Pharmacy OneSource Blog

Clinical Corner: Sepsis – Which Checklist is Best?

Posted on 04/20/16

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The most common signs of sepsis, systemic inflammatory response syndrome (SIRS), are the definitive measure for identifying sepsis, right? Possibly not. According to a task force recently formed between the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, the SIRS criteria may be inadequate for identifying patients at risk of death from multi-organ failure.

The study, published in the Journal of the American Medical Association, identified some key issues with the SIRS criteria, namely, “an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the SIRS criteria.”1 In addition to the study, a survey of 94 physicians displayed extremely subjective and variable results when evaluating potential sepsis case vignettes.2 Both studies highlighted the need for updated sepsis-related definitions and clinical criteria.

Another study detailed in the New England Journal of Medicine3 noted some discrepancies regarding the common wisdom about the relationship between SIRS and Sepsis. The study investigated patients in Australia and New Zealand’s intensive care units and categorized them by whether the patients met two or more SIRS criteria, or less than two of the SIRS criteria. After comparing characteristics of patients and outcomes, the researchers discovered that one out of every eight patients in the group did not meet two or more SIRS criteria, despite the presence of severe sepsis.

The increased focus on SIRS criteria to identify sepsis may now shift to three criteria known as the Sequential Organ Failure Assessment (SOFA): altered mental status (confusion), systolic blood pressure equal to or less than 100 mmHg, and a breathing rate equal to or greater than 22 respirations per minute. The presence of any two of those associated risk factors correlates to an increased risk of in-hospital mortality of 10%. These three criteria were found to miss fewer cases of potential severe sepsis as well as decreasing overtreatment of less severe cases.

It appears that this new assessment tool could start to replace the SIRS criteria as the most objective measurement of sepsis risk. The change may be slowly adopted in the US, as the Center for Medicare and Medicaid Services (CMS) continues to rely on the SIRS criteria as the basis for its sepsis quality measure. This quality of care measure may also delay widespread acceptance of the SOFA criteria, as hospitals may face punishment in the form of reduced CMS reimbursement for failing to meet SIRS-based quality measures. As continued emphasis on sepsis mounts, expect to see changes in criteria down the road.

SOFA Criteria1

  • Respiratory Rate ≥ 22 / min
  • Altered mentation (confusion)
  • Systolic blood pressure ≤100 mm Hg
SIRS Criteria4

Two or more of the following:

  • Fever greater than 100.4 F
  • Heart rate > 90 bpm
  • Respiratory Rate > 20 per minute or
  • White blood cell count > 12,000 / mm3 or < 4000 / mm3 or > 10 % immature bands

 

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References:

  1. http://jama.jamanetwork.com/article.aspx?articleid=2492881
  2. Rhee et al. Critical Care (2016) 20:89
  3. http://www.nejm.org/doi/full/10.1056/NEJMoa1415236
  4. http://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=1992&issue=06000&article=00025&type=abstract

 

Topics: Infection Prevention

About the Author

Richard Dion, PharmD is a Pharmacy Clinical Program Manager for Pharmacy OneSource. Richard has 10 years of experience in the areas of medication use safety, pharmacy informatics, and clinical decision support in varied settings including academic medical centers and community hospitals. He has a keen interest in developing workflow practices that improve both pharmacist efficiency and job satisfaction. Richard received his PharmD from the University of Rhode Island and completed both a PGY1 residency in Pharmacy Practice and PGY2 residency in Medication Use Safety at the University of Massachusetts Memorial Medical Center.