Pada tahun 1995 insiden severe sepsis di Amerika Serikat mencapai 300 kasus,

dengan angka kematian 250.000/tahun (Angus et al, 2001). Sedangkan kasus

kematian di Inggris yang diakibatkan oleh severe sepsis pada tahun 2004 mencapai
level 14.000 kasus (Harrison et al, 2006). Selain itu, total biaya yang dikeluarkan
untuk pengobatan sepsis mencapai 20.3 milyar dolar Amerika per tahun pada tahun
2011. Atau dengan kata lain biaya yang harus dikeluarkan untuk mengatasi sepsis
per episode sepsis mencapai 25.000 – 50.000 dolar Amerika (325 – 550 juta) rupiah
(Martin, 2012). Sumber infeksi yang bisa menyebabkan sepsis diantaranya berasal
dari infeksi saluran pernapasan (35%), infeksi saluran perkemihan (21%), intra
abdominal (16.5%) dll. Menurut konsensus internasional ke 3 pada tahun 2016,
sepsis merupakan ancaman kehidupan akibat disfungsi multipel organ yang
disebabkan oleh proses infeksi. Untuk pengkajian awal sepsis kita bisa
menggunakan SOFA Score (Sequential Organ Failure Assessment Score) atau
qSOFA. qSOFA digunakan pada pasien-pasien non ICU. Adapun elemen penilaian
pada qSOFA adalah sebagai berikut (JAMA, 2016) : 1. Tekanan Darah (Hypotensi
dengan nilai tekanan darah sistolik < 100 mmHg. 2. Perubahan pada status mental
3. Respirasi (terjadi takipneu dengan RR > 22 x/menit) Jika score qSOFA
menunjukkan nilai lebih atau sama dengan 2, maka akan berisiko mengalami
perburukan outcome kesehatan. Jika klien menunjukkan tanda-tanda infeksi dan
disertai dengan nilai qSOFA 2 atau lebih, maka pasien harus segera dirujuk ke ICU
tanpa harus diperiksa laboratorium terlebih dahulu. Untuk SOFA, direkomendasikan
untuk pasien yang dirawat di ICU. Peningkatan score 2 (dua) atau lebih
diindikasikan adanya kecurigaan infeksi dan gagal organ. Gejala sepsis dan disertai
dengan MAP < 65 dengan penggunaan vasopressor, lactate serum > 2 mmol/L,
serta tidak ada gejala hipovolemi menunjukkan adanya SHOCK SEPTIC. SIRS masih
digunakan sebagai panduan klinis dalam mendeteksi adanya infeksi, tetapi “severe
sepsis” tidak digunakan dalam klasifikasi baru (SEPSIS 3). qSOFA direkomendasikan
untuk mendeteksi secara dini adanya sepsis. Hipotensi dan pemeriksaan laktat
menjadi poin penting dalam kriteria Shock Septic yang baru.

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).
The score ranges from 0 to 3 points. The presence of 2 or more qSOFA
points near the onset of infection was associated with a greater risk of
death or prolonged intensive care unit stay. These are outcomes that are
more common in infected patients who may be septic than those with
uncomplicated infection. Based upon these findings, the Third
International Consensus Definitions for Sepsis recommends qSOFA as a
simple prompt to identify infected patients outside the ICU who are likely
to be septic.
The Third International Sepsis Consensus Definitions Task Force sought to
differentiate sepsis from uncomplicated infection, and to update
definitions of sepsis and septic shock. They defined sepsis as "as life-
threatening organ dysfunction due to a dysregulated host response to
infection". To operationalize this definition, they recommended specific
criteria for clinicians that had two elements: infection and acute, life
threatening organ dysfunction.
 The
diagnosis of infection was left to the clinician, while the TF recommended
that an acute change of more than 2 sepsis-related organ dysfunction
assessment (SOFA) points would identify sepsis.
But the SOFA score requires multiple laboratory tests and may not be
available in a timely manner. To facilitate simple recognition in
prehospital, ward, and the emergency department, the Task Force
recommended a prompt called "qSOFA" for quick sepsis-related organ
dysfunction assessment score.
qSOFA (described above) can be easily measured by clinicians, and was
derived from 1.3 million electronic health record encounters from 2010
to 2012 at 12 hospitals in southwestern Pennsylvania. The analyses were
conducted among encounters with suspected infection identified by a
combination of body fluid cultures and antibiotic administration.
Seymour and colleagues tested the construct and criterion validity of
qSOFA compared to other criteria like the SOFA score, change in SOFA

