SIRS, NICE, SOFAs and CQUINs:
Challenges of changing definitions
and guidelines
Dr Sian Coggle
Consultant Acute Medicine and
Infectious Diseases
Objectives
• Context
• Case
• Changing definitions
• Systems for recognition and management
• Evidence behind treatment
• Balances
• CUH work
• Cases/quiz
• 123,000 cases of sepsis occur in England each
year
• Approx. 37,000 deaths annually
• More than breast, bowel and prostate cancers
combined
• Prompt recognition of sepsis and rapid
intervention will help reduce the number of
deaths occurring annually.
63 yr old P.S
• From wife
• Whole family “flu-like illness”
• PS cough for last 3 days
• Headache
• Sweaty, drowsy, not following commands
• DH:
• Mirtazipine
• PMH:
• Measles aged 7 yrs
• Right petrousectomy 2014
25.12.16 19:02 = 0 mins
Minute ED action
0 T 40.4 at home, to resus
1 RR20, SpO2 96% (non rebreath bag), HR
99, BP 158/97, GCS 13, T 38.2 – NEWS 4
3 Sepsis criteria alert triggered
6 Bloods and cultures taken
10 Lactate 2.1, Ceftriaxone, Aciclovir, CT
head, CXR, urine dip, ECG, fluid balance
chart – ordered
34 WCC 16.7, neut 15, lymph 0.78, CRP 116,
Cr 77
35 IV ceftriaxone 2grm given
38 Hartmann’s 1l over 15 mins given
Minute ED action
60-120 Aciclovir given, lact repeated 3.0, Medical
and RRT review, CXR, CT head
340 LP – turbid fluid, OP 17.5 cmH2O
Dexamethasone added 0.15mg/Kg
480 PMN 1060, lymph 0, gluc and prot
pending. Gram stain difficult
Discussed with microbiology and ID SpR
Add Amoxicillin and Vancomycin
720 Concerns about pupils and GCS, repeat CT
head on way to RRT bed on IDA
2001 definition• Systemic inflammatory response syndrome (SIRS) requires 2 or more of the following
• 1. T >38 C or <36 C2. P >90/min3. RR >20/min or PaCO2 <32 mmHg4. WCC >12 or >10% immature band forms
• Sepsis
• Sepsis is SIRS + confirmed or presumed infections
• Severe Sepsis
• Severe Sepsis is sepsis with organ dysfunction
• organ dysfunction includes:
– SBP <90 mmHg or MAP < 65 mmHg or lactate > 2.0 mmol/L (after initial fluid challenge)
– INR >1.5 or a PTT >60 s
– Bilirubin >34 µmol/L
– Urine output <0.5 mL/kg/h for 2 h
– Creatinine >177 µmol/L
– Platelets <100 ×109/L
– SpO2 <90% on room air
• Septic Shock
• Septic shock is defined as sepsis with refractory hypotension
– hypotension is defined as SBP <90 mmHg or MAP <70 mmHg
– refractory means that hypotension persists after 30 mL/kg crystalloid; i.e. vasopressor dependence after adequate volume resuscitation
Definition – Sepsis - 3
• Sepsis “life-threatening organ dysfunction caused by a dysregulated host response to infection”
• Septic shock “a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.”
• Inclusion of organ dysfunction in the definition
of sepsis, the term “severe sepsis” was
eliminated in this new iteration
• European Society of Intensive Care Medicine and Society of Critical
Care Medicine Third International Consensus Task Force
• Singer M et al. JAMA 2016 Feb 23. Seymour CW et al. JAMA 2016 Feb 23.
Shankar-Hari M et al. JAMA 2016 Feb 23. Abraham E. JAMA 2016 Feb 23
• Sepsis is a life-threatening organ dysfunction
due to a dysregulated host response to
infection.
• Suspected sepsis is used to indicate people
who might have sepsis and require face-to-
face assessment and consideration of urgent
intervention.
• NICE guidelines July 2016
Recognising
• Sequential Organ Failure Assessment (SOFA) scores compared with Logistic Organ Dysfunction System (LODS) and SIRS criteria
• Performed same – chose SOFA
• Suspected infection plus a change in baseline SOFA score ≥2 points
• 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.
qSOFA
• Limitations – starting to be addressed
• Defining sepsis by an increase in SOFA score
provided greater prognostic accuracy for in-
hospital mortality than either SIRS criteria or
qSOFA
• “Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for
In-Hospital Mortality Among Adults With Suspected Infection Admitted to
the Intensive Care Unit” Raith et al JAMA. 2017;317(3):290-300
• 8% in hospital mortality - qSOFA helped predict who
• 3% for those with qSOFA of 1,
• 24% for those with a qSOFA ≥2
• Adding lactate to the model did not improve the predictions
• Data were incomplete on 14% of patients, limiting the conclusions' strength
• “Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency Department” Freund et al JAMA. 2017;317(3):301-308.
