Septic Shock: Difference between revisions

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(→‎Discussion 1 - Resolved April 19.10: this discussion was related to the QA project and misplaced in this article; it's addressed there as "use your judgment", I believe.)
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{{DX tag | Cardiovascular Problems | [[:Category: Medical Problem | Medical Problem]] | Septic Shock| SEPTIC SHOCK | [[ Septic Shock - 4400]] | No| 0 |'''Critical Care and Medicine''' | Currently Collected | |}}
{{PreICD10 dx | NewDxArticle = Shock, septic }}  


{{DX tag | Cardiovascular Problems | Medical Problem | Septic Shock| SEPTIC SHOCK | 4400 | No| 0 |'''Critical Care and Medicine''' | Currently Collected | |}}


Mutually exclusive with [[Severe Sepsis]]
Mutually exclusive with [[Severe Sepsis]]
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Also see [[Septicemia]] definition.
Also see [[Septicemia]] definition.


See [[QA Septic Shock]] audit started September 2009.
See [[QA Septic Shock]]- special project
 
Use definition in [[Shock, septic]]. <!-- as per AG in discussion at that page 2018-11-30 -->
 
{{LegacyContent
|explanation=use new definition in [[Shock, septic]]
|successor=[[Shock, septic]]
|content=


==Definition ==
==Definition ==
===(1) Blood pressure (BP) criteria===
Dr. Kumar would like to emphasize to collectors that SEPTIC SHOCK means shock is thought to be '''DRIVEN BY infection''' and not just associated with infection.  Example, if someone has another obvious cause of shock with infection (like massive hemorrhage with it), that does not mean it is combined hemorrhagic and septic shock.  Basically, septic shock '''should not be called''' if there '''is another obvious cause for shock'''.--[[User:TOstryzniuk|Trish Ostryzniuk]] 18:23, 2012 June 11 (CDT)
*If at least '''one''' of the following is present, code Septic Shock:
 
** '''systolic BP''' < 90 mmHg for > 30 minutes '''and not responding to fluid resuscitation or'''
==Criteria for coding septic shock==
** mean (m)BP < 65 mmHg '''''(is this an "and" to the next line?)'''''
*If at least '''one''' of the following is present:
** BP '''drop''' of > 40 mmHg '''from baseline''' for  > 30 min '''or'''
** '''systolic BP''' < 90 mmHg for > 30 minutes '''and not responding to fluid resuscitation  
** use of '''vasopressor''' to maintain systolic BP >= 90 mmHg in the '''absence of other causes''' of shock, e.g.:  
***'''or'''
*** no hypovolemia
** mean (m)BP < 65 mmHg for  > 30 min
*** no MI
***'''or'''
*** no pulmonary embolus
** BP '''drop''' of > 40 mmHg '''from baseline''' for  > 30 min  
*If none of the BP criteria are met:
***'''or'''
** see [[Severe Sepsis]]
** use of '''vasopressor''' to maintain systolic BP >= 90 mmHg in the '''absence of other causes''' of shock, e.g. Go to: [[:Category: Shock | Other types of shock]]  


=== (2) Other Criteria ===
*Plus at least '''two''' of:  
Plus at least '''two''' of:  
* [[temperature]]  > 38.5 C
* [[temperature]]  > 38.5 C
* [[HR]]  > 90  
* [[HR]]  > 90  
* [[RR]]  > 20
* [[RR]]  > 20


=== (3) Organ Failure Criteria ===
Plus at least '''one''' of ('''organ failure'''):  
Plus at least '''one''' of ('''organ failure'''):  
* '''Neuro changes''': GCS < 14
* '''Neuro changes''': GCS < 14
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** NR >1.5
** NR >1.5


== Data  Integrity Rules ==
==Examples of other conditions that can cause shock:==
Septic shock (44-00) is mutually exclusive with 45-00 [[Severe Sepsis]].
*hypovolemia ([[Hypovolemic/Hemorrhagic Shock]])
 
