Sepsis-3 Definitions

Abstract

I am concerned that the recent “No SIRS: Quick SOFA Instead” column authored by Jeremy Faust and featured in the May News & Perspectives section is inaccurate. Specifically, the table labeled Figure 1 and titled “Sepsis Definitions” in row 2, column 3 seems to have simply substituted quick Sequential Organ Failure Assessment (qSOFA) and Sequential Organ Failure Assessment (SOFA) in place of systemic inflammatory response syndrome (SIRS) in the old definition, implying that Sepsis-3 defines sepsis as “suspected or documented infection + ≥2 of qSOFA or Rise in SOFA score ≥2 points.” As presented in the table, this definition is not contained in the published findings of the Sepsis-3 investigators. As spelled out in the Sepsis-3 documents published in the Journal of the American Medical Association, qSOFA is presented neither as a stand-in for SIRS nor as a diagnostic criterion of sepsis but rather a risk-stratification tool and a prompt to consider possible sepsis and assess for the presence of organ dysfunction in patients with suspected infection. As the Sepsis-3 task force wrote, “…the task force recommended use of a SOFA score of 2 points or more in encounters with infection as criteria for sepsis and use of qSOFA in non-ICU setting to consider the possibility of sepsis.”1Seymour C.W. Liu V.X. Iwashyna T.J. et al.Assessment of clinical criteria for sepsis: for the third international consensus definitions for sepsis and septic shock (sepsis-3).JAMA. 2016; 315: 762-774Crossref PubMed Scopus (2059) Google Scholar Additional passages from the Sepsis-3 publications further reflect this: “The task force suggests that qSOFA criteria be used to prompt clinicians to further investigate for organ dysfunction, to initiate or escalate therapy as appropriate, and to consider referral to critical care or increase the frequency of monitoring, if such actions have not already been undertaken.”2Singer M. Deutschman C.S. Seymour C.W. et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016; 315: 801-810Crossref PubMed Scopus (11873) Google Scholar “…qSOFA could be a useful clinical tool…to promptly identify infected patients likely to fare poorly.”2Singer M. Deutschman C.S. Seymour C.W. et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016; 315: 801-810Crossref PubMed Scopus (11873) Google Scholar “Neither qSOFA nor SOFA is intended to be a stand-alone definition of sepsis. It is crucial, however, that failure to meet 2 or more qSOFA or SOFA criteria should not lead to a deferral of investigation or treatment of infection….”2Singer M. Deutschman C.S. Seymour C.W. et al.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016; 315: 801-810Crossref PubMed Scopus (11873) Google Scholar The Surviving Sepsis Campaign's Sepsis-3 response document also reflects this in its qSOFA Clarification section: “qSOFA does not define sepsis (but the presence of 2 qSOFA criteria is a predictor of both increased mortality and ICU stays of more than 3 days in non-ICU patients).”3Surviving Sepsis Campaign. Surviving Sepsis Campaign responds to Sepsis-3. 2016. Available at: http://www.survivingsepsis.org/News/Pages/Surviving-Sepsis-Campaign-Responds-to-Sepsis-3.aspx. Accessed May 16, 2016.Google Scholar No SIRS; Quick SOFA Instead: SCCM Redefines Sepsis Without Emergency Medicine InputAnnals of Emergency MedicineVol. 67Issue 5PreviewIt’s barely noon and already 5 patients have triggered a sepsis alert in triage. Once that happens, patients are expedited into the emergency department (ED), assessed, and treated urgently. Laboratory tests are ordered; fluids are given. Two systemic inflammatory response criteria and suspect infection is all it takes to sound the alarm, but this may be about to change. Full-Text PDF In reply:Annals of Emergency MedicineVol. 68Issue 6PreviewMr. Gheen’s letter points out an important and common misconception in the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) about the difference between the new definitions and the clinical criteria for identifying sepsis.1 Specifically, many fail to notice that the task force defines sepsis as life-threatening organ dysfunction resulting from a dysregulated host response to infection while stating that an increase in Sequential Organ Failure Assessment (SOFA) or a quick Sequential Organ Failure Assessment (qSOFA) is a clinical criterion that should prompt appropriate investigations. Full-Text PDF