Septic Shock

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

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Category/Organ System:	Category: Cardiovascular Problems (old)
Type:	[[:Category: Medical Problem (old)]][[Category: Medical Problem (old)]]
Main Diagnosis:	Septic Shock
Sub Diagnosis:	SEPTIC SHOCK
Diagnosis Code:	Septic Shock - 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

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)

(1) Blood pressure (BP) criteria

• 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
  • 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
    • Dr. Kumar has advised that anyone who has a diagnosis of shock WITHOUT overt evidence of major infection do not code as septic shock. Examples of other condition that can cause shock:
      • hypovolemia (Hypovolemic/Hemorrhagic Shock)
      • MI (Cardiogenic Shock)
      • pulmonary embolus
      • liver failure
      • pancreatitis
      • drug overdoses
      • burns
• If none of the BP criteria are met:
  • see Severe Sepsis

(2) Other Criteria

Plus at least two of:

• temperature > 38.5 C
• HR > 90
• RR > 20
  • See question 1 below.

(3) Organ Failure Criteria

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

Notes

• a POSITIVE CULTURE is NOT required for septic shock

• 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). --Trish Ostryzniuk 18:21, 2012 June 11 (CDT)

All other shock codes Available

Go to category: Shock

Data Integrity Rules

Septic shock (44-00) is mutually exclusive with 45-00 Severe Sepsis.

Questions & Answers

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)
     • 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)
2. are any collectors only using the 1st BP criteria (BP<90mmhg) for septic shock study in TMP? Reason asking is that the drop down list in TMP files only gives hint of BP<90 so wondering if folks are forgetting there are two other option for low BP that they need to consider as indicated in criteria for BP in this article.Gail Hall, Joyce Peterson, Marie Laporte.
   • Tina, with the drop down list in TMP only noting above, collector may forget to be reminded that there are also 2 other low BP criteria that could be use. TIna anything you can change. Trish Ostryzniuk 18:15, 2012 June 11 (CDT)
     • I believe the question here also is if other collectors are forgetting there are other BP criteria?Trish Ostryzniuk 18:15, 2012 June 11 (CDT)
     • I can change the dropdowns however you want; it would change the way they would show up in outputs, so Julie would need to know and should probably be consulted before we do. Could change it so something like "BP criteria"?Ttenbergen 17:00, 2012 June 14 (CDT)

• Maybe use "time first BP criteria met". (If the data collector is using the tmp file for sepsis then they have already coded septic shock. All the criteria for septic shock is already on the wiki so I do not see why someone would be mixed up with the low BP wording in the tmp file. The only problem I have is saying <90 systolic because this is not always the case). --LKolesar 11:02, 2012 June 18 (CDT)
  • "time first BP criteria met" is a bit long, don't think it would fit visibly into the field. How about "BP criteria"? If a collector does not know what that means we have other problems. And, it would eliminate the suggestion that <90 is the only one. Ttenbergen 11:28, 2012 June 18 (CDT)

1. 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)
2. Question about the criteria: 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)

NOTE from Dr. Kumar June 6, 2012

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)