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Las nuevas definiciones de consenso de la sepsis: lo bueno, lo malo y lo feo.
The new sepsis consensus definitions: the good, the bad and the ugly.
Introduction
The new sepsis consensus definitions: the good, the bad and the ugly
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).
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Las definiciones de sepsis-3 predicen la mortalidad en la UCI en un país de ingresos medios bajos.
Sepsis-3 definitions predict ICU mortality in a low-middle-income country.
Besen BA1,2, Romano TG3,4, Nassar AP Jr5,6, Taniguchi LU5,3, Azevedo LC5,3, Mendes PV5,3, Zampieri FG7,8, Park M5.
Abstract
BACKGROUND: Sepsis-3 definitions were published recently and validated only in high-income countries. The aim of this study was to assess the new criteria's accuracy in stratifying mortality as compared to its predecessor (Sepsis-2) in a Brazilian public intensive care unit (ICU) and to investigate whether the addition of lactate values would improve stratification. METHODS: Retrospective cohort study conducted between 2010 and 2015 in a public university's 19-bed ICU. Data from patients admitted to the ICU with sepsis were retrieved from a prospectively collected database. ICU mortality was compared across categories of both Sepsis-2 definitions (sepsis, severe sepsis and septic shock) and Sepsis-3 definitions (infection, sepsis and septic shock). Area under the receiving operator characteristic curves were constructed, and the net reclassification index and integrated discrimination index for the addition of lactate as a categorical variable to each stratum of definition were evaluated. RESULTS: The medical records of 957 patients were retrieved from a prospectively collected database. Mean age was 52 ± 19 years, median SAPS 3 was 65 [50,79], respiratory tract infection was the most common cause (42%, 402 patients), and 311 (32%) patients died in ICU. The ICU mortality rate was progressively higher across categories of sepsis as defined by the Sepsis-3 consensus: infection with no organ dysfunction-7/103 (7%); sepsis-106/419 (25%); and septic shock-198/435 (46%) (P < 0.001). For Sepsis-2 definitions, ICU mortality was different only across the categories of severe sepsis [43/252-(17%)] and septic shock [250/572-(44%)] (P < 0.001); sepsis had a mortality of 18/135-(13%) (P = 0.430 vs. severe sepsis). When combined with lactate, the definitions' accuracy in stratifying ICU mortality only improved with lactate levels above 4 mmol/L. This improvement occurred in the severe sepsisand septic shock groups (Sepsis-2) and the no-dysfunction and septic shock groups (Sepsis-3). Multivariate analysis demonstrated similar findings. CONCLUSIONS: In a Brazilian ICU, the new Sepsis-3 definitions were accurate in stratifying mortality and were superior to the previous definitions. We also observed that the new definitions' accuracy improved progressively with severity. Serum lactate improved accuracy for values higher than 4 mmol/L in the no-dysfunction and septic shock groups.
KEYWORDS: Infection; Intensive care unit; Lactate; Organ dysfunction; Sepsis; Septic shock
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Definiciones del tercer consenso internacional para la sepsis y el choque séptico (Sepsis-3).
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
Singer M1, Deutschman CS2, Seymour CW3, Shankar-Hari M4, Annane D5, Bauer M6, Bellomo R7, Bernard GR8, Chiche JD9, Coopersmith CM10, Hotchkiss RS11, Levy MM12, Marshall JC13, Martin GS14, Opal SM12, Rubenfeld GD15, van der Poll T16, Vincent JL17, Angus DC18.
JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287.
Abstract
IMPORTANCE: Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination. RECOMMENDATIONS: Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. CONCLUSIONS AND RELEVANCE: These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.
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Segundo Curso-Taller de Anestesia y Dolor
Zapopan Jalisco, México
Dic 1-2, 2016
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California Society of Anesthesiologists
Annual Meeting April 27-30, 2017
San Francisco California
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