Sensitive Specific Positive
predictive
value
Negative
predictive
value
SIRS 97% 2.4% 15.9% 80%
qSOFA 48% 90% 42% 92%
• Retrospective review 200 cases presenting to ED six month
period who had a sepsis 6 form completed
• qSOFA is a more specific test to identify patients requiring
critical care input or at risk of death. Although SIRS is more
sensitive, its lack of specificity makes it a much less effective
screening tool for severe sepsis
• “TRIAGE OF SEPSIS PATIENTS: SIRS OR QSOFA – WHICH IS BEST?” Gunn
et al emermed-2016-206402.23
• qSOFA
• sBP <100
• Altered mental status
• RR > 22
• >2 = 10% mortality rate
Management the evidence:
• Early directed goal therapy:
• Randomized trial of 263 patients with suspected
sepsis reported a lower mortality in patients when
ScvO2, CVP, MAP, and urine output were used to
direct therapy compared with those in whom only
CVP, MAP, and urine output were targeted (31 vs 47
%)
• Both groups initiated therapy, including
antibiotics, within six hours of presentation.
There was a heavy emphasis on the use of red
cell transfusion (for a hematocrit >30) and
dobutamine to reach the ScvO2 target in this
trial
• “EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS
AND SEPTIC SHOCK” Emanuel Rivers et al N Engl J Med, Vol. 345, No. 19
November 8, 2001
• Three subsequent multicenter randomized
trials of patients with septic shock, ProCESS,
ARISE and ProMISE and two meta-analyses all
reported no mortality benefit (20 to 30 %),
associated with an identical protocol
compared with protocols that used some of
these targets or usual care
• A systematic review and meta-analysis of early goal-directed therapy for
septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care
Med 2015; 41:1549. Angus DC, Barnato AE, Bell D, et al
• PRISM Investigators. Early, Goal-Directed Therapy for Septic Shock - A
Patient-Level Meta-Analysis. N Engl J Med 2017
Sepsis 6
Author n Setting Median time
(mins)
Odds Ratio for
death
GaieskiCrit Care Med 2010;
38:1045-53
261 ED, USA
(Shock)
119 0.30(first hour vs all times)
DanielsEmerg Med J 2010;
doi:10.1136
567 Whole hospital,
UK
121 0.62(first hour vs all times)
KumarCrit Care Med 2006;
34(6):1589-1596
2 154 ED, Canada
(Shock)
360 0.59(first hour vs second hour)
AppelboamCritical Care 2010;
14(Suppl 1): 50
375 Whole hospital,
UK
240 0.74(first 3 hours vs delayed)
LevyCrit Care Med 2010; 38
(2): 1-8
15 022 Multi-centre 0.86(first 3 hours vs delayed)
LevyNEJM 2017;
10.1056/NEJMoa1703058
49 331 Multi-centre 57 1.04 per hour( increased odds per
hour delay)
Antibiotics – for every hour delayed 7-8% increase in mortality
• Retrospective cohort study of adult patients who presented to a single emergency department with severe sepsis over an 8-year period
• Approx. 1000 patients from severe sepsis to septic shock
• median time to initial antimicrobial administration was significantly longer for patients who progressed to septic shock than for those who did not progress (3.77 hours vs. 2.76 hours)
• Multivariable logistic regression showed an 8% increase in the odds of progression to septic shock for each 1 hour delay in antimicrobial administration
• “Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients.” Whiles BB et al. CritCare Med 2017 Feb 6
Surviving Sepsis Campaign/Society of Critical Care
Medicine/European Society of Intensive Care
Medicine
• IV antibiotics within one hour of presentation
• source control and antibiotic stewardship
• infusion of crystalloid solution at a rate at 30
mL/kg/hour within three hours for early fluid
resuscitation
• movement away from previously recommended
early goal-directed therapy targets (eg, central
venous pressure) to use of dynamic predictors of
fluid responsiveness, when feasible.
