What is Sepsis?
The evolution of sepsis definition:
Sepsis 3, Sepsis 2016 and Sepsis
Bundle 2018
Fahrul Razi
INTRODUCTION
POPULASI SEPSIS
2001 United States insiden 300 episodes per 100,000 populasi
2016 population-based study from Sweden identified an incidence of 780 per
100,000 per annum. With a population of just over 65 million.
Di Benua Asia :
penelitian pada tahun 2009
150 ruang perawatan intensif
16 negara (termasuk Indonesia)
sepsis berat dan renjatan septik 10,9% di perawatan intensif
angka kematian mencapai 44,5%.
RSCM tahun 2012 :
Sepsis berat dan renjatan septik ditemukan pada 23 dari 84
kasus perawatan intensif
Angka kematian dalam perawatan mencapai 47,8%
Angka kematian pada fase dini mencapai 34,7%.
KEPUTUSAN MENTERI KESEHATAN REPUBLIK INDONESIANOMOR HK.01.07/MENKES/342/2017 TENTANG PEDOMAN NASIONAL PELAYANAN
RSCM : jumlah pasien yang dirawat dengan diagnosis
sepsis sebesar 10,3 % dari keseluruhan pasien yang
dirawat di ruang rawat penyakit dalam.
Renjatan septik merupakan penyebab kematian
tertinggi selama 3 tahun berturut-turut (2009-2011),
yaitu pada 49% kasus kematian pada tahun 2009 dan
meningkat menjadi 55% pada tahun 2011 (data tidak
dipublikasi).
KEPUTUSAN MENTERI KESEHATAN REPUBLIK INDONESIANOMOR HK.01.07/MENKES/342/2017 TENTANG PEDOMAN NASIONAL
What is sepsis
anyway?
“We therefore propose the phrase systemic
inflammatory response syndrome (SIRS) to
describe this inflammatory process…”
1992; 1st
Definition of SIRS when 2 or more of the following
Sepsis criteria met:
published in (1)Temperature > 38∘C or < 36 ∘C
CHEST (2)Heart rate >90
(3)Respiratory rate >20 or PaCO2 <32
(4) White blood cell count > 12,000/cu mm,
<4,000/cu mm, or >10% bands
SIRS + Infection = Sepsis
Bone et al. CHEST (1992)
Surviving Sepsis Campaign Responds to Sepsis-3
March 1, 2016
Implications of the New Definitions for Screening and
Management
STEP 1: SCREENING AND MANAGEMENT OF INFECTION
The appropriate first step in screening should be
identification of infection. Hospitals should continue
to use signs and symptoms of infection to promote
the early identification of patients with suspected or
confirmed infection.
In those patients identified as having infection,
management should begin by obtaining blood
and other cultures as indicated, administering
tailored antibiotics as appropriate, and
simultaneously obtaining laboratory results to
evaluate the patient for infection-related organ
dysfunction.
Surviving Sepsis Campaign Responds to
Sepsis-3
March 1, 2016
Implications of the New Definitions for Screening and
Management
STEP 2: SCREENING FOR ORGAN DYSFUNCTION AND
MANAGEMENT OF SEPSIS (FORMERLY CALLED
SEVERE SEPSIS)
Patients with sepsis (formerly called severe sepsis) should still be
identified by the same organ dysfunction criteria (including lactate
level greater than 2 mmol/L). Organ dysfunction may also be
identified in the future using the quick Sepsis-Related Organ
Failure Assessment (qSOFA). Importantly, evidence of two out of
three qSOFA elements (altered mental status, respiratory rate
greater than or equal to 22 breaths/min and systolic blood
pressure less than or equal to 100 mm Hg) in patients who have
screened positive for infection may be used as a secondary screen
to identify patients at risk for clinical deterioration. Practitioners
should strongly consider closer monitoring of these at-risk
patients.
