Friday, March 10, 2017

Rethinking the sepsis definition: should we go back to SIRS?

Objective   A proposed revision of sepsis definitions has abandoned SIRS, defined organ dysfunction as an increase in total SOFA score of greater than or equal to 2, and conceived “qSOFA” as a bedside indicator of organ dysfunction. We aimed to (1) determine the prognostic impact of SIRS, (2) compare diagnostic accuracy of SIRS and qSOFA for organ dysfunction, and (3) compare standard (Sepsis-2) and revised (Sepsis-3) definitions for organ dysfunction in emergency department patients with infection.

Methods   Consecutive ED patients admitted with presumed infection were prospectively enrolled over three years. Observational data were collected sufficient to calculate SIRS, qSOFA, SOFA, comorbidity and mortality.

Results  8871 patients were enrolled, 4176 (47.1%) with SIRS. SIRS was associated with increased risk of organ dysfunction (RR 3.5), and mortality in patients without organ dysfunction (OR 3.2). SIRS and qSOFA showed similar discrimination for organ dysfunction (AUROC 0.72 vs 0.73). qSOFA was specific but poorly sensitive for organ dysfunction (96.1%, 29.7% respectively). Mortality for patients with organ dysfunction was similar for Sepsis-2 and Sepsis-3 (12.5%, 11.4%) although 29% of patients with Sepsis-3 organ dysfunction did not meet Sepsis-2 criteria. Increasing number of Sepsis-2 organ dysfunctions was associated with greater mortality.

Conclusions   SIRS was associated with organ dysfunction and mortality, and abandoning the concept appears premature. Although qSOFA greater than or equal to 2 showed high specificity, poor sensitivity may limit utility as a bedside screen. Although mortality for organ dysfunction was comparable between Sepsis-2 and Sepsis-3, more prognostic and clinical information is conveyed using Sepsis-2 regarding number of organ dysfunctions. ​The SOFA score may require recalibration.

I believe clinicians talking to one another and communicating in the chart should use the most current and agreed upon clinical terminology, which is Sepsis-3. Unfortunately the coding and regulatory world still operates in Sepsis-2. These competing influences pull providers all over the map when they document, such that these days, when I see the word sepsis at the top of the problem list I have no idea what the patient actually has. I always have to go back and examine the raw data.

There were good reasons for transitioning to Sepsis-3 and abandoning SIRS which failed to capture many patients who were infected and had a high risk of death. Moreover, many infected patients with SIRS are not at risk of death.

But, as the article points out, neither definition is perfect. Clinical judgment dictates that patients must be assessed for their risk of mortality and organ failure regardless of what label is applied. Unfortunately the word sepsis has become as much an administrative term as a clinical one.

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