VIDEO: Best practices for diagnosing sepsis early

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Diagnosing sepsis early really comes down to two clinical questions. First, does the patient have an infection, and second, does the patient have signs of organ dysfunction that might be resulting from the infection? Now, it's important to understand that sepsis-associated organ dysfunction not only includes low blood pressure, which is I think what most clinicians think of when it comes to sepsis, but also a broad range of manifestations, including altered mental status, hypoxemia, acute kidney injury, liver injury and coagulopathy.

So, sometimes it's obvious that a patient has sepsis, but oftentimes it's much more ambiguous, especially since there are a lot of other conditions that can mimic sepsis. So, diagnosing sepsis therefore requires a combination of taking a careful clinical history, performing a detailed physical exam, and obtaining appropriate radiologic studies and checking a range of laboratory and microbiologic tests. Now, there is a lot of debate around the best screening criteria for the early identification of sepsis.

Now, traditionally a sepsis screening has been done using the systemic inflammatory response syndrome criteria, or SIRS, which refers to two or more abnormalities in temperature, heart rate, respiratory rate, and white blood cell count. But these have long been criticized since they're really non-specific for sepsis, and using these criteria can lead to a lot of antibiotic overuse. The quickSOFA score, or the qSOFA score, was developed with the latest set of consensus sepsis definitions, or sepsis-3, back in 2016, and this includes hypertension, altered mental status, or elevated respiratory rates. And a patient is considered qSOFA positive if two or more of those criteria are met. And these are associated with worse outcomes than patients who are infected. But while these criteria may be more specific for sepsis than SIRS, their sensitivity is low and they still are often found in other non-infectious conditions. Lastly, lactate measurements play an important role in identifying sepsis because a high lactate often signifies tissue hyperperfusion and occult or impending shock. So, in conjunction with clinical signs of infection a high lactate is very suggestive of sepsis. However, a high lactate alone can also be seen in many other conditions, and patients can have sepsis even with normal lactates.