COMMENTARY

New Sepsis Definition and Initiation of Treatment--What Changed?

Alok S. Patel, MD; Patricia A. Kritek, MD

Disclosures

April 19, 2019

This transcript has been edited for clarity.

Alok S. Patel, MD: How's it going, everyone? This is Dr Alok Patel, coming at you live from National Harbor, Maryland, at the Society for Hospital Medicine Conference 2019. We're talking to everyone about an incredible topic, sepsis, which is something that we all need to pay attention to and we all need to understand.

Fortunately, I'm here with an expert, Dr Patricia Kritek, from the University of Washington, who's going to tell us all about her amazing talk on sepsis this morning. Dr Kritek, could you please give me an overview of the talk?

Patricia A. Kritek, MD: We started off talking about our definition of sepsis because that's evolved in the past several years. We talked about how to identify sepsis early on, because there's a bunch of stuff that we think we should do for patients who are early in their treatment of sepsis, often bundled care. We talked a little bit at the end—because I'm an intensivist—about what to do when somebody is really sick with sepsis. That was the spectrum we covered.

Patel: Identifying sepsis and then what to do. Now, I was in med school not that long ago and we had this definition of sepsis. From your talk, I remember the New England Journal article demonstrating that the sepsis guidelines had been overturned. People were using these headlines like "radical" and "It's overturned, 25 years in the making." Could you explain the changes from the previous guidelines to where we are now?

Kritek: Yes. Sepsis-3 was published in JAMA ,[1] saying it's time for a new definition of sepsis because we thought maybe we were putting too many people in the bucket of sepsis using SIRS [systemic inflammatory response syndrome] plus infection. Additionally, we have greater understanding now. Sepsis-1 was defined back in 1991, so we've had a lot of evolution of science since that time.

Patel: It's been a few years.

Kritek: Yes. Even I wasn't a doctor back in 1991. What did they say? They said, let's change our definition and include organ dysfunction in the definition of sepsis. That used to be in a separate category that we called severe sepsis.

They got rid of severe sepsis and they said there are two buckets, including sepsis, which is going to be defined as organ failure due to infection, and then septic shock, which is going to be hypotension with an elevated lactate, requiring vasopressors to maintain your blood pressure in a certain range (mean arterial pressure greater than 65).

Those are the definitions. I think the goal of that was to be more specific about who should fit into those buckets so we could understand incidence, we could study it better, and we could understand outcomes better.

Patel: That was the first thing that people were interested in during your talk. The second thing I thought was awesome was when you were asking the audience about what type of fluid they use during resuscitation. That made me think of the SMART trial, which was in the New England Journal .[2]

What was the overview of the SMART trial? When you were talking about lactated Ringer's versus saline, what fluids, really, do we want to be looking at?

Kritek: They specifically compared saline and what they would call balanced crystalloid. The predominant crystalloid that people chose was lactated Ringer's, but they also could have used Plasma-Lyte. The thought is that those fluids are more like plasma because they don't have a high chloride. Saline has a chloride of 154 mEq.

Patel: Hyperchloremia is a thing.

Kritek: Yes, it's bad. We think that hyperchloremia is bad for the kidneys. The SMART trial was really cool. I gave props to the folks at Vanderbilt in my talk and I'll give props to them again now. They did this really novel thing and leveraged their EMR so that, by month, patients submitted to the ICU either got balanced crystalloid (more commonly, lactated Ringer's) or saline.

The EMR directed people to order it that way. You could override it, but almost nobody did. They stocked their unit with it.

They found that in their primary outcome, which was called MAKE30 (major adverse kidney events at 30 days), there was a statistically significant—small, but statistically significant—difference between the groups, favoring the people who got balanced crystalloid.

Patel: Favoring balanced crystalloid. There's so much to learn about this. What is one take-home point you want the med students to know about managing sepsis?

Kritek: I think the biggest thing for everybody is that if you think a patient is septic, get antibiotics into them quickly and cover broadly enough so that it covers everything you think could be going on. That's not to say that every person needs to get vancomycin and piperacillin/tazobactam. That is not what I'm saying.

Patel: The kidneys aren't a fan.

Kritek: You need to be broad enough to cover whatever it could be. Once you treat up-front, think just as hard in the next day or two about how you could narrow the treatment. If you were wrong and it's not really sepsis, stop the antibiotic. Cover broadly up-front and be a steward later.

Patel: Dr Kritek, thank you so much. We have all been indoctrinated in how to manage sepsis.

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