If organ dysfunction is identified, ensuring that the
three-hour bundle elements have been initiated
continues to be a priority. For instance, patients with
organ dysfunction require blood cultures if only non-
blood cultures had previously been obtained and
administration of broad-spectrum antibiotics if only
narrow-spectrum antibiotics had previously been
administered
Implications of the New Definitions for
Screening and Management
STEP 3: IDENTIFICATION AND MANAGEMENT OF INITIAL
HYPOTENSION
In those patients who have infection and hypotension or a
lactate level greater than or equal to 4 mmol/L,
providing 30 mL/kg crystalloid with reassessment of
volume responsiveness or tissue perfusion should be
implemented. The six-hour elements of care should be
completed. For the six-hour bundle, repeat lactate level
is also recommended if initial lactate level was greater
than 2 mmol/L.
SOFA Score
HAT “Magic HAT predicts
Limitations of SOFA + qSOFA
• SOFA and qSOFA scores were designed as research tools at a
population level to predict which patients with sepsis were likely to
die…they do not define sepsis
• Clinical deterioration in patients with a positive qSOFA score may be due
to causes other than sepsis
• New organ dysfunction should prompt you to consider occult infection
• *** The addition of serum lactate to qSOFA did not significantly change
the ability of qSOFA to predict mortality.
Singer et al. JAMA (2016)
“…qSOFA was poorly sensitive (60.8%) and moderately (72%)
specific for prediction of mortality. Whereas SIRS were more
sensitive but much less specific.”
qSOFA had better sensitivity in ICU population. Better
specificity in non-ICU patients.
Q SO FA = Q U I C K B ED SI D E ST RA T I F I C A T I O N T O O L
. . N O T A D I A G N O ST I C F O R SEPSI S
neurological
cardiovascular
dysfunction?
dysfunction? low systolic BP (≤ 100 mmHg)
qSOFA altered mentation
respiratory ±
metabolic
tachypnoea (≥ 22/min) dysfunction?
qSOFA mortality (%)
0 ~1
1 ~3
2 ~8-10
3 >20
Singer et al. JAMA (2016); adapted from Vincent et al
CONCLUSIONS
The need for two or more SIRS criteria to define
severe sepsis excluded one in eight otherwise similar
patients with infection, organ failure, and substantial
mortality and failed to define a transition point in the
risk of death. (Funded by the Australian and New
Zealand Intensive Care Research Centre.)
Sepsis-3: Out with SIRS, in with SOFA
1992; 1st 2001: International 2016: International
1992; 1st 2001: International 2016: International
Definition of
Definition of Sepsis
SepsisConsensus
Consensus Sepsis Consensus
Sepsis Consensus
SepsisSepsis Published Conference;
Conference; Conference; Conference;
in CHEST "Sepsis-2" "Sepsis-3"
Published in "Sepsis-2" "Sepsis-3"
CHEST
2018 Sepsis Treatment Guidelines
“Sepsis-4”: What does the future hold?
1992; 1st Definition 2001: International 2016: International
of Sepsis Sepsis Consensus Sepsis Consensus
Published in Conference; Conference; The Future: ???
CHEST "Sepsis-2" "Sepsis-3"
Sepsis is life-threatening organ dysfunction caused by a dysregulated
host response to infection
Septic Shock: Subset of sepsis with circulatory and cellular/metabolic
dysfunction associated with higher risk of mortality
Take Home Points
• Sepsis is a life threatening organ dysfunction caused by
dysregulated host response to infection
• Surviving Sepsis 2018 bundle (hour 1 Bundle)
– Measure lactate, re-measure if elevated
– Give antibiotics as early as possible
– Fluid resuscitate for hypotension or lactate > 4; balanced crystalloids are
probably preferred
– Start vasopressors for hypotension refractory to fluids; adjunct steroids are
reasonable for vasopressor dependent shock
• Consider transfer to the ICU and/or “Intensivist consult” if not
clinically improving
Thank you
