KK: We’re still struggling to identify who actually has sepsis. The average reader and average emergency physician are at risk to interpret this new information to mean, “We’re moving away from SIRS, and instead we’re plugging in qSOFA as a screening tool,” even though a qSOFA was intended to be a risk stratification tool once you’ve identified those with sepsis.
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ACEP Now: Vol 35 – No 07 – July 2016DY: Kevin, I think you’ve hit the nail on the head. I don‘t think it’s a question of whether qSOFA is better or worse than SIRS; they’re intended for different purposes. qSOFA is new, and we don’t know how well it will stand up. They do different things.
JR: From the community physician perspective, the definitions aren’t particularly helpful. They seem to be more theoretical. I come away scratching my head thinking, “So, what am I supposed to do?” The answer is that you’re not supposed to do anything different than what you‘re already doing. I also worry about leaving out that severe sepsis group, those at high risk for deterioration, and identifying only those at a high risk of mortality (eg, septic shock).
KK: Maybe this whole change in definition is an academic discussion that has no applicability to the bedside. Does it move us any further along with our understanding of sepsis and our ability to diagnose it? I recall a quote by Niccolo Machiavelli in The Prince Book III, 1498: “Hectic fever [sepsis] at its inception is difficult to recognize, but easy to treat. Left untended, it becomes easy to recognize but difficult to treat.” I don’t think we’re much further along with identifying sepsis today than we were when he made this statement.
“At this time ACEP will reserve endorsement pending the response(s) to our feedback and suggestions. We also ask that moving forward that emergency physicians be included on this and future efforts given the high impact and frequency of sepsis, severe sepsis, and septic shock in the emergency department setting.”
—Michael J. Gerardi, MD, FAAP, FACEP, Past President, ACEP, letter to President of Society for Critical Care Medicine regarding release of consensus definitions for sepsis
TO: What the authors have done is very, very difficult, and I give them credit. But one of the problems is that they included only people who saw sepsis in one phase of the disease—the ICU guys. They basically said, “We’ll make the decisions and then send it out for you to comment on.” There was no North American EM group involved in creating or that has endorsed these definitions. There was no North American hospitalist group involved, and in fact, globally, there’s only one EM professional organization that endorsed the definitions. The people who see these patients at the most proximal stage of the disease weren’t included in the discussion. As Don points out, we’re in a business of sensitivity rather than specificity. Some think ACEP didn‘t endorse it because they weren’t part of the discussion. In my opinion, there are two reasons why ACEP didn’t give their endorsement: They don’t agree with the actual guidelines that are being drafted or the science behind it, and they don’t agree with the process.
2 Responses to “A Marriage of Old Data and New Concepts: New Sepsis Definitions Raise Concerns about Accuracy, Usefulness in Emergency Medicine”
July 26, 2016
Lawrence LynnWe were encouraged that sepsis science was trying to move toward evidenced based crteria from the guessed SIRS of the past. The use of the guessed SIRS criteria in clinical trials was not scientific and was producing runaway inflation of the sepsis diagnosis, inflating the perceived benefit of intervention and rendering any positive benefit of RCT (in comparison with a control population) nonreproducible. SIRS had to be abandoned as the standard definition used in sepsis research.
However the needs of clinical medicine in a vacuum of objective data are different than the needs of scientists in that same vacuum. It is therefore not surprising that ER physcians have been disappointed with qSOFA which was derived from an effort to improve the scientific study of sepsis.
The problem is that there was no determination of when, on the timeline of the different dynamic relational patterns of common sepsis phenotypes, qSOFA criteria are met.
To illustrate this, consider the case of Rory Staunton. He was alert, non hypotensive, yet he had tachypnea, over 50% bands (evolving neutrophilic failure), a low platelet count (although not down to 100) and evidence of infection. Later (perhaps too late) he had hypotension and mental status changes.
When we called for a new sepsis definition we expected that the data from large trials would be reviewed to determine the dynamic relational patterns of the common sepsis phenotypes and then EARLY markers components of the patterns selected as a screening definition with the addition of the time patterns in the scientific definition. Alas, in the statistical search for correlates, time was, once again, overlooked. ER docs never overlook time as the essence of the word “emergency” is time.
The problem with setting up late criteria is the risk of a false sense of security. Altered mental state and hypotension are proven markers of all sepsis phenotypes but so is death. All three are often late findings and markers of diagnostic delay.
July 31, 2016
Mike GertzThe recommendations by the surviving sepsis campaign have always been to only screen patients who are “seriously ill appearing.” As a specialty, we know what that means. The problem is that we are trying to screen everyone with a lot of resultant noise. In the end, sepsis is like pornography, difficult to define but we all know it when we see it.