Sandbox sepsis diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The 1992 statement from the ACCP/ SCCM Consensus Conference introduced into common parlance the Systemic Inflammatory Response Syndrome (SIRS) which represents the complex findings resulting from systemic activation of the innate immune response triggered by localized or generalized infection, trauma, thermal injury, or sterile inflammatory processes. However, criteria for SIRS are considered to be too nonspecific to be of utility in diagnosing a cause for the syndrome or in identifying a distinct pattern of host response. Sepsis is defined as the presence (probable or documented) of infection together with systemic manifestations of infection, whereas severe sepsis refers to sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion. Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation, in the absence of other causes for hypotension.

Diagnostic Criteria

Systemic Inflammatory Response Syndrome (SIRS)

The 1992 statement from the ACCP/ SCCM Consensus Conference introduced into common parlance the Systemic Inflammatory Response Syndrome (SIRS) which represents the complex findings resulting from systemic activation of the innate immune response triggered by localized or generalized infection, trauma, thermal injury, or sterile inflammatory processes. However, criteria for SIRS are considered to be too nonspecific to be of utility in diagnosing a cause for the syndrome or in identifying a distinct pattern of host response.

SIRS is considered to be present when patients have two or more of the following clinical findings:

Body temperature >38 °C (100.4 °F) or <36 °C (96.8 °F) Heart rate >90 beats per minute Hyperventilation evidenced by a respiratory rate of >20 breaths per minute or a P<sub>a</sub>CO<sub>2</sub><32 mm Hg White blood cell count of >12000 cells/mm³ or <4000 cells/mm³ (>12 x 10<sup>9</sup>cells/L or <4 x 10<sup>9</sup>cells/L) or bandemia (>10% band forms)

Sepsis

Sepsis is defined as the presence (probable or documented) of infection together with systemic manifestations of infection. Diagnostic criteria for sepsis are as follows:

Sepsis = infection (documented or suspected) and some of the following:

General variables Fever (>38.3°C) Hypothermia (core temperature <36°C) Heart rate >90/min–1 or more than two sd above the normal value for age Tachypnea Altered mental status Significant edema or positive fluid balance (>20 mL/kg over 24 hr) Hyperglycemia (plasma glucose >140mg/dL or 7.7 mmol/L) in the absence of diabetes

Inflammatory variables Leukocytosis (WBC count >12,000 μL–1) Leukopenia (WBC count <4000 μL–1) Normal WBC count with greater than 10% immature forms Plasma C-reactive protein more than two sd above the normal value Plasma procalcitonin more than two sd above the normal value

Hemodynamic variables Arterial hypotension (SBP <90mm Hg, MAP <70mm Hg, or an SBP decrease >40mm Hg in adults or less than two sd below normal for age)

Organ dysfunction variables Arterial hypoxemia (Pao2/Fio2 <300) Acute oliguria (urine output <0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation) Creatinine increase >0.5mg/dL or 44.2 μmol/L Coagulation abnormalities (INR >1.5 or aPTT >60 s) Ileus (absent bowel sounds) Thrombocytopenia (platelet count <100,000 μL–1) Hyperbilirubinemia (plasma total bilirubin >4mg/dL or 70 μmol/L)

Tissue perfusion variables Hyperlactatemia (>1 mmol/L) Decreased capillary refill or mottling

Severe Sepsis

Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion.

Severe sepsis = sepsis-induced tissue hypoperfusion or organ dysfunction (any of the following thought to be due to the infection)

Sepsis-induced hypotension (SBP of <90 mm Hg or MAP <70 mm Hg or a SBP decrease >40 mm Hg or <2 SD below normal for age in the absence of other causes of hypotension) Lactate above upper limits laboratory normal Urine output <0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation Acute lung injury with PaO2/FIO2 <250 in the absence of pneumonia as infection source Acute lung injury with PaO2/FIO2 <200 in the presence of pneumonia as infection source Creatinine >2.0 mg/dL (176.8 μmol/L) Bilirubin >2 mg/dL (34.2 μmol/L) Platelet count <100,000 μL Coagulopathy (international normalized ratio >1.5)

Septic Shock

Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation, in the absence of other causes for hypotension.

• Septic shock in adults refers to a state of acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes.
• Septic shock in pediatric patients is defined as a tachycardia (may be absent in the hypothermic patient) with signs of decreased perfusion including decreased peripheral pulses compared with central pulses, altered alertness, flash capillary refill or capillary refill 􏰀2 seconds, mottled or cool extremities, or decreased urine output.

Refractory Septic Shock

Refractory Septic shock is defined as sepsis with refractory arterial hypotension and maintenance of the systemic mean blood pressure of >60 mmHg or >80 mmHg (in hypertensives) despite adequate fluid resuscitation requires:

• Dopamine >15 mcg/kg/min
• Norepinephrine >0.25 mcg/kg/min
• Epinephrine >0.25 mcg/kg/min
• Adequate fluid resuscitation is defined as infusion of the following at the said rates:
  • 20 to 30 mL/kg of starch,
  • 40 to 60 mL/kg of saline solution
  • Measured pulmonary capillary wedge pressure - 12 to 20 mmHg
  • Central venous pressure of 8 to 12 mmHg

Multiple Organ Dysfunction Syndrome

• It is defined as a progressive organ dysfunction that require interventions for maintenance of homeostasis.
• It is the most severe manifestation of either SIRS or sepsis continuum.
• Primary MODS can be directly connected to the source of infection. However, secondary MODS occurs as a result of host response to the primary insult.
• Parameters used to judge MODS are:
  • Liver - Serum bilirubin
  • Nervous system - Glasgow coma scale
  • Hematology - Platelet count
  • Renal - Serum creatinine
  • Respiratory - PO2/FiO2 ratio
  • Cardiovascular - Pressure-adjusted heart rate = Heart rate multiplied by the ratio of central venous pressure and mean arterial pressure

Neonatal Sepsis

The criteria for diagnosing an adult with sepsis does not apply to infants under one month of age (neonatal sepsis). In infants, only the presence of infection plus a "constellation" of signs and symptoms consistent with the systemic response to infection are required for diagnosis.