Balances• Does the patient have an infection?
• Is it likely to be bacterial/fungal/viral?
• Source control achieved?
• “Start Smart - Then Focus”
CQUIN
Sepsis at CUH
0
10
20
30
40
50
60
70
80
90
100
Jun
-15
Jul-
15
Au
g-1
5
Se
p-1
5
Oct
-15
No
v-1
5
De
c-1
5
Jan
-16
Fe
b-1
6
Ma
r-1
6
Ap
r-1
6
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Se
p-1
6
Oct
-16
No
v-1
6
De
c-1
6
Jan
-17
Fe
b-1
7
Ma
r-1
7
Ap
r-1
7
%
Sepsis Management in CUH ED
% antibiotics within 60 mins
% full sepsis 6 bundle in 60 mins
% antibiotics within 90 mins
% full sepsis 6 bundle in 90 mins
SEPSIS IS A MEDICAL EMERGENCY
ACT FAST, SAVE LIVES
Mortality increases by 8% for every hour of delay in antibiotics
SEPSIS
Does your
patient have a
NEWS >5
and/or look
sick?
ANY HIGH RISK
CRITERIA?� Mottled or blue
� Altered mental state
� Respiratory rate >25/min
� Increasing oxygen
requirement
� Heart rate >130/min
� Systolic BP <90mmHg
� Urine output lower than
0.5ml/kg/hr
� Not passed urine for
>18hrs
URGENT SENIOR
REVIEW NOW
GET HELP
Senior medical
review within
30 mins and/or
RRT if
deteriorating
OPEN SEPSIS
ORDER SET ON
EPIC
GIVE ANTIBIOTICS
WITHIN 60
MINUTES
Think: Could
this be
infection?
Quiz 1
18 yr old man presents to ED on Friday night
with his friends. Been on night out in town and
friends concerned patient is now acutely
confused. Observations:
T37, HR 135, BP 110/70, sats 98% OA, RR 22
What would you do next?
A. Meets high risk criteria start sepsis 6
B. Obtain more history
C. Give some fluids and reassess HR before
considering antibiotics
D. Wait for bloods including a lactate and Cr
before starting any management
Answer 1
• B – obtain more history
• Consider if infection present before assessing
for sepsis
Quiz 2
75 yr old on surgical ward following recent
resection for bowl obstruction. HCA performs
observations as part of routine rounds and
patient mentions some increased redness and
pain in surgical wound. Observations are:
T 38.5, HR 100, BP140/70, RR 20, Sats 98 %
OA
You are the medical SpR covering wards what
would you do next?
A. Phone the surgeons and arrange CT scan
B. Ensure adequate analgesia and fluid
intake, then reassess observations
C. Arrange an urgent set of bloods including
lactate and creatinine
D. Start sepsis 6 immediately
Answer 2
• C – meets criteria for intermediate risk sepsis
and need urgent bloods to ensure not high
risk
Quiz 3
61 yr old lady bed bound from MS, catheter
in situ (changed yesterday) with history of
recurrent UTI’s. Found that morning by her
carer acutely confused and now barely
rousable. Observations in ED:
T 37.5, HR 140, BP 90/60, sats 94%OA, RR 25
What would you do next:
A. This is high risk sepsis start sepsis 6 within
an hour of presentation, target antibiotics
to likely source
B. Arrange full set of bloods and CT head as
confused
C. Further history
D. Hold off sepsis 6 until central line in situ
for monitoring
Answer 3
• A – high risk sepsis, a medical emergency
Quiz 4
84 yr old lady brought into ED by daughter
“not quite right”. Had a fall last night and
maybe slightly confused. Has had a cough over
last few days and GP started on antibiotics.
Observations:
T 36.5, HR 110, BP 150/90, RR 22, Sats 94 %
OA
Bloods back – CRP 250, WCC 22, neut 16, Cr
80, lact 1.5
What would you do:
A. Meets high risk criteria start sepsis 6
B. Measured oxygen, CXR, infection screen
C. Find out baseline creatinine, if stable start
antibiotics in timely manner and reassess
in hour
D. Reassure daughter antibiotics likely to start
working soon and discharge
Answer 4
• C – meets intermediate criteria. Need to
ensure not in AKI and reassess. Does require
treatment for sepsis, but less urgency
Summary
• Context
• Case
• Changing definitions
• Systems for recognition and management
• Evidence behind treatment
• Balances
• CUH work
• Cases/quiz