*MI ([[Cardiogenic Shock]])
 
*pulmonary embolus
 
*liver failure
== Discussion 2 - Resolved April 26, 2010==
*pancreatitis
*What should I record as first low BP in this case.--Marylou
*drug overdoses
**Final answer: First low BP April 16th at 17:26--[[User:TOstryzniuk|TOstryzniuk]] 12:54, 28 April 2010 (CDT)
*burns
 
*Note: Although these conditions can cause shock on their own, if the patient has an obvious serious sepsis with shock, you can still code septic shock even with these conditions.  
*Here is another scenario:
*If the above criteria are not met:
*'''Apr 16 @ 1148 hrs''' - '''to ER''': with hematemesis and confusion, rhabdo and ARI.  '''BP ok'''. '''Temp N''',  WBC 10.6,  '''Hgb 124''',  '''Lactate 8.7''',  Creatinine 244 (elevated for this pt),  and elevated INR,  '''HR 110''',  '''RR 60'''.  Treatment included iv rate 200cc/hr with bicarb. 1.5 l n/s bolus
** see [[Severe Sepsis]]
**1610 - CT shows no surgical issues
**1625 - intubated for increased WOB (work of breathing)
**'''1726'''- '''First drop in BP 81/57''' and '''started on dopamine'''
**1750 '''- To ICU'''. '''Hgb now 80''' and given 2 units blood. '''CVP 13-17''' prior to blood.
*'''1930''' Dr. wrote in the chart that '''septic shock could not be ruled out''' so '''pip-taz''' was '''orderd empirically'''
**'''2100''' '''- First antibiotic (pip-taz) given empirically'''
**2150 - scoped and found esophagitis and old blood in stomach but no new bleeding.
*'''Apr 17''' @ '''0100 hrs:''' Hbg now 104.  '''CVP 18-20''' and still on '''levo (switched from dopamine)'''
**0635 - '''another drop in BP 82/53'''.  '''CVP 11''' treated with fluid and FFP
**0730 - Temp now 38
**1130 - Temp 38.3


*My question is this: '''Is the FIRST low BP related to sepsis on Apr 16th at 1726 or Apr 17th at 0625? The first BP drop could have been related to hypovolemia from bleeding'''?
=== Positive Culture nor required ===
**does the pt meets the criteria for septic shock '''after''' he was intubated and his BP first dropped on April 16 @ 1726 hrs? 
*'''a POSITIVE CULTURE''' is '''NOT required''' for '''septic shock'''
**I am not sure because his Hgb was 80 so the hypotension could be related to a bleed not noticed on the scope although his CVP was 13-17? 
*By April 17th @ 0100 hrs, his hgb is 104 and has had alot of fluid.  The '''next drop in BP is at 0625'''.  He is well hydrated now although his CVP is down to 11 and his temp begins to rise shortly after this. --[[User:MWaschuk|MWaschuk]], 20 April 2010 (CDT)


***Did the doctors make a diagnosis?  To me the lactate of 8.7 is certainly a red flag and usually means that there is ischemia somewhere like the gut.  If this is the case, it is obviously a septic source and antibiotics should be started in my opinion.  I would definitely use the first drop in BP on April 16 as the time of septic shock if pressors were started as well as if the other septic shock criteria were evident.  The drop in BP is not related to bleeding according to your data. --[[User:LKolesar|LKolesar]] 11:45, 21 April 2010 (CDT)  
*'''Dr. Kumar''' advised that we should not routinely code ''distributive shock'' as septic shock, it should be coded as "other shock.'' Because we do not have a code called "other shock" use: [[Hypotension NYD (not due to shock or post op)]]. --[[User:TOstryzniuk|Trish Ostryzniuk]] 18:21, 2012 June 11 (CDT)


*******A few questions for point of clarification:
== All other shock codes Available ==
#What is the admitting and working diagnosis?
Go to category: [[:Category: Shock | ''Shock'']]
#Please quantify BP parameters.
#What antibiotic was ordered April 16th at 2100h? Thanks--Brenda Kline, April 21.10 1012 hrs.


