1. Madiha Hashmi FFARCSI
Director SICU & Assistant Professor
Department of Anaesthesiology
Agha Khan University
Karachi, Pakistan
2.
3.
4. Regional Cooperation for Development:
(RCD)
Founded in 1964-1979
The Economic Cooperation Organization
(ECO)
In 1985, Iran, Pakistan and Turkey joined to
form the ECO that later expanded to
include seven new members;
Afghanistan, Azerbaijan, Kazakhstan, Kyrgyzstan, Tajikistan,
Turkmenistan and Uzbekistan
7. Need for sepsis definition
“The systemic response to infection ”
Terms like “INFECTION”, “BACTERAEMIA” , “SEPSIS”,
“SEPTICEMIA”, “SEPTIC SYNDROME”, and “SEPTIC
SHOCK” were used interchangeably.
Delayed bedside detection of sepsis delayed therapeutic
intervention.
Clinical trials could not be conducted in a systematic
fashion because it was impossible to assure enrollment of
homogenous groups of patients.
8. 1992- ACCP-SCCM Consensus Conference Definition
Infection:
A microbial phenomenon characterized by an inflammatory response
to the presence of microorganisms or the invasion of normally sterile
host tissues by those organisms.
Bacteremia:
Presence of Viable bacteria in the blood. The presence of viruses,
fungi, parasites in the blood should be described similarly as Viremia,
Fungemia etc.
Septicemia:
This term should be eliminated from current usage
SIRS:
Systemic inflammatory response to a variety of severe clinical insults
Chest 101(6):1644-1455
9. 1992- ACCP-SCCM Consensus Conference Definition
Sepsis is a syndrome of suspected or proven infection with at
least two of the four SIRS Criteria;
1. Heart rate >90 beats/min
2. Respiratory rate >20 breaths/min or PaCO2 < 32mmHg
3. Temperature >38°C or < 36°C
4. White blood cell >12000/mm³, <4000/mm³, or
>10% immature cells
Chest 101(6):1644-1655
10. 1992- ACCP-SCCM Consensus Conference Definition
Severe sepsis:
Sepsis associated with organ dysfunction, hypoperfusion, or
sepsis-induced hypotension. Hypoperfusion abnormalities
Include lactic acidosis, oliguria, or an acute alteration in mental
state.
Septic Shock:
Sepsis-induced hypotension, persisting despite adequate fluid
resuscitation along with the presence of perfusion abnormalities
or organ dysfunction.
Multiple organ dysfunction syndrome (MODS)
Presence of altered organ function in an acutely ill patient such
that homeostasis cannot be maintained without intervention
Chest 101(6):1644-1655
11.
12. “…what this initial application of the new definition has
achieved, therefore is an increase in the number of
patients classified by the definition…”
Sensitive but lacks specificity
Signs of systemic inflammation can and do occur in the
absence of infection among patients with burns,
pancreatitis and other disease states without infection
13. 2001- SCCM/ESICM/ACCP/ATS/SIS international
sepsis definitions conference
ESICM/SCCM physician attitudinal survey revealed that
71% of respondents cited no common definition of sepsis
Critical Care 8:R409-R413
Increase in clinical trials data relating to a number of new
interventions
14. 2001- SCCM/ESICM/ACCP/ATS/SIS international
sepsis definitions conference
To review strengths and weaknesses of 1992 definitions
To identify ways to improve the current definitions
To identify methodologies for increasing accuracy,
reliability and/or clinical utility of the diagnosis of sepsis
Intensive Care Med (2003) 29:530-538
15. 2001- SCCM/ESICM/ACCP/ATS/SIS international
sepsis definitions conference
Current concepts of sepsis, severe sepsis, and septic shock
remain useful to clinicians and researchers. Until further
evidence arises that justifies altering these categories that
describe the host response to infection, they should remain
as described 10 years ago.
While SIRS remains a useful concept, the diagnostic criteria
for SIRS published in 1992 are overly sensitive and
nonspecific.
An expanded list of signs and symptoms of sepsis may
better reflect the clinical response to infection.
The operational definitions of sepsis may be refined and
tested in the future as we increase our understanding of the
immunological and biochemical characteristics of these
conditions.
These definitions do not allow precise staging or
prognostication of the host response to infection.
16. SIRS-NEGATIVE SEPSIS?
Elderly patients
Beta blockers
Immunocompromised
Source of infection
Distributive shock
Should the fluid resuscitation and antibiotics be
withheld?
17. SIRS-NEGATIVE SEPSIS?
A data base of 1.2 million patients, from 172 ICUs in
Australia and New Zealand, from 2000-2013.
100,000 patients had an acute infection and organ failure.
1 in 8 patients (12%) had SIRS-negative severe sepsis or
septic shock
SIRS-screening criteria is a poor test in terms of sensitivity
1 in 8 patients may be missed
N Engl J Med (April 2015) 372;17:1629-1638
18. Need for refining and revisiting
sepsis definitions?
The requirement of 2 or more SIRS criteria for the
diagnosis of severe sepsis excludes a sizable group of
patients in the ICU with infection and organ
dysfunction.
The risk of death in the SIRS-positive and the SIRS-
negative groups increased linearly with each
additional SIRS criterion from 0-4, without a
transitional increase in risk at two criteria that would
justify this consensus cutoff point.
N Engl J Med (April 2015) 372;17:1629-1638
19. Need for refining and revisiting
sepsis Definitions?
SIRS Criteria are too non-specific to retain value
20. Need for refining and revisiting
sepsis Definitions?
Wide variation in the Sepsis incidence and outcome
Proliferation of definitions to suit;
Trial entry criteria
Management Guidelines
Retrospective analysis of databases
Crit Care Med 41:1167-1174
21. Need for refining and revisiting
sepsis Definitions?
Identifying septic patients on the basis of Discharge
Diagnosis Codes may be complicated by the likely
influence of;
Awareness campaigns
High-profile research papers
Enthusiastic implementation of Hospital protocols
22. Need for refining and revisiting
sepsis Definitions?
Tracking sepsis incidence using insurance-claims
based data may be unreliable
170% increase in sepsis between 2003-2011, yet during
the same period 22% reduction in the number of
patients admitted to hospitals in the US with
pneumonia
N Engl J Med (2014) 370;18:1673-1676
23. 2010-Merinoff Symposium
A public definition of sepsis:
“a life-threatening condition that arises when the body’s
response to an infection injures its own tissues and
organs, leading to shock, multiple organ failure and
death if not recognized early and treated promptly…”
A molecular definition of sepsis:
“Host-derived molecules and foreign products of
infection converge on molecular mechanisms that cause
unbalanced activation of innate immunity…”
24. There is a need for refining and
revisiting sepsis definitions because…
Existing definition is neither sensitive nor specific
Using the current definitions is leading to a wide
variation in incidence of sepsis and mortality of severe
sepsis and septic shock.
Knowledge of the underlying pathophysiology has
expanded and the fundamental role of the host
response in producing self-harm is now well
established.
