jama. 2016;315(8):801-810. doi:10.1001/jama.2016 7/01... · 2018-01-19 · septic shock definition...
TRANSCRIPT
![Page 1: JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016 7/01... · 2018-01-19 · SEPTIC SHOCK DEFINITION (3): cohort studies • Surviving Sepsis Campaign (SSC) (2005-2010; n=28 150) adequate](https://reader033.vdocument.in/reader033/viewer/2022052518/5f09c2e27e708231d4286289/html5/thumbnails/1.jpg)
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JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
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SEPSIS 3
• life-threatening organ dysfunction caused by a
dysregulated host response to infection
• organ dysfunction:
an increase in the SOFA score of 2 points or more
associated with an in-hospital mortality greater than 10%
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Vincent et al Intensive Care Med 1996;22:707-10
SOFA SCORE
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SOFA SCORE AND MORTALITY Vincent et al Intensive Care Med 1996;22:707-10
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KEY CONCEPTS OF SEPSIS
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KEY CONCEPTS OF SEPSIS
• primary cause of death from infection
• syndrome shaped by pathogen and host factors
• characteristics evolve over time
• differs from infection:
aberrant/dysregulated host response
organ dysfunction
• organ dysfunction may be occult
• infection may go unrecognized
• preexisting acute illness, comorbidities, medications, and
interventions may modify clinical presentation («phenotype»)
• specific infections may cause local organ dysfunction without
sepsis (dysregulated host response)
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EARLY ACTIVATION OF BOTH PRO- AND ANTI-INFLAMMATORY RESPONSES
vs
PROGRESSIVE SYSTEMIC INFLAMMATORY RESPONSE
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SEPSIS DEFINITION FOR LAY PUBLIC
“sepsis is a life-threatening condition that arises when the
body’s response to infection injures its own tissues”
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SEPTIC SHOCK DEFINITION
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MULTIPLE SEPTIC SHOCK DEFINITIONS
• heterogeneity in outcomes due to
varying cutoffs for systolic or mean blood pressure
diverse levels of hyperlactatemia
vasopressor use
concurrent new organ dysfunction
defined fluid resuscitation volume/target
the data source and coding methods
enrollment dates
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SEPTIC SHOCK DEFINITION (3): three sets of studies
• a systematic review and meta-analysis
observational studies in adults published between January 1, 1992, and
December 25, 2015, to determine clinical criteria currently reported to
identify septic shock and inform the Delphi process;
• a Delphi study to achieve consensus on a new septic shock
definition and clinical criteria
3 surveys and discussions of results from the systematic review,
surveys, and cohort studies
• cohort studies to test variables identified by the Delphi process
Surviving Sepsis Campaign (SSC) (2005-2010; n=28 150)
University of Pittsburgh Medical Center (UPMC) (2010-2012; n=1 309 025)
and Kaiser Permanente Northern California (KPNC) (2009-2013; n=1 847
165) electronic health record (EHR) data sets
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SEPTIC SHOCK DEFINITION (3): cohort studies
• Surviving Sepsis Campaign (SSC) (2005-2010; n=28 150)
adequate fluid resuscitation as judged by the collecting sites,
2 or more systemic inflammatory response syndrome criteria
1 or more organ dysfunction criteria
lactate: in 84% of patients (in 71% within first 6 hrs), 67% included
• electronic health record (EHR) data sets
hypotension, highest serum lactate level, and vasopressor therapy as a
binary variable [yes/no]) during the 24-hour period after infection was
suspected
hypotension: systolic blood pressure was 100mmHg or less for any
single measurement during the 24-hour period after infection was
suspected
lactate: in 9% of infected patients at UPMC and in 57% at KPNC.
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SEPTIC SHOCK (3)
a subset of sepsis:
• particularly profound circulatory, cellular, and metabolic
abnormalities, associated with a greater risk of mortality
vasopressors to maintain a mean arterial pressure
>65mmHg
serum lactate >2 mmol/L in the absence of hypovolemia
• associated with hospital mortality rates greater than 40%
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SEPTIC SHOCK DEFINITION (3)
• «hypotension»
• «need for vasopressor therapy»
• «adequate fluid resuscitation»
• «elevated blood lactate»
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SEPTIC SHOCK DEFINITION (3)
clinical criteria for septic shock :
• hypotension and hyperlactatemia in combination rather
than either alone
encompasses both cellular dysfunction and cardiovascular
compromise
associated with higher risk-adjusted mortality
approved by a majority (13/18) of voting members
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SEPTIC SHOCK DEFINITION (3)
Delphi process and voting by 17 experts
• «hypotension»
MAP <65mmHg (14/17 agreed)
• «need for vasopressor therapy»
could not be explicitly specified
• «adequate fluid resuscitation»
could not be explicitly specified
• «elevated blood lactate» (11/17 agreed)
> 2 mmol/L tested in combination with «fluid resistant
hypotension requiring vasopressors»
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agree disagree neither
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agree disagree neither
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OPEN QUESTIONS/ MAJOR CONTROVERSIES
• «need for vasopressors»
definition of blood pressure targets
• «adequate fluid resuscitation»
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«…On page 1647, under the definition of "septic shock,"
the phrase "despite adequate fluid resuscitation"
is used without any qualification...»
correspondence in CHEST from 1992
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WHY ARE THESE QUESTIONS IMPORTANT ?
• interventions to achieve the desired blood pressure may
influence outcome
vasopressor load
fluid load
• fluid resuscitation strategy may influence outcome
association of positive fluid balance with increased risk of death
• «need for vasopressors» and «adequate fluid resuscitation»
context and interpretation highly variable – effects unknown
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identification of patients with infection
evaluation of 4 different severity scores for construct validity and
outcome prediction (sepsis vs uncomplicated infection)
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qSOFA:
assessment of organ dysfunction outside the ICU
risk of poor outcome in patients with suspected infection
and any 2 of
• GCS<15
• systolic blood pressure < 100 mmHg
• respiratory rate > 22 breaths/min
(multivariable logistic regression modeling; GCS<14 in original model)
prompt to search organ dysfunction and/or infection
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WORSENING ORGAN FUNCTION IN
PATIENTS WITH SUSPECTED INFECTION
IS AN EARLY WARNING FOR RISK OF DEATH
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