What Pharmacists Need to Know About the New Sepsis Roadmap

Pharmacists who have encountered septic patients or ever suspected sepsis understand the complexity and difficulty with diagnosing this syndrome.

The systemic inflammatory response syndrome (SIRS) criteria have been used to identify septic patients since the 1990s. They are incorporated into the Surviving Sepsis Campaign guidelines and are now included into the Sepsis Core Measures.¹

However, the health care community’s understanding of the pathophysiology of sepsis and its treatment has advanced tremendously, leading to revisions in the definition of sepsis and septic shock by a task force of experts convened by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine.^2-4

Sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Under some circumstances, a host’s response to infection could include several SIRS criteria but still be considered normal.

The effort to redefine sepsis focused on differentiating the syndrome from other uncomplicated infections in order to identify all elements of sepsis more easily and rapidly in a cost-effective manner. In doing so, the focus on the SIRS criteria was shifted to alternative, evidence-based scoring tools that are intended to be used in conjunction with standardized sepsis care.

Patients should meet the criteria for high risk of mortality and have evidence of severe organ dysfunction before being considered to have sepsis.

As an alternative to SIRS, the task force recommended using the quick Sequential Organ Failure Assessment (qSOFA) score. This consists of altered mental status (anything below a Glasgow Coma Scale score of 15), respiratory rate greater or equal to 22 breaths per minute, and systolic blood pressure of 100 mm Hg or less. Any patient with a qSOFA score of 2 or more and suspected infection should be assessed for organ dysfunction.

The full version of the SOFA score should be used to identify acute organ dysfunction, which is defined as an acute change in SOFA score of 2 or more with suspected infection. Of course, knowing a patient’s baseline SOFA score may not always be possible. A score of zero can be assumed in patients with no known preexisting organ dysfunction.

The task force also proclaimed the term “severe sepsis” redundant and no longer needed. As a result, sepsis and septic shock are the only 2 definitions remaining.

Septic shock is now defined as patients who have been identified as having sepsis under the new criteria but have persistent hypotension requiring vasopressors to maintain adequate perfusion (MAP >65 mm Hg) and a serum lactate level greater than 2 mmol/L despite adequate volume resuscitation.

The new sepsis updates will certainly be met with controversy and there are some obstacles to implementation, most obviously the misalignment with the current Core Measures that still consider the SIRS criteria. However, this document is a description of the direction in which the medical and scientific community are steering the care of septic patients.

Naturally, the first step in such a journey is creating the roadmap.

References

• Bone RC, et al. American College of Chest Physicians/Society of Critical Care Medicine consensus conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20(6): 864-874
• Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377.
• Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
• Singer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA, 2016; 315(8):801-809.