Sepsis Series, part II
In case you missed it… Part I
Sepsis: Through the Eyes of CMS
In the fall of 2015, the Center for Medicare and Medicaid Services outline new Core Measures for the care of patients with severe sepsis and septic shock.
Classic sepsis definitions of sepsis have revolved around the SIRS criteria and these definitions were used in the above mentioned trials that have shaped the evidenced base of sepsis management
SIRS: T >38 or <36/RR >20 /HR >90 /WBC >12K or <4K or >10% bands/PCO2 <32 mmHg
Sepsis = 2 SIRS + infection
Severe sepsis = sepsis + signs of end organ damage, hypotension or lactate >4 mmol
Septic shock = sepsis + persistent hypotension
Per CMS Core Measures:
Severe sepsis = ≥2 SIRS criteria + infection + ≥1 area of organ dysfunction (hypotension, creatinine >2, bilirubin >2 or INR >1,5, or thrombocytopenia <100,000)
Management: Measure a lactate, obtain cultures, and start broad-spectrum antibiotics all within 3 hours, followed by a repeat lactate within 6 hours if the initial lactate was elevated6.
Septic shock = ≥2 SIRS criteria + infection + persistent hypotension after fluid bolus OR lactate ≥4 mmol/L
Management: Same as severe sepsis + 30 cc/kg crystalloid bolus within the first 3 hours, and then, if hypotension persists, the addition of vasopressors.
At this point, CMS does not leave much leeway in regards to physician discretion about a patient’s ability to handle this fluid bolus, a point that has led to much criticism of the new Core Measures
Documentation of a reassessment of volume status within 6 hours using a focused exam or by completing two of the following: measurement of CVP, ScvO2 measurement, cardiovascular US or dynamic assessment of fluid responsiveness6.
6) Center for Medicare and Medicaid Services. Sepsis Bundle Project. October 2015.
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