-Reply to Brenda's question above-
==Cross checks==
*at '''admission''' on '''April 16 at 1715'''- The '''working diagnosis''' was: '''upper GI bleed''', '''lactate acidosis NYD''' and '''shock due to hypovolemia'''.
* Septic shock (4400) is mutually exclusive with 4500 [[Severe Sepsis]].
**Surgery had assessed pt twice prior to admission to ICU and the pt did not have an acute abd.  **Entrance complaint: severe adb pain and leg pain. 
I don't think this was ever implemented, can't find any evidence of it. Do we need it?
**The pt's lipase was 2000 but surgery was not convinced he had acute pancreatitis because CT was unremarkable except for a 6cm AAA (non-leaking).
**The leg mottling was thought to be due to hypoperfusion secondary to shock as opposed to a thrombis.
*'''Apr 16th at 1726''' was the first drop in '''BP 81/57''' 
*'''April 16th @ 1930''' Dr. wrote in the chart that '''septic shock could not be ruled out''' so '''pip-taz''' was '''orderd empirically''' and was '''given at 2100 hrs'''.
*'''Apr 17th at 0635''' a second significant drop in '''BP 82/53''' (pt was on levophed at the time).
*'''Apr 18 at 1500''', 46 hrs after admission to ICU, the pt was '''transferred''' to '''HSC MICU''' with the '''working dx''' of '''metabolic acidosis secondary to hypovolemia shock''' and '''hypoperfusion plus or minus septic shock'''.--[[User:MWaschuk|MWaschuk]], 21 April 2010 (CDT)


* "query s tmp QASeptic Dx no tmp"
* [[query s tmp QASeptic tmp no dx]]


*Thanks for the update. This is a good example because of the multiple potential septic sources and standard practice of addressing hypovolemic shock. After reading Laura's response, she validated my initial thoughts, but I wanted that wee bit more info, which was provided. Thus, I agree with the first drop in BP as the start of septic shock (may be in combo with hypovolemic). HOWEVER, I do want to discuss further with Kendiss, or she may respond before I get a chance. I am impressed with the critical thinking that is going on around some of your cases. Thank you!--[[User:Bkline|Bkline]] 12:04, 22 April 2010 (CDT)
== Questions & Answers ==


*Link with updated information sent over the Kendiss.  Stay tuned.........--[[User:TOstryzniuk|TOstryzniuk]] 19:14, 22 April 2010 (CDT)
=== use your judgement ===
This case is challenging…..
#If the 1st criteria for low BP "IS" met but 2nd criteria is "NOT" met (which is tmp >38.5 or HR >90 or RR >20) examples may be patient is either sedated, ventilated, or patient is hypothermic or heart rate is less than 90 for what ever reason, would they still meet the definition of septic shock if only 1st and 3rd criteria (organ failure) are met? OR....do we code as [[Severe Sepsis]] (which includes organ failure but excludes low BP). If so, how do we capture the low BP?  [[Severe Sepsis]] is organ failure but excludes low BP.[[User: GHall |Gail Hall]], [[User: Jpeterson | Joyce Peterson]], [[User: Mlaporte | Marie Laporte]][[User:TOstryzniuk|Trish Ostryzniuk]] 15:52, 2012 June 1 (CDT)
#*Dr. Kumar & Roberts both advise this: use judgement, if it appears to be a shock '''related specifically to an infection''' and is being treated as such even though the criteria for (T,HR,RR) is not met for some of the above stated reasons, then code as septic shock  This is different from [[VAP]] because for VAP no one in the world agrees on a standard definition, that is why we stick to very specific criteria regarding VAP for our purposes. (as per Dr. Kumar).[[User:TOstryzniuk|Trish Ostryzniuk]] 18:15, 2012 June 11 (CDT)


