Sepsis Multicast 4/5

In this episode (#4) we discuss new Sepsis CMS core measures, new Sepsis 3.0 definitions.

  • Went into effect 10/2015
  • Definitions for severe sepsis and septic shock
    • Shock: Elevated lactate and hypotension despite adequate fluid bolus
    • Severe Sepsis: Sepsis + Organ Dysfunction
  • 3 hour bundle (no controversy)
    • Fluids
    • Lactate
    • Early Broad Spectrum Antibiotics
    • Blood cultures
  • Requirements for severe sepsis/septic shock
    • TWO of the following 4 items
      • CVP
      • Scvo2
      • Dyanmic measurement of fluid responsiveness
        • Passive Leg Raise (PLR) or fluid challenge
      • Focused Physical Exam
        • includes
          • Vitals
          • cardiopulmonary assessment
          • capillary refill
          • pulse
          • skin findings
 
CMS Metrics Discussion:
  • Makes it easier to run EGDT than more dynamic measures (ultrasound, etc)
  • Timing of release after new trials discussed last episode
  • Use your clinical judgement
    • have to option to admit to wards and do focused physical exam/measure of fluid responsiveness without CVL if they are appropriate for that based on your judgement
    • if sick, may be easiest to place CVL and run EGDT with mindful deviation to meet metrics
  • Measures not meant for the Sepsis expert at a large tertiary facility but to give some guidance to the average provider at a community hospital
 
  • collaboration with ESICM and SCCM
  • First time the definitions have been redefined since 2002 and before that 1991
  • SIRS is out
  • qSOFA and SOFA are in
  • qSOFA = 2 of the 3 of the following:
    • AMS
    • RR > 22
    • SPB > 100 
  • Sepsis = Suspected Infection + qSOFA positive or increase in SOFA by 2
  • Septic Shock = vasopressor therapy AND lactate > 2 despite adequate fluid resuscitation
 
Sepsis 3.0 Discussion:
  • SIRS while overly sensitive catches a lot of patients who could transition along the spectrum of sepsis without being noticed
  • Hospitals have added SIRS to EMR alerts 
  • Early thoughts on qSOFA feel that it is less sensitive but more specific than SIRS
  • New Churpek article compared qSOFA to MEWS/NEWS/SIRS
    • MEWS/NEWS superior at predicting mortality or ICU admission
    • qSOFA and SIRS performed similarly
  • It has been too long between sepsis definition updates
    • could become much more refined with more frequent updates
    • this is a step in the right direction? at least in reference to frequency of updates 
  • Conclusion? Continue to use MEWS/SIRS EMR alerts for now and begin to apply qSOFA to our practice and see where it might make a difference
  • New Surviving Sepsis Guidelines coming out later this winter
Jeremy AmayoComment