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    3 Comments for this article
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    International Consensus Definitions for Sepsis and Septic Shock
    Phoebe Atieno RN, MHA | Sepsis Data Manager
    After reading your article, I looked at your definitions and that of CMS. It seems to me that the overarching idea for your article was to increase responsiveness and identify patients who have sepsis or might have sepsis in a timely manner to improve outcomes. It also seems that while CMS uses the bundle approach to organize the care, your article advocates for SOFA and QSOFA to help identify and care for this patients. Having been in healthcare for a few years, it seems to me that using the term "severe" might elicit certain quick actions to be implemented as opposed to not using that term as your article suggests that the term "severe sepsis" is redundant. Would you please comment on that?

    CONFLICT OF INTEREST: None Reported
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    Author Reply
    Mervyn Singer, MD, FRCP | Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom
    Thank you for your question. As a clinician I’ve never heard anyone proclaim at the bedside or by a phone referral that a patient has ‘severe sepsis.’ They are merely called ‘septic’. 'Severe sepsis' is reserved for coding, epidemiology, and for fulfilling entry criteria into research studies. The problem then arises with the old definitions that everyone who has suspected infection + SIRS becomes ‘septic’ regardless of whether they’re sick or not. With the new definitions we tried to distinguish between a routine uncomplicated infection and the sicker variety which leads to organ dysfunction. So ’septic’ in the new terminology should indicate concern.
    CONFLICT OF INTEREST: Dr Singer reports serving on the advisory boards of InflaRx, Bayer, Biotest, and Merck and that his institution has received grants from the European Commission, UK National Institute of Health Research, Immunexpress, DSTL, and Wellcome Trust.
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    Definition of "Bands"
    Eddie Ferguson, BS Microbiology, MT(ASCP) | Industry Hematology Applications Specialist Representative
    Thanks so much to Dr. Singer, et al for all their hard work on developing Consensus Definitions for Sepsis and Septic Shock.

    Box 1 states that a criterion for SIRS is >"10% immature bands."

    However, nowhere in the Consensus Definitions does it define what a "band" is.

    The published literature specifically addressing "bands" since approximately 1990 has discussed the inconsistent agreement on what a "band" is.

    The CAP (College of American Pathologists) has been on the forefront of deemphasizing the use of "bands" because of the disagreement on the definition of "bands."

    CAP has for
    several years - as part of their quarterly morphology survey challenges - does not distinguish between "segs" or "bands."

    I appreciate any feedback and would ask special consideration be given to how "bands" are defined and perhaps consider a change in this specific criteria.

    Thank you very much,

    Eddie Ferguson, MT(ASCP)

    CONFLICT OF INTEREST: None Reported
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    Special Communication
    Caring for the Critically Ill Patient
    February 23, 2016

    The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

    Author Affiliations
    • 1Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom
    • 2Hofstra–Northwell School of Medicine, Feinstein Institute for Medical Research, New Hyde Park, New York
    • 3Department of Critical Care and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
    • 4Department of Critical Care Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
    • 5Department of Critical Care Medicine, University of Versailles, France
    • 6Center for Sepsis Control and Care, University Hospital, Jena, Germany
    • 7Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, and Austin Hospital, Melbourne, Victoria, Australia
    • 8Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University, Nashville, Tennessee
    • 9Réanimation Médicale-Hôpital Cochin, Descartes University, Cochin Institute, Paris, France
    • 10Critical Care Center, Emory University School of Medicine, Atlanta, Georgia
    • 11Washington University School of Medicine, St Louis, Missouri
    • 12Infectious Disease Section, Division of Pulmonary and Critical Care Medicine, Brown University School of Medicine, Providence, Rhode Island
    • 13Department of Surgery, University of Toronto, Toronto, Ontario, Canada
    • 14Emory University School of Medicine and Grady Memorial Hospital, Atlanta, Georgia
    • 15Trauma, Emergency & Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
    • 16Interdepartmental Division of Critical Care, University of Toronto
    • 17Department of Infectious Diseases, Academisch Medisch Centrum, Amsterdam, the Netherlands
    • 18Department of Intensive Care, Erasme University Hospital, Brussels, Belgium
    • 19Department of Critical Care Medicine, University of Pittsburgh and UPMC Health System, Pittsburgh, Pennsylvania
    • 20Associate Editor, JAMA
    JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
    Abstract

    Importance  Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination.

    Objective  To evaluate and, as needed, update definitions for sepsis and septic shock.

    Process  A task force (n = 19) with expertise in sepsis pathobiology, clinical trials, and epidemiology was convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Definitions and clinical criteria were generated through meetings, Delphi processes, analysis of electronic health record databases, and voting, followed by circulation to international professional societies, requesting peer review and endorsement (by 31 societies listed in the Acknowledgment).

    Key Findings From Evidence Synthesis  Limitations of previous definitions included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality. The task force concluded the term severe sepsis was redundant.

    Recommendations  Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.

    Conclusions and Relevance  These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.

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