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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A few days ago&#44; new definitions of sepsis and septic shock were launched as a result of a consensus of 19 experts SCCM &#40;Society of Critical Care Medicine&#41; and ESICM &#40;European Society of Intensive Care Medicine&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Perhaps the greatest contribution of this expert opinion consensus has been to recognize sepsis as a difficult to characterize syndromic condition&#44; with a cellular metabolic disorder as a lead condition along with the development of organ failure&#46; However&#44; as the most important feature&#44; the new definition excludes the concept of SIRS &#40;Systemic Inflammatory Response Syndrome&#41; since this term is being considered of not useful anymore&#46; The authors supported this decision mainly based on a retrospective study conducted in Australia and New Zealand<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> in which it was observed &#40;glass half-empty approach&#41; that 1 out of 8 patients &#40;12&#46;5&#37;&#41; with sepsis and multiorgan failure &#40;MOF&#41; did not have at least 2 SIRS criteria&#46; However&#44; these results &#40;glass half-full approach&#41; could be reinterpreted as 7 out of 8 patients &#40;87&#46;5&#37;&#41; did present positive SIRS criteria&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Furthermore&#44; the authors&#44; in the paper on new sepsis definitions&#44; affirmed that SIRS does not represent a dysregulated systemic response compromising host survival for the diagnosis of sepsis anymore&#46; The concept of SIRS&#44; such as expressed by Bone et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> is a clear one and refers to non-specific inflammatory response of the host to an injury&#46; The theory of &#8220;CHAOS&#8221; proposed by Bone &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; masterfully develops the different interactions between the pro and anti-inflammatory response of the host taking into account a translational view&#44; which has elucidated the different phases or states of patients with sepsis&#46; Moreover&#44; several studies have found a direct association between SIRS severity and clinical progression&#46; Rangel-Frausto et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> showed that mortality significantly increased from 7&#37; to 17&#37; based on the number of SIRS criteria &#40;from two to four respectively&#41;&#46; Interestingly&#44; Napolitano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> observed in trauma patients the relative risk &#40;RR&#41; of mortality increased from 3&#46;46 &#40;interquartile range &#91;IQR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;48&#8211;8&#46;11&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41; with a SIRS score<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#8211;6&#46;88 &#91;1&#46;81&#8211;22&#46;8&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004 for SIRS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46; In addition&#44; Barie and Hydo<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> reported that the change in SIRS score within the first 24<span class="elsevierStyleHsp" style=""></span>h of treatment was significantly associated with mortality &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Moreover&#44; to define sepsis based on organ dysfunction may have serious limitations&#46; The SOFA score was designed to estimate more objectively organ dysfunction associated with sepsis<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> and its use is common in intensive care units &#40;ICUs&#41;&#44; but not in other health care settings&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> where a more large number of patients with sepsis are screened&#46; This is by far the area of detection and Sepsis Code activation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the other hand&#44; it important to highlight that with the previous definitions and international campaigns implementations based on such&#44; mortality of sepsis has dramatically decreased&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> As other authors have previously acknowledged it&#44; SIRS and MOF are not syndromes but merely concepts&#46; SIRS criteria are non-specific physiological responses to an aggression to the host&#46; Whilst SIRS should be promptly identified&#44; MOF should be considered a delayed failure to an inadequate clinical response&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Another important aspect of the recently launched definitions of sepsis is the proposal of &#8220;quick SOFA&#8221; as a criterion for suspected sepsis if there are two of the three criteria chosen &#40;systolic blood pressure &#60;100<span class="elsevierStyleHsp" style=""></span>mmHg&#44; tachypnea &#62;22<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">&#8211;1</span> or altered mentation &#91;derived from Glasgow Coma Score &#60;13&#93;&#41; while SIRS &#40;including tachycardia &#62;90 and tachypnea &#62;20&#41; criteria is deleted&#46; Unfortunately&#44; there is a potential exclusion of physiopathology concept&#46; Vasoconstriction and tachycardia