Shock, septic

ICD10 Diagnosis
Dx:	Shock, septic
ICD10 code:	R57.2
Pre-ICD10 counterpart:	Septic Shock
Charlson/ALERT Scale:	none
APACHE Como Component:	none
APACHE Acute Component:	2019-0: Sepsis
Start Date:
Stop Date:
External ICD10 Documentation	ICD-10 CM Wikipedia ICD-10 Wikipedia WHO ICD10 documentation ICD10data.com

This diagnosis is a part of ICD10 collection.

• SMW
  • 2019-01-01
  • 2999-12-31
  • R57.2

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Additional Info

General Information

• As of June 2024 we have modified our approach for identifying sepsis and related entities. Prior to this we were using Sepsis-2 definitions, which depended on identifying SIRS (Systemic Inflammatory Response Syndrome). Instead, we are changing to the CDC Adult Sepsis Episode (ASE) criteria.
• ASE defines two entities, which we will call Severe sepsis, and Shock, septic. We are omitting what has been called "Sepsis", defined as SIRS due to infection.
  • The terminology can be confusing. Since Sepsis-3 (which we are NOT using herein), what used to be called "Severe sepsis" is now just called "Sepsis". But in order to avoid confusion, and be consistent within ICD-10, we will use:
    • Severe sepsis = acute organ dysfunction due to proven or presumed infection
    • Shock, septic = severe sepsis which includes cardiovascular dysfunction (as defined by either elevated serum lactate, or use of iv vasopressors)

Identifying the Acute Organ Failure of Severe sepsis and Shock, septic

• As part of the June 2024 change from Sepsis-2 to ASE criteria for sepsis-related entities, our criteria for acute organ dysfunction are any of the 6 ASE criteria:
  • (1) Serum lactate >=2.0 mmol/L
  • (2) Use of any of the following vasopressors: norepi, dopamine, epinephrine, phenylephrine or vasopressin
  • (3) Use of invasive mechanical ventilation -- noninvasive ventilation does not count
  • (4) Doubling of serum creatinine relative to baseline
    • "baseline" can be a value prior to hospitalization, or if that's not available, use the BEST value from the entire current hospitalization
    • this criterion does not apply if the person had end-stage renal disease prior to hospitalization, i.e. chronically
  • (5)Total bilirubin >=34.2 AND at least a doubling from baseline
    • "baseline" can be a value prior to hospitalization, or if that's not available, use the BEST value from the entire current hospitalization
  • (6) Platelet count <100 AND >=50% fall from the baseline value
    • "baseline" can be a value prior to hospitalization, or if that's not available, use the BEST value from the entire current hospitalization

Identifying the organism responsible

• Until Jan 2019, the rule was that you only identify the responsible organism if it was present in blood culture. THIS RULE HAS CHANGED AS OF 1/1/2019 -- because in fact the majority of even septic shock cases never grow anything from the blood and most derive from localized infections (pneumonia, UTI, etc)
• The rule now is that you make all efforts to identify the specific organism, even if blood cultures never grow anything
• At the same time, however, if the person IS bacteremic, then you must ALSO code the Bacteremia -- see that article for information on whether or not to link the bacteremia code to others.
• In the presence of bacteremia or fungemia, with or without other infection(s) (e.g. pneumonia) ALL showing the same bug, consider that bug to be the agent for the sepsis
• Without bacteremia or fungemia, with one or more other infections occurring around the same time that all have the same bug, consider that bug to be the agent for the sepsis
• With multiple infections occurring around the same time as the sepsis, having DIFFERENT bugs, the bug responsible for the sepsis is not clear (even if one of those infections is bacteremia it’s still not clear), so in this case choose Infectious organism, unknown.

Example:

e.g. Patient has Severe sepsis with the acute organ failure being acute renal failure due to ATN --- and it's felt to be due to a pseudomonas pneumonia. So in this case the pseudomonas is the bug that should be combined with the Severe sepsis (and with with the pneumonia, of course) e.g. Patient with septic shock has an E.coli UTI and a pseudomonas pneumonia. The team is not certain which of those two bacteria is causing the septic shock, but of course is treating them both. In this case the bug is known to be a bacterium, but not clear which, so the bug to combine with the Septic shock is Bacteria, NOS

Combining a sepsis code with a specific infection code

• Guidelines for such combination to include (this changed Feb 19, 2020, prior rule was to not combine sepsis codes with any specific infection):
  • Combine if it is reasonably clear that the specific infection is the source of the sepsis episode. But if it is NOT clear then do not combine.
    • Clear example, so DO combine: Sepsis and the only evident infection is pneumonia
    • Unclear example, so do NOT combine: Sepsis with both pneumonia and a UTI.
    • Clear example, so DO combine. Sepsis with pneumonia developing around the same time, and then 5 days later a UTI occurs. Here it’s appropriate to combine the sepsis + pneumonia but not with the UTI.
    • Clear example, so DO combine: Sepsis with pneumonia and bacteremia, with the same bug isolated from the lungs and blood. Here it’s reasonable to conclude that all 3 are causally related and combine all 3, with the same bug as cause in all 3.
• Also recognize that not all vasodilatory (aka distributive) shock is due to infection. When it is due to infection then use THIS code, when it's not due to infection, then use one of the other appropriate codes, such as: Anaphylactic reaction (anaphylaxis), or Shock, NOS

When to code an Admit Diagnosis vs Acquired Diagnosis

• There are sometimes subtle issues here, especially for diagnoses that use lab test results.
• An example is patient comes in to ED with shock presumed due to pneumonia and a lactate=1.7 --> this doesn't meet the requirement for Shock, septic, but by 3 hours later the next lactate checked in the ICU is 2.7, so that threshold for septic shock IS met. Clearly this person was "brewing" septic shock at admission and it seems logical to include that diagnosis as an admit diagnosis. THUS -- in such cases where it seems pretty clear, in retrospect, that a diagnosis was brewing/present at admission but only became fully evident after admission, that diagnosis SHOULD be coded as an Admit Diagnosis IF it becomes fully evident within 6 hours of admission.
• Note that an individual during a single episode of illness can evolve over time from Severe sepsis to Shock, septic -- if this occurs, make sure to also code the more advanced subtype
  • e.g. admitted on Monday with Severe sepsis which is coded, but by Tuesday has progressed to Shock, septic which should then be added to the codes, in this case as an Acquired Diagnosis.
  • however, as a person improves there is NO NEED to "downcode" their sepsis

Alternate ICD10s to consider coding instead or in addition

• Anaphylactic reaction (anaphylaxis) -- includes anaphylactic shock

• Severe sepsis

• Bacteremia AND Fungemia, NOS -- these are laboratory manifestations, and while it's OK to code them if present, if you do so you should also code the clinical manifestation (such as sepsis, etc).

Candidate Combined ICD10 codes

• Also code the causative infection.

Related CCI Codes

Data Integrity Checks (automatic list)

	App	Status
Query s tmp QASeptic tmp no dx	CCMDB.accdb	implemented
Query s tmp QASeptic Dx no tmp ICD10	CCMDB.accdb	implemented
Query check ICD10 Inf Infection req Pathogen must have one	CCMDB.accdb	implemented
Query Check Inf Pathogens must have Infection requiring pathogen or Potential Infection	CCMDB.accdb	implemented

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