquitous in
hospitalized patients and occurs in many benign
conditions, related or not to infection, thus is not
specific for diagnosis of sepsis
JAMA 2016;325(8):757-759
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Results
Among ICU encounters in the validation cohort
(n= 7932 with suspected infection, of whom 16%
died), the predictive validity for in-hospital
mortality was lower for SIRS (AUROC 0,64) and
qSOFA (AUROC 0,66) vs SOFA (AUROC 0,74) or
LODS (AUROC 0,75)
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Results
Among non-ICU encounters in the validation
cohort (n=66.522 with suspected infection, of
whom 3% died), qSOFA had predictive validity
(AUROC 0,81) that was greater than SOFA
(AUROC 0,79) and SIRS (AUROC 0,76)
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Results
JAMA, Supplementary online contents 2016;318(8)
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Because SOFA is better known and simpler than
LODS, the task force recommends using a
change in baseline of SOFA > 2.
The baseline SOFA score should be assumed to
be zero unless the patient is known to have
preexisting organ dysfunction
SOFA score
Jama, Febraury 2016 Vol 315, Num 8
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SOFA score
Patients with SOFA score >2 had an overall
mortality risk of 10% in a general hospital
population with presumed infection.
This is greater than the overall mortality rate of 8%
for ST-segment elevation myocardial infarction
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The consensus document also introduces a bedside
index, called qSOFA, which is proposed to help identify
patients with suspected infection who are being
treated outside of critical care units and likely to
develop complications of sepsis.
The qSOFA requires at least 2 of the 2 risk variables
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qSOFA and lactate
JAMA, Supplementary online contents 2016;318(8)
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Identification of infection
• Order of administration of antibiotics
• Order of body fluid culture
• “Time zero” of infection: time at which the first of these 2 events
occurred
• Exclusion: antibiotic doses administrated as a single doses or in
operating room and administration without cultureJAMA, Supplementary online contents 2016;318(8)
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Septic shock
Defined as a subset of sepsis in which circulatory,
cellular, and metabolic abnormalities are
associated with greater risk of mortality than
sepsis alone
JAMA 2016;315(8):775-787
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Septic shock – clinical criteria
• Sepsis with fluid-unresponsive hypotension
• Need for vasopressors to maintain mean
arterial pressure > 65 mmHg
• Serum lactate level > 2 mmol/L
JAMA 2016;315(8):775-787
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Septic shock – clinical criteria
Three sets of studies were conducted to determine clinical criteria currentlyreported to identify septic shock
VASOPRESSOR + LAC >2 mmol/LHIGHER MORTALITY
(42,3%)
LAC > 2 mmol/L alone or + hypotention, vasopressor and LAC < 2 mmol/L
vs
JAMA 2016;315(8):775-787
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Septic shock and lactate
JAMA 2016;315(8):775-787
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Grazie per l’attenzione