   
=== shock that is not septic shock ===
Dr. Kumar has also advised that anyone who has shock due to liver failure, pancreatitis drug overdoses or burns '''WITHOUT overt evidence of major infection''' don't code as septic shock. In his audit he has seen a lot of these codes as septic shock.
#***Dr. Kumar would like to emphasize to collectors that SEPTIC SHOCK means shock is thought to be DRIVEN BY infection and not just associated with infection.  Example, if someone has another obvious cause of shock with infection (like massive hemorrhage with it), that does not mean it is combined hemorrhagic and septic shock.  Basically, septic shock should '''not''' be called if there is another obvious cause for shock.[[User:TOstryzniuk|Trish Ostryzniuk]] 18:15, 2012 June 11 (CDT)


*This patient had 2 things going on resulting in shock; GI bleed and non-GI bleed –cause, likely sepsis.  Was an actual septic source ever identified in this man?
=== does unmeasurably low BP count as "first low BP === 
Patient in ER with no measurable BP. Tx with fluids, still no measurable BP.  Difficulty inserting central line, suspected sepsis.  Started on dopamine in ER.  Also given antibiotic for suspected sepsis. '''Question''' is this, if BP unmeasurable or not registering but pt is being treated for septic shock is this the time of the first low BP ? I spoke to Kendiss this morning-the answer is "yes"-the  unmeasurable BP could be the first low BP for the study if the patient is thought to be is shock due to infection. --[[User:Mlaporte|Mlaporte]] 08:00, 2012 June 4 (CDT)[[User:TOstryzniuk|Trish Ostryzniuk]] 18:15, 2012 June 11 (CDT)


*I think his initial blood pressure drop on April 16, 17:26 was at least partially (or all) due to GI bleed.  He had a significant drop in haemoglobin with some blood seen on EGD.  By the next day, his shock was definitely not due to GI bleeding as his CVP is up and his haemoglobin is stable.  
=== should criteria include hypothermia? ===
*most criteria for septic shock include [[Hypothermia]].
**'''After''' of [[QASeptic]] Project is completed in June or July 2012, we will add hypothermia to septic shock criteria as per Kendiss Olfason. Critical Care QI team agree to add.  [[User:TOstryzniuk|Trish Ostryzniuk]] 18:15, 2012 June 11 (CDT)  
* Brought this up again at our staff meeting that should hypothermia should be in the criteria for septic shock as discussed in 2012?[[User:GHall|GHall]] 15:53, 2017 March 9 (CST)
** And? Was there an answer? Ttenbergen 16:12, 2017 March 9 (CST) No answer yet TBA.


*I think you could make an argument for 2 times:
=== criteria met initially, but resolved by "Arrive DtTm" ===
If a patient meets all criteria for septic shock and this was the reason they were accepted to the ICU, however by the time they arrive to the ICU hours later,their vital signs are stable, and their GCS has improved/creatinine has normalized how should this be coded? Would it still be coded as septic shock, or would it simply be coded as infection ie.)cellulitis/cystitis?[[User:Mlagadi|Mlagadi]]


#April 16th at 17:26; This patient’s CVP is not low and therefore there is a real good possibility that GI bleeding is not the only reason for shock at this point.  The doctor’s notes also put sepsis in the differential at this point.   
=== 80% coded correctly ===
#April 17th at 1 am.  The patient has been well resuscitated and his CVP is now 18-20.  He remains hypotensive and is switched to levophed.  It is clear now that GI bleed is no longer the cause of his hypotension and he is likely septic.
About 10% of cases of septic shock in the database are overtly miscoded and are really obviously something else.  Another 10% are not clearly septic shock.  80% are solidly coded.  This is higher than any other database he has used.[[User:TOstryzniuk|Trish Ostryzniuk]] 18:15, 2012 June 11 (CDT)
*I would favour listing the time of septic shock onset as April 16th at 17:26, however as stated above one could also make the argument for April 17th 1 am.-Kendiss
*It would be nice to compare with Dr Kumar which cases he felt were not true septic shock pictures and use that info to help us in fine tuning our data collecting.In other words to learn from our mistakes.
**Marylou, have you resolved?--[[User:TOstryzniuk|TOstryzniuk]] 13:03, 29 April 2010 (CDT)
***April 29.10 - Yes I have.  I sent the file in the last batch.  The pt was transfered to St B. and they had septic shock and hypovolemic shock as their admits so '''I opted to go with the second drop in BP as the first drop related to septic shock'''. Kendiss wrote that I would have an argument with either BP but seeing as they were treating the GI bleed first I chose the second drop for the study. [[User:MWaschuk|MWaschuk]]


