Severe sepsis: Difference between revisions
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== Additional Info == | == Additional Info == | ||
{{ICD10 Guideline Sepsis}} | |||
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== Alternate ICD10s to consider coding instead or in addition == | == Alternate ICD10s to consider coding instead or in addition == | ||
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== Related CCI Codes == | == Related CCI Codes == | ||
== Background == | |||
=== Introduction of ... === | |||
*Even though as of November 2017 ICD-10 has not yet been modified to reflect it, we are using the 2016 consensus definition of sepsis and septic shock (JAMA 315(8):801-10, 2016). These new definitions completely do away with talking about the Systemic Inflammatory Response Syndrome (SIRS). In the 2016 definitions | |||
{{Data Integrity Check List}} | {{Data Integrity Check List}} | ||
Revision as of 08:05, 2018 December 14
| ICD10 Diagnosis | |
| Dx: | Severe sepsis |
| ICD10 code: | R65.1 |
| Pre-ICD10 counterpart: | Severe Sepsis |
| Charlson/ALERT Scale: | none |
| APACHE Como Component: | none |
| APACHE Acute Component: | 2019-0: Sepsis |
| Start Date: | |
| Stop Date: | |
| External ICD10 Documentation | |
This diagnosis is a part of ICD10 collection.
Additional Info
- As of January 2019, we are still using the SEPSIS-2 approach to diagnosis. We may or may not switch over to the SEPSIS-3 definition. SEPSIS-2 delineates 3 subtypes of sepsis:
- Sepsis (SIRS due to infection, without acute organ failure) -- defined as SIRS due to a known or presumed infection but NOT satisfying criteria for severe sepsis or septic shock (see SIRS critera, below)
- Severe sepsis -- defined as sepsis PLUS one or more acute organ failures
- Shock, septic -- defined as severe sepsis where an acute organ failure is the cardiovascular system (see criteria below)
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 a less advanced to a more advanced subtype of sepsis --- and as this occurs, make sure to code the more advanced subtypes as they occur
- 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
Identifying the Acute Organ Failure of Severe sepsis
- There are many different scoring systems for this: SOFA, LOD, MODS, Brussels score, others
- They're all problematic for various reasons, but the biggest problem with them is the inability to distinguish acute vs. chronic organ dysfunction -- which is why the SEPSIS-3 definition uses the acute CHANGE in the SOFA score, not the score itself. However, while that makes sense, it's also VERY difficult to do, since we rarely know all the information needed to do the pre-sickness SOFA score.
- So, for our purposes we will be using the Brussels score:
- Consider a patient to have Severe sepsis if they meet criteria for sepsis AND have any one of the following 6 criteria:
- Systolic BP <90 and iv fluids alone are not sufficient (e.g. on any vasoactive agents) ............AND THIS IS NOT KNOWN TO BE CHRONIC
- PaO2/FIO2 ratio <300............AND THIS IS NOT KNOWN TO BE CHRONIC
- GCS<13.................................AND THIS IS NOT KNOWN TO BE CHRONIC
- Platelet count <80..................AND THIS IS NOT KNOWN TO BE CHRONIC
- Serum creatinine >180..........AND THIS IS NOT KNOWN TO BE CHRONIC
- Total bilirubin >34..................AND THIS IS NOT KNOWN TO BE CHRONIC
- Consider a patient to have Severe sepsis if they meet criteria for sepsis AND have any one of the following 6 criteria:
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.
| Example: |
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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.
- 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.
Identifying the bug responsible for sepsis
- 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.
Criteria for SIRS
- SIRS is defined as 2 or more of the following things:
- Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
- Heart rate of more than 90 beats per minute
- Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO 2) of less than 32 mm Hg
- Abnormal white blood cell count (>12,000/µL or <4,000/µL or >10% immature [band] forms)
Criteria for the SHOCK in Septic Shock
- Persisting hypotension requiring vasopressors to maintain MAP>65mmHg AND serum lactate>2 mmol/L -- both despite adequate volume resuscitation.
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How hard of a rule is lactate >2? If they meet the criteria for septic shock with the exception of a high enough lactate, can we code septic shock Lisa Kaita 12:17, 2024 April 17 (CDT)
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- The CAUSE is proven infection OR presumed infection -- thus positive cultures are not required.
| Example: |
if someone has another obvious cause of shock (e.g. massive hemorrhage) and also has infection, that does not mean it is combined hemorrhagic and septic shock. Basically, septic shock should not be called if there is another more obvious cause for shock. |
- 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
| background about 2016 sepsis consensus |
|
Alternate ICD10s to consider coding instead or in addition
- Sepsis (SIRS due to infection, without acute organ failure)
- Shock, septic
- Puerperal (post-delivery) infections or 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).
| shock codes: |
Candidate Combined ICD10 codes
- Also code the causative infection.
Infections
Infections in ICD10 have combined coding requirements for some of their pathogens. Any that have antibiotic resistances would store those as Combined ICD10 codes as well. If the infection is acquired in the hospital, see Nosocomial infection, NOS. See Lab and culture reports for confirmation and details about tests. See Infections in ICD10 for more general info.
Possible Simultaneous Presence of Multiple Different Types of Infection in a Single Site
- This refers to the situation where there may be simultaneous infection with multiple types of organisms -- e.g. 2 of bacteria, virus, fungus. While a classic example is a proven viral pneumonia (e.g. influenza) with a suspected/possible bacterial pneumonia superimposed, this kind of thing can occur in places other than the lungs, e.g. meningitis.
- The "signature" of this is typically the patient being treated simultaneously with antimicrobial agents for multiple types of organisms. BUT don't confuse this with there being infections at DIFFERENT body sites.
- As per our usual practice, we will consider a diagnosis as present if the clinical team thinks it's present and are treating it, with the exception that the team initially treated for the possible 2nd type of infection but then decided it likely was NOT present and stopped those agents.
- And remember that Infectious organism, unknown is used when the the specific organism is unknown (this could be not knowing the TYPE of organism, or suspecting the type but not having identified the specific organism of that type), while when the organism has been identified but it's not in our bug list, THEN use Bacteria, NOS, Virus, NOS or Fungus or yeast, NOS.
Attribution of infections
Related CCI Codes
Background
Introduction of ...
- Even though as of November 2017 ICD-10 has not yet been modified to reflect it, we are using the 2016 consensus definition of sepsis and septic shock (JAMA 315(8):801-10, 2016). These new definitions completely do away with talking about the Systemic Inflammatory Response Syndrome (SIRS). In the 2016 definitions
Data Integrity Checks (automatic list)
| App | Status | |
|---|---|---|
| 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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