Sepsis

Definitions

Sepsis is defined as systemic inflammatory response syndrome (SIRS) in the presence of, or as a result of, suspected or proven infection. 

According to the CDC, sepsis affects all parts of the body and can happen in response to an infection and quickly become life-threatening.  In severe cases of sepsis, one or more organs fail. In the worst cases, sepsis causes a drop in blood pressure and weakens the heart, leading to septic shock.

If cultures are negative but infection is probable, document culture negative sepsis.

Systematic Inflammatory Response Syndrome (SIRS)

Systemic inflammatory response syndrome (SIRS) is a widespread inflammatory response that may or may not be associated with infection.  The presence of 2 or more following criteria, ONE of which MUST BE abnormal temperature or leukocyte count.

Pediatric criteria:

  • Fever: core temperature >38.5°C or <36°C

  • Tachycardia:

    • Mean HR >2 SD above normal for age in the absence of external stimulus, chronic drugs, or painful stimuli; or otherwise unexplained persistent elevation over a 0.5- to 4-hr time period.

    • For children <1 yr old: bradycardia, defined as mean HR <10%ile for age in the absence of external vagal stimulus, beta-blocker drugs, or congenital heart disease; or otherwise unexplained persistent depression over a 0.5-hr time period.

  • Tachypnea: mean respiratory rate >2 SD above normal for age

  • Abnormal WBC: WBC elevated or depressed for age (not secondary to chemotherapy-induced leukopenia) or >10% immature neutrophils

Example diagnosis: Kawasaki’s Disease w/ SIRS

Severe Sepsis/ Multiple Organ Dysfunction Syndrome

Sepsis plus 1 of the following: cardiovascular organ dysfunction OR acute respiratory distress syndrome OR two or more other organ dysfunctions 

“Bacteremia” is bacteria in the blood.  Within coding guidelines, bacteremia does not convey the same level of acuity within documentation as sepsis. 

Organ Dysfunction Criteria*

Cardiovascular

dysfunction

Despite administration of isotonic IV fluid bolus ≥ 40 mL/kg in 1 hr

1. Decrease in BP (hypotension) <5%tile for age or systolic BP < 2 SD below normal for age

OR

2. Need for vasoactive drug to maintain BP in normal range (dopamine ≥ 5 ug/kg/min or dobutamine, epinephrine, or norepinephrine at any dose)

OR

3. Two of the following:

· Unexplained metabolic acidosis: base deficit > 5.0 mEq/L

· Increased arterial lactate > 2 times upper limit of normal

· Oliguria: urine output < 0.5 mL/kg/hr

· Prolonged capillary refill: > 5 secs

· Core to peripheral temperature gap > 3°C

Respiratory

PaO2/FiO2 < 300 in absence of cyanotic heart disease or preexisting lung disease

OR

PaCO2 > 65 mmHg or 20 mm Hg over baseline

OR

Proven need for > 50% FiO2 to maintain saturation >92%

OR

Need for non-elective invasive or noninvasive mechanical ventilation

Neurologic

Glasgow Coma Score ≤11

OR

Acute change in mental status with a decrease in Glasgow Coma Score
≥3 points from abnormal baseline
Hematologic

Platelet count <80,000/mm3 or a decline of 50% in platelet count from highest value recorded over the past 3 days (for chronic hematology/oncology patients)

OR

International normalized ratio >2
Renal

Serum creatinine ≥ 2 times upper limit of normal for age or
2-fold increase in baseline creatinine
Hepatic

Total bilirubin ≥4 mg/dL (not applicable for newborn)

OR

ALT 2 times upper limit of normal for age

Sepsis in Infants Less Than 90 Days Old

Febrile infants younger than 90 days old are at higher risk for invasive bacterial or serious viral infections than older children. They may require empiric antimicrobial therapy and hospitalization. A young febrile infant may demonstrate few clues to the underlying illness on physical exam. 

Sepsis should be considered and presumptively treated for infants less than 90 days old when:

  • Febrile (Rectal temperature greater than 38°C or 100.4° F)

  • Hypothermic (Rectal temperature less than 36.4°C or 97.5°F)

  • Appears ill regardless of age 

  • Presenting with exam findings suggestive of HSV infection (mucocutaneous vesicles, seizures, or focal neurologic findings)

  • Younger than 28 days of age, even if an identifiable etiology for infection

  • 29 to 60 days of age (corrected for prematurity as indicated) with any one of the following risk factors for infection and has: 

    • Rectal temperature greater than 101.4°F

    • Congenital or chromosomal defects

    • Technology dependent (i.e. home oxygen, home ventilator, indwelling central line)

    • Received antibiotic therapy in past 3 to 7 days

  • 29 to 90 days old with focal infection (i.e. cellulitis, abscess, osteomyelitis, bacterial arthritis, pneumonia) and abnormal white blood cell (WBC) count, absolute neutrophil count (ANC), inflammatory markers (procalcitonin [PCT] and/or C-reactive protein [CRP] if rapidly available), or urinalysis.

Neonatal Fever

Neonatal fever may be coded as neonatal fever or rule out sepsis during the stay of a baby in the hospital. On discharge, it is documented as viral syndrome, especially for babies less than 28 days.

For older babies, on discharge, it can be documented as culture negative or viral sepsis.

Tips For Documentation

  • Write “treating for sepsis”, “probable sepsis”, “suspected sepsis” when unsure but managing patient for sepsis

  • DO NOT WRITE “concern for sepsis” or “meets sepsis criteria”, these ARE NOT a diagnosis of sepsis

  • When known, document the underlying systemic type or causal organism

  • When patient has severe sepsis, document “severe” or describe organ dysfunction

  • If circulatory failure AND sepsis are related, document septic shock

  • Septic shock includes severe sepsis in its description

  • Urosepsis only captures UTI, not sepsis; indicate sepsis due to pyelonephritis

  • Document sepsis onset, either at admission or during admission

  • Always include sepsis in the Discharge Summary

Quick Tips!

SIRS Criteria (Systematic Inflammatory Response Syndrome)

Core temperature > 38.5C OR <36C

Tachycardia (HR>2SD) for age
OR
bradycardia (HR<10%ile for age) for at least 30 min

Tachypnea (mean RR >2SD for age)
OR
acute need for mechanical ventilation

Elevated or depressed WBC count
OR
>10% immature neutrophils

Defining Sepsis:

  • Sepsis is SIRS in the presence of OR as a result of suspected or proven infection.

  • SIRS needs to meet TWO or more criteria (see below)

  • If cultures are negative, document “Culture negative sepsis”

Severe Sepsis = Sepsis PLUS

  • Cardiovascular organ dysfunction OR

  • Acute respiratory distress syndrome OR

  • Two or more other organ dysfunctions

Septic Shock = Sepsis with PERSISTENT cardiovascular organ dysfunction

  • Hypotension despite IV fluid bolus ≥ 40 ml/kg in 1 hr

  • Need for vasoactive drug(s) to maintain normal BP

Document "Sepsis" as soon as recognized

  • Indicate when "when present on arrival" OR "developed during admission"

    • Symptoms present within initial 6 hours of admission OR

    • Suspected | Probable | Rule out Sepsis | Evolving on admission

  • Include at least 2 supporting indicators

    • Appendicitis with suspected sepsis present on arrival, due to fever & leukocytosis

  • Include in the discharge summary

    • Sepsis, due to peritonitis from perforated appendicitis