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

Notes

• a positive culture is not required for septic shock
• you can use septic shock to code distributive shock unless it can be coded more accurately:
  • causes for distributive shock that should not be coded as septic shock are:
    • Anaphylactic Shock
    • Neurogenic or Spinal Shock

Data Integrity Rules

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

Questions

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)
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.
3. 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 studyMlaporte 08:00, 2012 June 4 (CDT)

• Marie, when you complete final question, let me know and I will email off to Kendiss the above.Trish Ostryzniuk 16:10, 2012 June 1 (CDT)

1. Question about the criteria: most criteria for septic shock include hypothermia. It is interesting that our criteria does not. I will paste the criteria from wikipedia for everyone to review, maybe ask Kendiss about that.--LKolesar 10:43, 2012 June 4 (CDT)

• Definition (of septic shock):

In humans, septic shock has a specific definition requiring several conditions to be met for diagnosis:

   First, SIRS (systemic inflammatory response syndrome) must be diagnosed by finding at least any two of the following:

   Tachypnea (high respiratory rate) > 20 breaths per minute, or on blood gas, a PCO2 less than 32 mmHg signifying hyperventilation.
   White blood cell count either significantly low, < 4000 cells/mm³ or elevated > 12000 cells/mm³.
   Heart rate > 90 beats per minute
   Temperature: Fever > 38.5 °C (101.3 °F) or hypothermia < 35.0 °C (95.0 °F)

   Second, there must be sepsis and not an alternative form cause of SIRS. Sepsis requires evidence of infection, which may include positive blood culture, signs of pneumonia on chest x-ray, or other radiologic or laboratory evidence of infection
   Third, signs of end-organ dysfunction are required such as renal failure, liver dysfunction, changes in mental status, or elevated serum lactate.
   Finally, septic shock is diagnosed if there is refractory hypotension (low blood pressure that does not respond to treatment). This signifies that intravenous fluid administration alone is insufficient to maintain a patient's blood pressure from becoming hypotensive.