What are the key changes?
- The SIRS criteria have been ousted due to poor sensitivity and specificity for sepsis.
- The new replacement is the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score. This is a fairly complicated multi-faceted score used in critical care settings as a definition for organ dysfunction.
A SOFA score change of ≥2 (I picture a plush 3-seater) is a marker of organ dysfunction; the baseline SOFA is presumed to be 0 (maybe a beanbag?) where no pre-existing abnormality is known. A score of ≥2 is associated with 10% mortality.
- Given the limited use of SOFAs outside the ICU (no time to sit down in ED), and its complicated nature, the quick SOFA (qSOFA) has been suggested as a bedside aide-memoire to identify sepsis.
The SOFA score is not intended to be used as a tool for patient management but as a means to clinically characterize a septic patient...
Although qSOFA is less robust than a SOFA score of 2 or greater in the ICU, it does not require laboratory tests and can be assessed quickly and repeatedly. The task force suggests that qSOFA criteria be used to prompt clinicians to further investigate for organ dysfunction, to initiate or escalate therapy as appropriate, and to consider referral to critical care or increase the frequency of monitoring... The task force considered that positive qSOFA criteria should also prompt consideration of possible infection in patients not previously recognized as infected
- The definition of septic shock has been broadened to a combination of hypotension requiring vasopressor support to maintain a MAP of 65 and a lactate greater than 2 despite fluid resuscitation. This is less than the previous lactate level required of 4. This definition identifies a mortality risk of 40%.
- The term "severe sepsis" has been removed from the definitions as superfluous.
What is a quick SOFA?
According to qSOFA.org:
The qSOFA score (also known as quickSOFA) is a bedside prompt that may identify patients with suspected infection who are at greater risk for a poor outcome outside the intensive care unit (ICU). It uses three criteria, assigning one point for low blood pressure (SBP≤100 mmHg), high respiratory rate (≥22 breaths per min), or altered mentation (Glasgow coma scale<15).
To help us remember this complicated set of observations, a number of acronyms:
- SOFA (Systolic BP, Off feet, Fight Apnoea... pretty terrible)
- HAT (Hypotension, Altered mental state, Tachypnoea)
- BAT (Blood pressure, Altered, Tachypnoea)
But seriously, it's not that hard to remember anyway.
How should we use this?
Always suspect sepsis and treat the patient! These are definitions, not a change in management. If you suspect sepsis, ensure early management with antibiotics and fluid resuscitation, with early vasopressor use as required.
The recommendation for use of these new definitions is shown below. Use the qSOFA to screen (and remember that a negative qSOFA does not exclude sepsis), then move onto assessing organ dysfunction and for septic shock.
Will this change management?
No, in themselves, these are just new definitions, and the management of sepsis remains the same. These definitions may change how we communicate about sepsis, with the adoption of the quick SOFA.
I suggest that implementation of these definitions in the ED should include a promotional sofa (at least a 3-seater).