score, logistic organ dysfunction

score (LODS), and systemic inflammatory response syndrome (SIRS)
criteria near the onset of infection. They found that mortality increased
among patients with suspected infection with each point.
They found that 24% of infected patients with 2 or 3 qSOFA points
accounted for 70% of deaths. Outside the ICU, there was a 3- to 14-fold
increase in the rate of in-hospital mortality across a range of baseline risk
comparing those with ≥2 vs. <2 qSOFA points (where baseline risk
determined by demographics and co-morbidity). The simple qSOFA model
performed similarly to more complex models like SOFA or LODS outside
the ICU.

Confirmatory analyses were performed in four datasets of more than

700,000 prehospital and hospital encounters at 165 US and non-US
hospitals (see Data Sources for more information).
What about lactate?

Lactate is a well-
studied prognostic marker in patients with sepsis. During statistical model
building, lactate was excluded from qSOFA. Seymour and colleagues
tested how serum lactate would improve qSOFA post hoc, using a variety
of serum lactate thresholds. They found that the criterion validity was
statistically improved (p<0.01) comparing qSOFA plus lactate versus
qSOFA alone, but actual changes in classification were minimal.
More work is forthcoming to test how lactate can substitute for or
improve qSOFA in centers where testing is both affordable and available.
How to measure altered mentation?

The assessment of altered mentation can be difficult at the bedside. The

primary analyses used Glasgow Coma Scale (GCS) score, but GCS is
variably measured by clinicians. The authors also tested a GCS threshold
of 15 (abnormal vs. not) and alternative models using the Laboratory and
Acute Physiology Score, version 2, in data from Kaiser Permanente
Northern California. These results were similar to the primary model.
Taken together, the Task Force recommended that a GCS threshold of 15
would be preferable for bedside use.

Although sepsis was described over 2,000 years ago, clinicians still
struggle to define it, and there is no 'gold standard.' As awareness of
sepsis increases, there is pressure for a widely deployable, consistent, and
accurate diagnostic criteria. And yet, this is a complex task, with
competing priorities, resulting in varying approaches and distinct criteria
for different uses.

A conceptual framework for how one might approach defining sepsis is

described by Angus and colleagues. The proposed framework intends to
aid in the understanding of the multiple current sepsis definitions and
guide the development of useful criteria that may serve different
purposes. Check out our video that explains this in more detail.

Over the past two decades, sepsis has been defined for clinical care
several times.
1991 2001 2016
Most recently, the 2016 Third International Consensus Definitions for
Sepsis and Septic Shock defined sepsis as:

A life-threatening organ dysfunction due to a dysregulated host response

to infection.
This is similiar to the lay definition of sepsis derived at the Merinoff
Symposium in 2010:
Sepsis is a life threatening condition that arises when the body's response
to an infection injures its own tissues and organs.
These lay definitions and consensus criteria are intended to assist in the
clinical care of patients. They are different, however, from those
proposed for the surveillance of sepsis, or those used to identify cases for
auditing and quality improvement purposes. Examples of these are found
in the Centers for Disease Control and Prevention EpiCenters surveillance
criteria or the Centers for Medicaid and Medicare Services SEP1 bundle.
To make sense of these different criteria, Seymour and colleagues further
investigated the framework described by Angus, in order to explain how
different purposes (surveillance, clinical care, audit, research) value
different domains of usefulness.
The proposed domains are shown in the Figure, and a heatmap of
priorities by purpose in the accompanying article.

As an example, Seymour submits

that clinical criteria will highly value validity and timeliness, while
surveillance criteria may place high value on reliability. In contrast,
criteria for randomized clinical trials may relax the priority on simplicity,
instead focusing on reliability across time and enrollment sites.

In the end, a case study in a 12-hospital integrated health system reveals

that sepsis case identification may vary four fold while in-hospital
mortality may vary three-fold when comparing criteria for clinical,
surveillance, and QI/audit.
Such differences are not unexpected when considered in the Angus
framework, and reinforce the notion that one single definition or criteria
is not "right." Please follow the links for the recent Critical Care Medicine