KK: From the board’s perspective, John, was it political sour grapes? Why didn’t ACEP endorse the new definitions?
Explore This Issue
ACEP Now: Vol 35 – No 07 – July 2016JR: The accusation that we were really just petulant children who were angry because we weren‘t invited to the party is not only dismissive, it’s patronizing and just frankly insulting. We didn’t agree with the process. We asked to be involved, and they said, “No, thank you,” which I think was a huge error on their part. More substantially, we don’t agree with their recommendations for a variety of reasons that were communicated to them. It was really disagreement on the substance.
DY: The failure in the process produced results that were incongruent with what an emergency physician thinks is most important. It isn’t the process; it’s the result that was created.
KK: The other issue we haven’t talked about is how the new definition of septic shock is exceptionally restrictive. It produces a group with a really high rate of mortality.
TS: If you look at the science critically, it looks like really good science. It looks like the authors did this amazing thing, and somehow, came up with qSOFA. But if you look at that final product, it doesn’t really work well for me as an emergency physician. The blood pressure part is simple, but they used a systolic of less than 100; we’re used to using less than 90. Their septic shock definition switched over to use mean arterial pressure (MAP), which makes it confusing. There are plenty of articles that show we’re really bad at agreeing on GCS [Glasgow Coma Scale] scores. How many of us who work in ERs know that everyone’s respiratory rate is 18? If you like historical quotes, in JAMA, 1957, Ross Kory wrote a cynical article about respiratory rate saying that it’s the biggest waste of time in medicine because everyone knows that those numbers aren’t accurate. Putting those three together may have seemed like it worked really well scientifically, but it makes for a really hard tool to use.
JR: When I first heard about qSOFA, I thought, “Great! This is going to make my life so much easier.” Then I looked at it and said, “You really did this by data mining. You haven’t studied it prospectively and validated it, and you want me to throw out SIRS.” Yes, I know SIRS isn’t the best thing since sliced bread, but I think at this point, it is premature to suggest that we should abandon SIRS for qSOFA.
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.