The BAT and the SOFA! The 3rd Consensus Definitions for Sepsis are out

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Sepsis certainly keeps us going... either when treating patients on ICU or when it comes to the discussion on what actually sepsis is and how to define it. So far the SIRS (Systemic Inflammatory Response Syndrome) criteria have provided some degree of handle to cope with this syndrome but of course we weren't all quite happy with this. In fact every person with any sort of infectious disease will respond with 2 or more SIRS criteria... but doesn't necessarily have to be septic. As a matter of fact a SIRS is nothing else but a physiologic response to any sort of inflammation.


The New Approach to Sepsis - The SOFA

The new international consensus definitions for sepsis and septic shock try to focus on the fact that sepsis itself defines
a life-threatening organ dysfunction caused by a dysregulated host response to infection. By saying this the aim is to provide a definition that allows early detection of septic patients and allow prompt and appropriate response. As even a modest degree of organ dysfunction is associated with an increased in-hospital mortality the SOFA score (Sequential or 'Sepsis-related' Organ Failure Assessment) was found to be the best scoring system for this purpose. It's well known, simple to use and has a well-validated relationship to mortality risk.

Sepsis (related organ dysfunction) is now defined by a SOFA score of 2 points or more



The Quick Approach to Sepsis - The BAT

In the out-of-hospital setting, on the general wards or in the emergency department the task force recommends an altered bed side clinical score called the quickSOFA - or alternatively 'the BAT' score:


The New Approach to Septic Shock -Vasopressors and Lactate

Septic shock is now defined as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of death than sepsis alone. Keeping a long story short:


Septic Shock is now:

- The need for vasopressors to maintain a mean arterial pressure of at least 65mmHg 
  AND
- a serum lactate level of more than 2mmol/L... after adequate fluid resuscitation 



The Bottom Line:

The way it looks like we are left with Sepsis and Septic Shock


Severe Sepsis has vanished and the question remains, whether these new definitions will actually benefit the ones that need it most... our septic patients!


Singer M et al. JAMA. 2016;315(8):801-810.

Seymour CW et al. 
JAMA. 2016;315(8):762-774.

Shankar-Hari M et al.  
JAMA. 2016;315(8):775-787.

The Myth of Cricoid Pressure – A Correspondence Worth Reading

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One of the most controversial manoeuvres in anaesthesia and critical care has got some new support since the Difficult Airway Society has published their new guidelines in which they basically continue to support the use of cricoid pressure (CP) for rapid sequence induction. The authors of the Obstetric Anaesthetists' Association and Difficult Airway Society Guidelines for the Management of Difficult and Failed Tracheal Intubation also continue to recommend routine CP, which is considered level 3b evidence.

Surprised on how obstinately CP persists in current guidelines I think that following statement by Priebe HJ is an important reading. It summarises nicely why there is such a disagreement with these recommendations.


He states that

not a single controlled clinical study provided convincing evidence that the use of cricoid pressure was associated with reduced risk of pulmon ary aspiration. At the same time, there is good evidence that nearly all aspects of airway management are adversely affected by cricoid pressure

-  if
cricoid pressure were considered a new airway device, it would not be considered for further evaluation because Level 3B evidence for its efcacy does not exist

- when
using cricoid pressure, we may well be endangering more lives by interfer ing with optimal
airway management than we are saving lives by preventing pulmonary
aspiration

Priebe HJ, Anaesthesia 2016, 71, 343–351


Want to get more information on the controversy of cricoid pressure? Read here:

Cricoid Pressure for RSI in the ICU: Time to Let GO?


Time to let go? Remarkable article on RSI and Cricoid Pressure


Difficult Airway Society DAS: New Guidelines OUT! Cricoid Pressure still IN?

Dexmedetomidine vs Midazolam for the Intubated

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Dexmedetomidine has shaken up the usual sedatives in ICU but remains a matter of debate among intensivists. One question is whether the higher costs compared to midazolam are justified by clinical advantages. There is research available suggesting that dexmedetomidine might be an attractive alternative to standard sedatives especially in regards of time to extubation and costs (Turinen et al., Jacob et al.). This seems to hold true for moderate to light sedation of intubated patients.

I've stepped over this prospective, double-blind, randomised trial by Riker et al. in which 68 centres in 5 countries recruited intubated 366 patients to received moderate to light sedation with either dexmedetomidine or midazolam. All patients received daily arousal assessment. 

Their primary end point was the percentage of time within the target sedation range (RASS score −2 to +1) and this did not differ between the two groups.

Looking at the secondary endpoints though make things a lot more interesting. Just before the beginning of the 
sedation period both groups had a similar prevalence of delirium. During study drug administration though, the effect of dexmedetomidine treatment on delirium was significant. A reduction of 24.9% with dexmedetomidine is rather impressive (see figure below). This effect was even greater in patients who were CAM-ICU-positive at baseline.

Finally patients on dexmedetomidine had shorter time to extubation (1.9 days in average) while their length of stay on ICU did not differ.

From a safety point of view the most common adverse effect of dexmedetomidine was bradycardia. It's noteworthy that patients on midazolam had more episodes of hypotension and tachycardia.

THE BOTTOM LINE

- This is another study indicating that dexmedetomidine seems to be beneficial in regards of delirium in mechanically ventilated patients and might speed up time to extubation

- Dexmedetomidine is safe in patients where moderate to light sedation is the aim



Riker et al. JAMA. 2009;301(5):489-499. doi:10.1001/jama.2009.56     OPEN ACCESS


Read more HERE on BIJC