}}


[[Category: Data Integrity Rules]]
[[Category:Shock (old)]]
[[Category:Diagnosis Coding]]
[[Category: Sepsis]]

Latest revision as of 16:45, 2022 April 14


Legacy Content

This page is about the pre-ICD10 diagnosis coding schema. See the ICD10 Diagnosis List, or the following for similar diagnoses in ICD10:Shock, septic

Click Expand to show legacy content.


edit dx infobox
Category/Organ
System: 		Category: Cardiovascular Problems (old)

Type:

Category: Medical Problem (old)

Main Diagnosis: Septic Shock
Sub Diagnosis: SEPTIC SHOCK
Diagnosis Code: 4400
Comorbid Diagnosis: No
Charlson Comorbid coding (pre ICD10): 0
Program: Critical Care and Medicine
Status: Currently Collected


Mutually exclusive with Severe Sepsis

Also see Septicemia definition.

See QA Septic Shock- special project

Use definition in Shock, septic.

Legacy Content

This page contains Legacy Content.

Click Expand to show legacy content.

Definition

Dr. Kumar would like to emphasize to collectors that SEPTIC SHOCK means shock is thought to be DRIVEN BY infection and not just associated with infection. Example, if someone has another obvious cause of shock with infection (like massive hemorrhage with it), that does not mean it is combined hemorrhagic and septic shock. Basically, septic shock should not be called if there is another obvious cause for shock.--Trish Ostryzniuk 18:23, 2012 June 11 (CDT)

Criteria for coding septic shock

  • If at least one of the following is present:
    • systolic BP < 90 mmHg for > 30 minutes and not responding to fluid resuscitation
      • or
    • mean (m)BP < 65 mmHg for > 30 min
      • or
    • BP drop of > 40 mmHg from baseline for > 30 min
      • or
    • use of vasopressor to maintain systolic BP >= 90 mmHg in the absence of other causes of shock, e.g. Go to: Other types of shock

Plus at least one of (organ failure):

  • Neuro changes: GCS < 14
  • Lactic Acidosis: at least one of
    • LA > 2.0 or
    • PH < 7.30 or
    • BE < 10
  • Oliguria: at least one of
    • urine < 0.5 cc/kg/hr or
    • urine output < 30 ml / hr or
    • serum creatinine increase > 40 uM from baseline
  • Hypoxia: at least one of
    • PaO2 < 75 on RA or
    • PaO2 / FiO2 ratio <280 (not valid due to pneumonia)
  • Coagulopathy: drop in platelets > 25% from baseline plus at least one of
    • > 25% PT or
    • > 25% PTT or
    • NR >1.5

Examples of other conditions that can cause shock:

  • hypovolemia (Hypovolemic/Hemorrhagic Shock)
  • MI (Cardiogenic Shock)
  • pulmonary embolus
  • liver failure
  • pancreatitis
  • drug overdoses
  • burns
  • Note: Although these conditions can cause shock on their own, if the patient has an obvious serious sepsis with shock, you can still code septic shock even with these conditions.
  • If the above criteria are not met:

Positive Culture nor required

  • a POSITIVE CULTURE is NOT required for septic shock

All other shock codes Available

Go to category: Shock

Cross checks

  • Septic shock (4400) is mutually exclusive with 4500 Severe Sepsis.

