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 audit started September 2009.

Definition

(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 (is this an "and" to the next line?)
  • 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.:
    • no hypovolemia
    • no MI
    • no pulmonary embolus
• 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

(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

Data Integrity Rules

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

Discussion 1 - Resolved April 19.10

What time should I record as the 1st BP related to septic shock?

• • FINAL answer: March 30th 2112 hrs.--TOstryzniuk 12:51, 28 April 2010 (CDT)
• Mar 10 admitted with HAP (e.coli, serratia, candida), pleural effusions, cardiomyopathy
• Mar 15 pleural tap of the effusions
• Mar 18 cardiac arrest no cool
• Mar 20 extubated
• Mar 23 Decreased LOC due to C02- reintubated
• Mar 24 tracheostomy
• Mar 25 C. diff positive
• Mar 25 slow decline in Hgb addressed
• Mar 26 abrupt decrease in Hgb from 81 to 68 Transfused
• Mar 27 on and off belly pain. Tarry stool. Transfused. CT abd showed no evidence of a bleed.
• Mar 28 Hgb again decreased to 68. Transfused.
• Mar 29 Gastroscopy showed non bleeding duodenal ulcer. Suggested a colonoscopy but never done. WBC 9.9. Afebrile. Still abd pain. ABG 7.41 CO2 35 O2 68 (low from his normal). Query ischemic gut.
• Mar 30 Lactate increased from 2.3 in the am to 6.5 at 2010.
  • CT abd at 2135 showed nothing definitive but ischemic colitis not ruled out.
  • 2115 hrs first systolic BP less that 90, started on neo.
  • T-36.4 HR 133 RR 34 WBC 10.6 INR increased to 1.9 Urine output adequate. ABG at 2210 7.20 CO2 47 PO2 77 Still query ischemic gut.
• Mar 31 By 0805 Neo stopped and levo started. Temp 37 RR controlled at 20 **HR 100 WBC 1.8 Lactate 4.5 ABG 7.22 CO2 56 O2 74 Anuric Accucheck 2.1 **Pip taz ordered at 0810 and given at 0815.
  • • By 1215 Levo at 1.4 Amiodarone started for SVT and Accucheck continue to be low and D50 amps given.
  • At 1320 a PA cath is inserted. T 38.3 CVP 12 PCWP 13 SVR 866 CI 2.5 Venous O2 35
  • At 1715 CI 1.7 and SVR 1424 Ph 7.1 Lactate 10.7 Now definately cardiogenic shock
  • At 2005 pt expires
• Blood cultures taken on Mar 31 were negative
• Sputum from Mar 31 continues to show e.coli and candida
• Urine from Mar 31 e. coli now growing.
• Antibiotic hx:
  • Cefotaxime Mar 10, 11, 12
  • Cipro Mar 12, 13, 14, 15, 16, 17, 18, 19
  • No antibiotics Mar 20-25
  • Flagyl Mar 25, 26, 27, 28, 29, 30
  • Pip-taz Mar 31
• For the septic study would I use the the first BP drop on Mar 30 at 2115 even though they thought they were dealing with ischemic gut which was not entirely ruled out or the BP on Mar 31 at 0805 when the switched to levo and first ordered pip-taz when they now thought they were dealing with septic shock. If I record Mar 30th BP it will show a big delay in receiving the antibiotic. Mar 31 too showed a mixed shock as evidenced by the PA numbers.--MWaschuk 16:18, 12 April 2010 (CDT)

• • Mary lou, this patient had a course of antibiotics for the HAP, then flagyl was started for the c.diff. The ischemic gut clearly is a septic source and as soon as they knew they had an ischemic gut they should have started antibiotics. If the first low BP was on Mar 30 at 2115 this would be the time I would use. ( I assume your BP was stable for the other prior septic sources of HAP and c.diff colitis). --LKolesar 13:26, 13 April 2010 (CDT)

• • • Link to this page's discussion has been sent to Dr. Kendiss Olafson and Brenda Kline for further comment. Thank you for posting your discussion here. -TOstryzniuk 11:56, 14 April 2010 (CDT)

• • • • In my opinion, following review of the information from the discussion and the definition we are using, I agree with using the Mar. 30th drop in BP. Mary Lou provides appropriate rationale and L Kolesar provides supportive rationale. Please await Kendiss’ opinion before responding to the query. Brenda Kline, Wednesday, April 14, 2010 9:36 AM

_______________________________________

• • • • • From: Kendiss Olafson Sent: Monday, April 19, 2010 1:37
        • I agree that septic shock onset should be recorded as Mar 30th. The patient turned out to be septic and this is when they first dropped their blood pressure. As a health team, part of the challenges in giving early antibiotics is identifying when we are dealing with septic shock versus other causes of hypotension. In this example, if we pick a later time b/c we think it is reasonable that the team missed sepsis diagnosis when they first dropped the blood pressure, we make our data look better but we would lose the learning opportunity to identify strategies to avoid that error in the future. --Kendiss

Discussion 2 - Resolved April 26, 2010

• What should I record as first low BP in this case.--Marylou
  • Final answer: First low BP April 16th at 17:26--TOstryzniuk 12:54, 28 April 2010 (CDT)

• Here is another scenario:
• 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
  • 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?
  • does the pt meets the criteria for septic shock after he was intubated and his BP first dropped on April 16 @ 1726 hrs?
  • 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. --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. --LKolesar 11:45, 21 April 2010 (CDT)

• • • • • • • A few questions for point of clarification:

1. What is the admitting and working diagnosis?
2. Please quantify BP parameters.
3. What antibiotic was ordered April 16th at 2100h? Thanks--Brenda Kline, April 21.10 1012 hrs.

-Reply to Brenda's question above-

• at admission on April 16 at 1715- The working diagnosis was: upper GI bleed, lactate acidosis NYD and shock due to hypovolemia.
  • 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.
  • 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.--MWaschuk, 21 April 2010 (CDT)

• 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!--Bkline 12:04, 22 April 2010 (CDT)

• Link with updated information sent over the Kendiss. Stay tuned.........--TOstryzniuk 19:14, 22 April 2010 (CDT)

This case is challenging…..

• 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?

• 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.

• I think you could make an argument for 2 times:

1. 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.
2. 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.

• 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
  • Marylou, have you resolved?--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. MWaschuk