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Friday 6 April 2018
3rd International Consensus Definitions for Sepsis and Septic Shock

This week, we suggest the reading of the 3rd International consensus definitions for sepsis and septic shock, recently published on JAMA.

Sepsis, a syndrome of physiologic, pathologic, and biochemical abnormalities induced by infection, is a major public health concern. Although the true incidence is unknown, sepsis is a leading cause of mortality and critical illness worldwide. Furthermore, patients who survive sepsis, often, have long-term physical, psychological, and cognitive disabilities.
A 1991 consensus conference developed initial definitions of sepsis, septic shock, and organ dysfunction, which have remained largely unchanged for more than 2 decades. Recognizing the need to re-examine the current definitions, the European Society of Intensive Care Medicine and the Society of Critical Care Medicine convened a task force of 19 specialists in January 2014. A systematic literature review and Delphi consensus methods were also used for the definition and clinical criteria describing septic shock.
Sepsis is a syndrome encompassing a still-uncertain pathobiology; it is life-threatening organ dysfunction caused by a dysregulated host response to infection, amplified by endogenous factors. No gold standard diagnostic test exists. Many existing terms are used interchangeably, whereas others are redundant or overly narrow. The current use of 2 or more Systemic Inflammatory Response Syndrome (SIRS) criteria to identify sepsis was unanimously considered by the task force to be unhelpful. Severity of organ dysfunction has been assessed with various scoring systems, that quantify abnormalities according to clinical findings, laboratory data, or therapeutic interventions. The predominant score in current use is the Sequential Organ Failure Assessment (SOFA): a higher SOFA score is associated with an increased probability of mortality. Patients with a SOFA score of 2 or more had an overall mortality risk of approximately 10% in a general hospital population with presumed infection. Depending on a patient’s baseline level of risk, a SOFA score of 2 or greater identified a 2- to 25-fold increased risk of dying compared with patients with a SOFA score less than 2.
Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality. Clinical criteria for septic shock were developed with hypotension and hyperlactatemia because the combination encompasses both cellular dysfunction and cardiovascular compromise and is associated with a significantly higher risk-adjusted mortality.
The authors highlighted that the task force focused on adult patients, recognizing the need to develop similar updated definitions for pediatric populations.
The task force has generated new definitions that incorporate an up-to-date understanding of sepsis biology, including organ dysfunction. However, the lack of a criterion standard, precludes unambiguous validation and instead requires approximate estimations of performance across a variety of validity domains.
The authors concluded that these updated definitions and clinical criteria should clarify long used descriptors and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing it.

AUTHORS: Mervyn Singer, MD, FRCPClifford S. Deutschman, MD, MSChristopher Warren Seymour, MD, MScManu Shankar-Hari, MSc, MD, FFICM;Djillali Annane, MD, PhDMichael Bauer, MDRinaldo Bellomo, MDGordon R. Bernard, MDJean-Daniel Chiche, MD, PhDCraig M. Coopersmith, MDRichard S. Hotchkiss, MDMitchell M. Levy, MDJohn C. Marshall, MDGreg S. Martin, MD, MScSteven M. Opal, MDGordon D. Rubenfeld, MD, MSTom van der Poll, MD, PhDJean-Louis Vincent, MD, PhDDerek C. Angus, MD, MPH.

To go to the full article, click here.