I don't think this was ever implemented, can't find any evidence of it. Do we need it?

Questions & Answers

use your judgement

  1. If the 1st criteria for low BP "IS" met but 2nd criteria is "NOT" met (which is tmp >38.5 or HR >90 or RR >20) examples may be patient is either sedated, ventilated, or patient is hypothermic or heart rate is less than 90 for what ever reason, would they still meet the definition of septic shock if only 1st and 3rd criteria (organ failure) are met? OR....do we code as Severe Sepsis (which includes organ failure but excludes low BP). If so, how do we capture the low BP? Severe Sepsis is organ failure but excludes low BP.Gail Hall, Joyce Peterson, Marie LaporteTrish Ostryzniuk 15:52, 2012 June 1 (CDT)
    • Dr. Kumar & Roberts both advise this: use judgement, if it appears to be a shock related specifically to an infection and is being treated as such even though the criteria for (T,HR,RR) is not met for some of the above stated reasons, then code as septic shock This is different from VAP because for VAP no one in the world agrees on a standard definition, that is why we stick to very specific criteria regarding VAP for our purposes. (as per Dr. Kumar).Trish Ostryzniuk 18:15, 2012 June 11 (CDT)

shock that is not septic shock

Dr. Kumar has also advised that anyone who has shock due to liver failure, pancreatitis drug overdoses or burns WITHOUT overt evidence of major infection don't code as septic shock. In his audit he has seen a lot of these codes as septic shock.

        • Dr. Kumar would like to emphasize to collectors that SEPTIC SHOCK means shock is thought to be DRIVEN BY infection and not just associated with infection. Example, if someone has another obvious cause of shock with infection (like massive hemorrhage with it), that does not mean it is combined hemorrhagic and septic shock. Basically, septic shock should not be called if there is another obvious cause for shock.Trish Ostryzniuk 18:15, 2012 June 11 (CDT)

does unmeasurably low BP count as "first low BP

Patient in ER with no measurable BP. Tx with fluids, still no measurable BP. Difficulty inserting central line, suspected sepsis. Started on dopamine in ER. Also given antibiotic for suspected sepsis. Question is this, if BP unmeasurable or not registering but pt is being treated for septic shock is this the time of the first low BP ? I spoke to Kendiss this morning-the answer is "yes"-the unmeasurable BP could be the first low BP for the study if the patient is thought to be is shock due to infection. --Mlaporte 08:00, 2012 June 4 (CDT)Trish Ostryzniuk 18:15, 2012 June 11 (CDT)

should criteria include hypothermia?

  • most criteria for septic shock include Hypothermia.
    • After of QASeptic Project is completed in June or July 2012, we will add hypothermia to septic shock criteria as per Kendiss Olfason. Critical Care QI team agree to add. Trish Ostryzniuk 18:15, 2012 June 11 (CDT)
  • Brought this up again at our staff meeting that should hypothermia should be in the criteria for septic shock as discussed in 2012?GHall 15:53, 2017 March 9 (CST)
    • And? Was there an answer? Ttenbergen 16:12, 2017 March 9 (CST) No answer yet TBA.

criteria met initially, but resolved by "Arrive DtTm"

If a patient meets all criteria for septic shock and this was the reason they were accepted to the ICU, however by the time they arrive to the ICU hours later,their vital signs are stable, and their GCS has improved/creatinine has normalized how should this be coded? Would it still be coded as septic shock, or would it simply be coded as infection ie.)cellulitis/cystitis?Mlagadi

80% coded correctly

About 10% of cases of septic shock in the database are overtly miscoded and are really obviously something else. Another 10% are not clearly septic shock. 80% are solidly coded. This is higher than any other database he has used.Trish Ostryzniuk 18:15, 2012 June 11 (CDT)

  • It would be nice to compare with Dr Kumar which cases he felt were not true septic shock pictures and use that info to help us in fine tuning our data collecting.In other words to learn from our mistakes.
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