What is Sepsis?

Definition and Sepsis Bundle

Fahrul Razi
INTRODUCTION
What is sepsis
anyway?
“We therefore propose the phrase systemic
inflammatory response syndrome (SIRS) to
describe this inflammatory process…”
1992; 1st
Definition of SIRS when 2 or more of the following
Sepsis criteria met:
published in (1)Temperature > 38∘C or < 36 ∘C
CHEST (2)Heart rate >90
(3)Respiratory rate >20 or PaCO2 <32
(4) White blood cell count > 12,000/cu mm,
<4,000/cu mm, or >10% bands

SIRS + Infection = Sepsis

Bone et al. CHEST (1992)
Surviving Sepsis Campaign Responds to Sepsis-3
March 1, 2016

Implications of the New Definitions for Screening and

Management

STEP 1:
SCREENING AND MANAGEMENT
OF INFECTION
Langkah pertama yang tepat dalam skrining harus identifikasi
infeksi

Gunakan tanda dan gejala infeksi untuk identifikasi awal

pasien dengan dugaan atau konfirmasi infeksi.

Dimulai dengan mendapatkan darah dan kultur lain sesuai

indikasi, memberikan antibiotik yang sesuai dengan
kebutuhan,

dan secara bersamaan memperoleh hasil laboratorium untuk

mengevaluasi pasien untuk disfungsi organ terkait infeksi.
Surviving Sepsis Campaign Responds to
Sepsis-3
March 1, 2016

STEP 2: SCREENING FOR ORGAN DYSFUNCTION AND

MANAGEMENT OF SEPSIS (FORMERLY CALLED
SEVERE SEPSIS)
Pasien dengan sepsis (sebelumnya disebut sepsis berat)
masih harus diidentifikasi dengan kriteria disfungsi organ
yang sama (termasuk tingkat laktat lebih besar dari 2
mmol/L).

Disfungsi organ juga dapat diidentifikasi menggunakan

Penilaian Kegagalan Organ Terkait Sepsis cepat (qSOFA).

Elemen qSOFA (perubahan status mental, laju pernapasan

lebih dari atau sama dengan 22 kali/menit dan tekanan darah
sistolik kurang dari atau sama dengan 100 mm Hg)
SOFA Score
HAT “Magic HAT predicts
Pada pasien yang telah diskrining positif untuk
infeksi maka lakukan skrining sekunder untuk
mengidentifikasi pasien yang berisiko
mengalami perburukan klinis.

Jika disfungsi organ diidentifikasi, maka

pastikan elemen bundel tiga jam telah dimulai
menjadi prioritas.
 Implications of the New Definitions for
Screening and Management

STEP 3:

IDENTIFICATION AND
MANAGEMENT OF INITIAL
HYPOTENSION
Pada pasien yang mengalami infeksi dan
hipotensi atau kadar laktat lebih besar atau
sama dengan 4 mmol/L, pemberian kristaloid
30 mL/kg dengan penilaian ulang respons
volume atau perfusi jaringan harus dilakukan.

Untuk bundel enam jam, laktat berulang juga

dianjurkan jika tingkat laktat awal lebih besar
dari 2 mmol/L.
 Limitations of SOFA + qSOFA

• SOFA and qSOFA scores were designed as research tools at a

population level to predict which patients with sepsis were likely to
die…they do not define sepsis

• Clinical deterioration in patients with a positive qSOFA score may be due

to causes other than sepsis

• New organ dysfunction should prompt you to consider occult infection

• *** The addition of serum lactate to qSOFA did not significantly change
the ability of qSOFA to predict mortality.

Singer et al. JAMA (2016)

“…qSOFA was poorly sensitive (60.8%) and moderately (72%)
specific for prediction of mortality. Whereas SIRS were more
sensitive but much less specific.”

qSOFA had better sensitivity in ICU population. Better

specificity in non-ICU patients.
 Q SO FA = Q U I C K B ED SI D E ST RA T I F I C A T I O N T O O L
. . N O T A D I A G N O ST I C F O R SEPSI S
neurological
cardiovascular
dysfunction?
dysfunction? low systolic BP (≤ 100 mmHg)

qSOFA altered mentation

respiratory ±
metabolic
tachypnoea (≥ 22/min) dysfunction?

qSOFA mortality (%)

0 ~1
1 ~3
2 ~8-10
3 >20
Singer et al. JAMA (2016); adapted from Vincent et al
CONCLUSIONS

The need for two or more SIRS criteria to define severe

sepsis excluded one in eight otherwise similar patients with
infection, organ failure, and substantial mortality and
failed to define a transition point in the risk of death.
(Funded by the Australian and New Zealand Intensive Care
Research Centre.)
Sepsis-3: Out with SIRS, in with SOFA

1992; 1st 2001: International 2016: International

1992; 1st 2001: International 2016: International
Definition of
Definition of Sepsis
SepsisConsensus
Consensus Sepsis Consensus
Sepsis Consensus
SepsisSepsis Published Conference;
Conference; Conference; Conference;
in CHEST "Sepsis-2" "Sepsis-3"
Published in "Sepsis-2" "Sepsis-3"
CHEST
2018 Sepsis Treatment Guidelines
A variety of clinical variables and
tools are used for sepsis screening:

such as systemic inflammatory response syndrome

(SIRS) criteria, vital signs, signs of infection, quick
Sequential Organ Failure Score (qSOFA) or
Sequential Organ Failure Assessment (SOFA) crite-
ria, National Early Warning Score (NEWS), or
Modified Early Warning Score (MEWS)
Therefore, the majority of studies used to establish evidence for these
guidelines referred to the 2005 nomenclature in which severe sepsis was
defined as

1) greater than or equal to 2 age-based systemic inflammatory response

syndrome (SIRS) criteria,
2) confirmed or suspected invasive infection, and
3) cardiovascular dysfunction, acute respiratory distress syndrome (ARDS),
or greater than or equal to 2 noncardiovascular organ system
dysfunctions; and

Septic shock was defined as the subset with cardiovascular dysfunc-tion,

which included hypotension, treatment with a vasoactive medication, or
impaired perfusion.
 Take Home Points
• Sepsis adalah disfungsi organ yang mengancam jiwa yang
disebabkan oleh respon host yang tidak teratur terhadap infeksi

• Berbagai variabel dan alat klinis digunakan untuk skrining sepsis

• Surviving Sepsis 2018 bundle
– Measure lactate, re-measure if elevated
– Give antibiotics as early as possible
– Fluid resuscitate for hypotension or lactate > 4; balanced crystalloids are
probably preferred
– Start vasopressors for hypotension refractory to fluids; adjunct steroids are
reasonable for vasopressor dependent shock
• Consider transfer to the ICU and/or “Intensivist consult” if not
clinically improving
Thank you