Definitions And Risk Categorization

In 1991, the American College of Chest Physicians and the Society of Critical Care proposed a set of definitions that could be applied to patients with sepsis and its sequelae. These definitions are contained in T.a.bIe.,.2.8.-1. The primary goals of this classification were to provide a conceptual and practical framework of the systemic inflammatory response to infection; to improve the ability of clinicians to make early bedside detection of sepsis, thus allowing early therapeutic intervention; and to standardize the definition which would allow better comparison and analysis of research protocols.

TABLE 28-1 Definitions

The identification of SIRS does not confirm a diagnosis of infection or sepsis because the features of SIRS can be seen in many other conditions such as trauma, pancreatitis, burns, or infection ( Fig. 28-1). SIRS is not a diagnosis nor is it a good indicator of outcome. Its presence, however, must be explained adequately.

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FIG. 28-1. The interrelationship between systemic inflammatory response syndrome (SIRS), sepsis, and infection. (From Chest 101:6, 1992.)

The SIRS criteria may be seen as a crude stratification for patients with systemic inflammation. In a recent prospective study of the epidemiology of SIRS in medical and surgical patients, mortality was 3 percent in patients without SIRS, 6 percent in those with two criteria, 10 percent in those with three positive criteria, and 17 percent in those meeting all four criteria. Death rates were similar for patients with culture-negative SIRS and those with culture-positive SIRS. Other investigators propose a complementary method of classification of sepsis based primarily on physiologic abnormalities such as the APACHE III acuity system. These investigators found that multivariate analysis using initial APACHE score, etiology of sepsis (urosepsis or other), and treatment location prior to ICU admission provided the greatest degree of discrimination of patients by risk of hospital death.

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