Sepsis and Septic Shock – Diagnosis
Critical Care / Resuscitation, Infections
- In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection” (1).
- Sepsis is now identified by an increase of at least 2 points in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score in patients with a suspicion of infection.
- The quick SOFA (qSOFA) score, a surrogate for SOFA in settings in which all components of SOFA are not routinely measured (i.e. Emergency Department) was introduced to screen for patients likely to have sepsis.
- In the Emergency Department qSOFA has been shown to be more sensitive and specific than SOFA, SIRS or the old definition of severe sepsis to predict in-hospital mortality.
- Although SIRS and lactate are no longer part of the definitions of sepsis, SIRS remains a sensitive tool to screen for infection and an elevated lactate continues to be strongly correlated with in-hospital mortality.
- Base deficit or anion gap measurement are poor surrogates for lactate measurement. Centers should have capacity for measuring lactate.
SIRS – 2/4 of heart rate > 90/min, respiratory rate >20/min, temperature > 38’C or < 36’C, WBC >12 or <4 (altered mental status often substituted for WBC at triage)
qSOFA – 2/3 of Altered Mental Status, Respiratory Rate >20/minute, Systolic Blood Pressure < 100 mmHg. In ED, this correlates to a 10% in-hospital mortality.
SOFA – Sequential Organ Failure Assessment Score (see Figure)
Sepsis – Infection with evidence of organ dysfunction (increase in SOFA score of greater or equal to 2). Correlates to a 10% in-hospital mortality. (see Figure)
Septic Shock – requirement of vasopressors to keep mean arterial pressure greater than 65 mmHg AND a serum lactate > 2 mmol/L. Correlates to a 40% in-hospital mortality.
- Detailed history and physical exam to determine source of sepsis and evidence of organ dysfunction (i.e. low urine output, mottling of extremities)
- Blood work to screen for organ dysfunction to confirm sepsis diagnosis as well to look for sepsis mimics (i.e. CBC, extended electrolytes, BUN, Cr, glucose, LFTs, Lipase, Lactate)
- Culture appropriate sites (blood, urine, sputum, stool, wounds)
- Imaging to help determine site and extent of infection; based on clinical exam, look for drainable focus of infection (ie Chest and other x-rays, CT scans, Ultrasounds, MRI)
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
- The new sepsis-3 definitions were derived from a database of over 1.3 million patient encounters and have been externally validated.
- The qSOFA score has been externally validated in the Emergency Department.
Figure: SOFA Score
Freund Y, Lemachatti N, Krastinova E, et al. Prognostic accuracy of Sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA. 2017; 317(3):301-308.
Raith EP, Udy AA, Bailey M, McGloughlin S, MacIsaac C, Bellomo R, Pilcher DV, for the Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcomes and Resource Evaluation (CORE). 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. JAMA. 2017;317(3):290-300. doi:10.1001/jama.2016.20328
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Aug 21, 2018
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