Hi Ron, I agree completely that a patient with infection and organ dysfunction who can't mount a "complete" SIRS response (2 or more criteria), should be treated aggressively. I was simply pointing out that the original definition for fever that was proposed by Bone, et al was more stringent than what we now use. I don't know if Bob Balk is on this list serve or not, but I think I'll copy him to get his insight. He was clearly involved from the first and was there at the initial ACCP-SCCM consensus conference in 1991. Perhaps he knows why the fever criterion was loosened at the consensus conference and won't mind sharing with us. I was a fellow under Roger Bone and Bob Balk at the time of the aforementioned publication describing the clinical importance of what they referred to at the time as sepsis syndrome. It is an important historical point to remember that previous to the 1991 consensus conference there was NO commonly accepted set of criteria for diagnosing sepsis. We owe a great debt to these men for moving us beyond the diagnostic free for all that existed previously. The definitions give us the means to educate many different types of provider and to improve our performance at caring for septic patients in a systematic way. They, of course, do not remove the obligation for any of us - doctors, nurses, mid-levels, or anyone else - to think and to err on the side of safe and effective patient care, if we are to err at all. Your points are very well taken and very germane. What they indicate is what I already know to be true, that you and your team have moved beyond the point of consistently recognizing the clear-cut cases of severe sepsis and on to making sure that no septic patient is left behind. Your efforts to get everyone on this list serve to that level are both laudable and appreciated.
SQS Steven Q. Simpson, MD Professor of Medicine Director, Fellowship Training Division of Pulmonary Diseases and Critical Care Medicine University of Kansas 3901 Rainbow Blvd. Kansas City, KS 66160-7381 Phone: (913) 588-6045 Fax: (913) 588-4098 >>> Ron Elkin <[email protected]> 3/6/2012 12:47 PM >>> Hi, At the risk of repetition: In some respects the strict definition of sepsis, 2 signs of SIRS + infection, can be an obstacle to diagnosis. Signs of SIRS lack sensitivity, specificity, and accuracy for the diagnosis of severe sepsis and septic shock. 10-15% of our patients with infection and organ failure - ie severe sepsis or septic shock - have FEWER than 2 signs of SIRS. These are mainly the elderly, the immunosuppressed, or patients on drugs or with other conditions that preclude tachycardia or fever, or even tachypnea (beta blockers, calcium channel blockers, NSAIDS, ASA, sedatives, narcotics, pacemakers, heart block, bradyarrhythmias, hypothyroidism, etc). Fever is a particularly fickle indicator of infection. I daresay we are all aware of debilitated elderly people who never exceed 36 degrees C in health and present with obtundation as the only manifestation of severe sepsis, ie no SIRS. Many of these patients have positive cultures and get better with fluid and antibiotics. If we don't call this severe sepsis because signs of SIRS are absent, what do we call it? In this context stipulating a temperature threshold for SIRS as 38 or 38.3 seems irrelevant. Signs of SIRS are undeniably useful for screening and often lead one to suspect infection as the probable cause of acute organ failure. One of the purposes of initial screening, however, is to avoid missing cases. The sensitivity of the initial screen should therefore be high, with the knowledge that there will indeed be false positives. It is an error to terminate screening because there are 0-1 sign of SIRS. Our screening methods have accordingly moved towards the following 3 questions which we regard as completely independent of one another: 1) Are there 1 or more new signs of SIRS? 2) Is there suspicion of infection? 3) Is there evidence of new organ dysfunction? "Yes" to any of these 3 questions is intended to trigger a call to the MD with further investigation to follow. References are attached. Thanks Ron Elkin, MD California Pacific Medical Center San Francisco, California On Tue, Feb 28, 2012 at 9:45 AM, Steven Simpson <[email protected]> wrote: It should be pointed out that the original validation of the sepsis syndrome (now called severe sepsis) was in the following landmark paper: Bone RC, et al. Sepsis Syndrome: A Valid Clinical Entity. Critical Care Medicine 17:389-393. The inclusion criterion for temperature was rectal T > 101 degrees F or < 96 degrees F. That would be 38.3 degrees C and 35.5 degrees C. I'm not sure how, exactly, we got to the numbers 38 and 36 in our "standard" criteria, nor how we wandered away from rectal temperatures, unless it was deemed more useful, i.e. more sensitive or more inclusive to allow different methods of obtaining temperature. Interestingly, TM probes and continuous bladder temps were not even available at the time of the original study! Nevertheless, the SSC has demonstrated very much improved survival of patients fitting the more standard criteria, and we should probably be circumspect about tossing them out at this juncture. SQS >>> Andy Bourgeois <[email protected]> 2/27/2012 11:48 AM >>> SIRS criteria have been defined differently in various studies. The temperature was 38 degrees C in a few early articles: One of the early definitions of sepsis: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Chest. 1992 Jun;101(6):1644-55. Review The original Early Goal Directed Therapy article from 2001 Early goal-directed therapy in the treatment of severe sepsis and septic shock. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. N Engl J Med. 2001 Nov 8;345(19):1368-77. Most of the more recent studies and reviews use 38.3 degrees C: International Sepsis Definitions Conference in 2001 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G; SCCM/ESICM/ACCP/ATS/SIS. Crit Care Med. 2003 Apr;31(4):1250-6. Review. In this 2006 review article from some of the original Early Goal Directed Therapy investigators: Severe sepsis and septic shock: review of the literature and emergency department management guidelines. Nguyen HB, Rivers EP, Abrahamian FM, et al. Ann Emerg Med. 2006 Jul;48(1):28-54. Epub 2006 May 2. Review. The Surviving Sepsis Campaign - 2008 Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Dellinger RP, Levy MM, Carlet JM, et al. Crit Care Med. 2008 Jan;36(1):296-327. Erratum in: Crit Care Med. 2008 Apr;36(4):1394-6. I'd recommend 38.3 degrees C to match the more recent definitions so that your sepsis statistics can be easily compared to published studies. Here's an article on comparison of methods of measuring temperature. Bottom line is that IR ear probes are somewhat variable and axillary reads too low. Go with oral, rectal or bladder. Erickson RS, Kirklin SK. Comparison of ear-based, bladder, oral, and axillary methods for core temperature measurement. Crit Care Med. 1993 Oct;21(10):1528-34. PubMed PMID: 8403963. Andy Bourgeois, MD, FAAEM, FACEP Emergency Medicine Simi Valley Hospital On Thu, Feb 23, 2012 at 11:47 AM, Johnston, Roberta <[email protected]> wrote: Hi everyone- Our Sepsis committee would like to know if the temp criteria is 38.3 or 38, and is the method of obtaining the temperature? Thanks in advance, Roberta Roberta Johnston, RN,BS,CMC. Cardiopulmonary Case Manager 700 High St. Williamsport, Pa. 17701 Phone:570-321-2112 ( tel:570-321-2112 ), Fax:570-321-2822 ( tel:570-321-2822 );Cell: 570-560-8993 ( tel:570-560-8993 ) [email protected] Confidentiality Notice: This message and any attachments originate by electronic mail from Susquehanna Health System and their subsidiaries/affiliates (“SHS”). 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