There’s been quite an explosion of discussion on the new sepsis guidelines in the FOAM world.
I had just assumed that ACEP was one of the 31 societies that endorsed the new guidelines, but notably absent are any US emergency medicine societies (the European Society of Emergency medicine did endorse them). I think it’s easy to see why ACEP passed on this as the new guidelines do not add much to change our recognition, definition, or treatment of sepsis in the emergency department.
One of the main assertions of the new guidelines is: “The current use of 2 or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful.”
We all recognize that the specificity of SIRS was lacking. While our patients with pharyngitis, pyelonephritis, and influenza often meet sepsis criteria using SIRS they rarely fit into our usual concept of sepsis. Worse yet is every anxious psych or trauma patient being flagged as having SIRS criteria.
However the authors provide no replacement for SIRS other than the very questionably useful qSOFA score (Altered mental status, hypotension, and tachypnea). If we haven’t considered sepsis in an obtunded patient in shock then a qSOFA score probably won’t help.
The new sepsis definitions essentially eliminate the old category of plain ‘sepsis.’ Instead, the new definitions don’t really start until we reach what we formerly called severe sepsis: sepsis + end organ dysfunction.
||SIRS + Infection
||Sepsis + end organ dysfunction
||Infection + SOFA ≥ 2
||Sepsis + hypotension
||Sepsis + vasopressors AND lactate ≥ 2
Anecdotally, I don’t think the challenge with sepsis in the ED is identifying the very sick, it’s trying to identify which patients might become sick that we could otherwise miss. These new definitions just push sepsis farther down the pathological spiral of infection rather than contributing anything to pre-hospital or ED diagnosis and management.
Maybe the SOFA score could help us pick up on some end-organ dysfunction we weren’t paying close attention to before, but by the time an ED patient has all the parameters necessary to calculate a SOFA score including CBC, BMP, LFTs, and an ABG they are well on their way into their sepsis workup and have already bought themselves an admission.
I won’t be throwing SIRS out the window in my practice and I don’t see qSOFA or SOFA having much impact on the majority of patients I see in the ED.
We’ll hear more on sepsis and the new guidelines from Dr. Mayglothling during the ID block in April. Until then here are several posts on the guidelines to keep you entertained:
PulmCrit/EMCrit – Top 10 problems with new sepsis definition
First10EM – Sepsis 3.0
First10EM – Is SIRS really that bad?
REBEL EM – Sepsis 3
St. Emlyn’s – Sepsis 3
Latin American Sepsis Institute – Why we did not endorse the new definition of sepsis