Published in:
01-12-2016 | Editorial
The new sepsis consensus definitions: the good, the bad and the ugly
Published in: Intensive Care Medicine | Issue 12/2016
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Despite improvements in diagnosis and management, sepsis and septic shock remain frequent causes of morbidity and mortality. Singer and colleagues [1‐3] recently updated the consensus definitions of sepsis and septic shock to improve both sensitivity and specificity compared with the previous definitions [4]. We present here our opinions of the potential ramifications of this important work (Table 1).
Table 1
The new sepsis consensus definitions: the good, the bad, and the ugly
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1. The good
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A. Internationally recognized, multidisciplinary group of sepsis experts
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B. Definitions developed utilizing objective data
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C. Easier-to-use terms and rapid bedside score without blood tests
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2. The bad
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A. SIRS is important
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1. Descriptor to label infected patients versus non-infected patients with similar characteristics
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2. Sensitive tool for the early recognition of septic patients at risk for mortality and morbidity
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3. Increased prevalence of infection, sevee disease, organ failure, and mortality
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4. Used for inclusion criteria in many sepsis trials
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5. Use in quality improvement initiatives and management bundles
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B. Definition of septic shock
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1. Databases should have been used to determine which SBP or MAP best defines septic shock
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2. Previous consensus definitions excluded lactate measurement because of its unavailability in some countries
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C. SOFA problems
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1. The complexity of SOFA means it is poorly suited for use in low and middle income countries and problematic even in the USA and Europe
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2. Retrospective derivation of the SOFA score is problematic, as data may not be available
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3. Current vasopressor regimens no longer utilize dopamine
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4. SOFA is an acute organ dysfunction assessment.
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D. qSOFA problems
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1. Data are frequently not available
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2. A qSOFA score with two of three components as a screening tool in LMICs will select a population with a higher mortality
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3. qSOFA may identify sick patients but not necessarily septic ones
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3. The ugly
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A. Early sepsis recognition
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1. The new definitions discard the sepsis spectrum
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2. The new definitions do not expedite early recognition and treatment, and delay recognition and therapeutic intervention
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3. Patients will be at a later stage of disease with less reversibility and a worse prognosis
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4. Septic shock patients require vasopressor therapy and elevated lactates
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5. The new definitions not useful for screening potentially septic patients who may benefit from early intervention
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B. Sepsis study comparisons
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1. Studies utilizing the new definitions will have higher mortality than those using prior definitions
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2. The interpretation of the benefit of new therapeutic interventions will be hampered if they are compared with past outcome data using old definitions
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C. Sepsis advances
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1. No explanation of how the new definitions will improve the outcome of patients with sepsis
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2. No biochemical, genetic, epigenetic, inflammatory, or anti-inflammatory components to the definitions
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3. Wide gap between scientific advances in understanding and the clinical deployment of insights
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4. Can we expect real benefits from a modest redefinition?
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