Shock, septic

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ICD10 Diagnosis
Dx: Shock, septic
ICD10 code: R57.2
Pre-ICD10 counterpart: Septic Shock
Charlson/ALERT Scale: none
APACHE Como Component: none
APACHE Acute Component: Sepsis
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:
  • 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

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:   
  • e.g. Patient has severe sepsis with the acute organ failure being acute renal failure due to ATN --- and it's felt to be due to a pseudomonas pneumonia. So in this case the pseudomonas is the bug that should be combined with the severe sepsis (and with with the pneumonia, of course)
    • e.g. Patient with septic shock has an E.coli UTI and a pseudomonas pneumonia. The team is not certain which of those two bacteria is causing the septic shock, but of course is treating them both. In this case the bug is known to be a bacterium, but not clear which, so the bug to combine with the Septic shock is Bacteria, NOS

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.

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.
  • 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 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   
  • 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).

Alternate ICD10s to consider coding instead or in addition

shock codes:
  • 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).

Candidate Combined ICD10 codes

  • Also code the causative infection.

Related CCI Codes

Data Integrity Checks (SMW)

 AppStatus
Query s tmp QASeptic tmp no dxCCMDB.accdbimplemented
Query s tmp QASeptic Dx no tmp ICD10CCMDB.accdbimplemented
Check Inf Pathogens must have Infection requiring pathogen or Potential InfectionCCMDB.accdbimplemented
Query check ICD10 Inf Infection req Pathogen must have oneCCMDB.accdbimplemented

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