Question 22

College answer

Not available.

Discussion

a) Sepsis-3 definitions of sepsis and septic shock:

Advantages of standard definitions:

• Theoretical arguments for the utility of strict definitions
  • Theoretical medicine requires strict definitions to separate patients into a "disease" group, to compare them to a "no disease" group
  • Standardisation of definitions is required to ensure a common language, to facilitate communication between clinicians and researchers
  • Standard definitions allow comparative evaluation of different therapies; without such definitions comparison between studies and their meta-analysis would be difficult.
• Pragmatic arguments for defining sepsis
  • Sepsis is a disease entity with significant mortality, and this mortality decreases with early detection and treatment.
  • Ergo, some of this mortality is due to a failure of early detection, and early detection would be facilitated by a set of diagnostic criteria that can be used to identify sepsis

Challenges of creating standard definitions for sepsis:

• Challenges of "sepsis" as a concept
  • Sepsis is non-specific and its manifestations are protean
  • It would be impossible to strictly and objectively define every possible permutation of sepsis
  • There is no gold standard test to compare any new definition against
  • Use of subjective elements to broaden the definition (eg. "suspected infection") reduces its validity
• Challenges in the use of biomarkers and clinical findings as criteria:
  • Some, eg. lactate, favour resource-rich environments, where lactate testing is possible
  • Some fail to distinguish between new and pre-existing organ dysfunction (eg. qSOFA)
  • The cut-offs for organ dysfunction scores are usually chosen arbitrarily. For the most, they do not represent any genuine physiologically relevant thresholds
  • Some, eg. SOFA and qSOFA are not well known outside of the ICU community, and decrease in their validity outside the ICU
• Challenges in the very process of creating definitions:
  • Delphi process encourages the suppression of outlier opinions, and promotes a trend towards mediocrity
  • Without an objective definition, worldwide sepsis mortality is on a decline, which makes it difficult to justify creating a new definition
  • Multiple possible stakeholder groups could claim they deserve to have input on the definition (intensivists, ED physicians, ID specialists), which makes it more difficult to achieve consensus
  • The new definitions would have to be comparable with old definitions, otherwise one risks the inability to compare new research with old research studies.