Thanks for your reply, Bob. I'm sorry that you and I are old enough to give "historical" perspective on these issues! I think you underscored Ron's point, which is that missing people with severe sepsis is potentially deadly and being more sensitive is a wise approach. I have to agree with you that some lack of specificity may be the reason that none of our tested pharmaceutical agents has been the magic bullet. But I will again reveal my bias when I say that early recognition and aggressive treatment is the best magic bullet of all. From the standpoint of quality improvement, it does indeed seem that getting everyone to recognize severe sepsis early would be magic!
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 >>> Robert A Balk <[email protected]> 3/7/2012 7:18 AM >>> Good Morning Steve and Group I have not been on this list serve discussion, but will be happy to provide some background on the 1991 Sepsis Definition Consensus Conference and the rationale for the 2/4 SIRS criteria. The 4 SIRS criteria as they were came from the entry criteria for the Upjohn sponsored High Dose Methylprednisolone in Severe Sepsis and Septic Shock study which seemed to identify a population of patients with presumed sepsis that had a significantly high risk for morbidity and mortality from the septic process. The truth of where the criteria actually came from is that a group of investigators sat is a room and came to agreement on workable, plausible criteria that would allow for rapid and early identification of potential patients with sepsis that could be enrolled into an early intervention study. As the subsequent article entitled “Sepsis Syndrome: A valid clinical entity” the concept of a systemic inflammatory response whether from documented infection, documented bacteremia, or presumed infection seems to yield a similar clinical picture. This background and the desire to come to a more uniform and acceptable definition for sepsis that would facilitate early identification of patients for enrollment in clinical intervention trials was the impetus for the 1991 Consensus Conference. The definition that was put forward has been criticized for being too sensitive and not specific, but that was the intention. Bill Knaus actually had data to guide the conference from the large APACHE and APACHE II data base that demonstrated the best combination of sensitivity and specificity came from having 2 of the 4 criteria. Obviously, the more criteria the better the specificity, but with the goal of having a clinical definition to allow for early identification of potential patients the 2/4 criteria won. The changes in temperature based on methods of measurement were not addressed with the definition and I do agree that axillary and tympanic temperature determinations do not seem to be reliable indicators of core temperature in our institution. The second consensus conference in 2001 attempted to open up the definition by adding further clinical criteria that suggests the presence of infection, but I do not know of any comparative trial that has demonstrated that one definition improves our ability to identify a severe sepsis population better than another. The original definition of severe sepsis and/or septic shock has actually been used with or without minor modification, in just about every sepsis trial conducted. (maybe that is why we are still struggling to find the “magic bullet” to reverse the process). Bob Balk Robert A. Balk, MD Director - Pulmonary and Critical Care Medicine Rush University Medical Center 1653 W. Congress Parkway Chicago, IL 60612 T- 312-942-6744 F- 312-942-8187 This message and any attachments contain information intended for the exclusive use of the individual, or entity, to whom it is addressed and may contain information that is privileged, confidential and/or exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or their employee or agent you are hereby notified that any distribution or copying of this communication is strictly prohibited. If you received this message in error, please phone me immediately at 312-942-6744. From: Steven Simpson [mailto:[email protected]] Sent: Tuesday, March 06, 2012 1:45 PM To: Ron Elkin Cc: Andy Bourgeois; [email protected]; Robert A Balk; Roberta Johnston Subject: Re: [Sepsis Groups] SIRS temperature criteria 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. 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