are physiological mediated responses aimed to keep adequate oxygen transport and metabolism&#46; This phenomenon has been extensively studied showing a good correlation between shock index &#40;heart rate&#47;systolic blood pressure ratio&#41; and mortality&#46; This concept is extremely valid and useful in young patients or patients without chronic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">10&#8211;12</span></a> Moreover&#44; based on new definitions&#44; to have chosen just hypotension or altered sensorium for sepsis detection&#44; may &#40;a&#41; delay essential therapeutic measures such as early administration of antibiotics and &#40;b&#41; accepting organ failure establishment as the first sign of detection&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As a common rule&#44; the choice of one or other clinical indicator should be related to the goal to be achieved&#46; Thus&#44; if the goal is to detect promptly a wide number of patients at risk &#40;even with the risk of over diagnosis&#41; of one event &#40;sepsis&#41;&#44; a very sensitive indicator should be chosen even when less associated specificity&#46; The recent definitions focus on a more specific goal&#44; organ dysfunction&#44; which will somehow jeopardize the detection of patients with sepsis with both lack or delayed identification of patients at risk&#46; Like in other diseases &#40;i&#46;e&#46; stroke&#44; myocardial infarction&#41;&#44; the efforts have been made in early detection campaigns rather than very specific approaches&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We have to acknowledge the limitations of the former definitions especially severe sepsis and the new interpretation of septic shock&#46; Now&#44; shock is defined&#44; as a clinical condition associated to vasopressor requirement to maintain a mean arterial pressure of 65<span class="elsevierStyleHsp" style=""></span>mm Hg or greater and serum lactate level greater than 2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L &#40;&#62;18<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; in the absence of hypovolemia&#46; This is something that might be applicable only within the first hours of resuscitation to identify patient&#39;s response but not to define a clinical state&#46; It is true that different recent clinical trials have shown an unexpected low mortality in some patients with septic shock&#46; However&#44; there is a lack of timing with this very important change in the concept&#46; For instance&#44; if a patient has a sustained high lactate level&#44; would this define a terminal event after a failure in resuscitation instead&#63;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary&#44; we consider that new definitions must foster to adequately characterize identification&#44; management and stratification with an integrative clinical and pathophysiological approach&#46; We wonder&#44; after a careful review of the new definitions&#44; if they are just a confusing episode of research or they bring anything truly needed to improve current clinical practice&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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Point of view
New definition of sepsis and septic shock: What does it give us?
Nueva definición de sepsis y shock séptico: ¿qué nos ofrece?
A. Rodrígueza,
Autor para correspondencia
ahr1161@yahoo.es

Corresponding author.
, I. Martín-Loechesb, J.C. Yébenesc
a Servicio de Medicina Intensiva, Hospital Universitario de Tarragona Joan XXIII/URV/IISPV/CIBERES, Tarragona, Spain
b Multidisciplinary Intensive Care Research Organization (MICRO), Department of Anaesthesia and Critical Care, St James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
c Servicio de Medicina Intensiva, Hospital Universitario de Mataró, Mataró, Spain
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        "titulo" => "Nueva definici&#243;n de sepsis y <span class="elsevierStyleItalic">shock</span> s&#233;ptico&#58; &#191;qu&#233; nos ofrece&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A few days ago&#44; new definitions of sepsis and septic shock were launched as a result of a consensus of 19 experts SCCM &#40;Society of Critical Care Medicine&#41; and ESICM &#40;European Society of Intensive Care Medicine&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Perhaps the greatest contribution of this expert opinion consensus has been to recognize sepsis as a difficult to characterize syndromic condition&#44; with a cellular metabolic disorder as a lead condition along with the development of organ failure&#46; However&#44; as the most important feature&#44; the new definition excludes the concept of SIRS &#40;Systemic Inflammatory Response Syndrome&#41; since this term is being considered of not useful anymore&#46; The authors supported this decision mainly based on a retrospective study conducted in Australia and New Zealand<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> in which it was observed &#40;glass half-empty approach&#41; that 1 out of 8 patients &#40;12&#46;5&#37;&#41; with sepsis and multiorgan failure &#40;MOF&#41; did not have at least 2 SIRS criteria&#46; However&#44; these results &#40;glass half-full approach&#41; could be reinterpreted as 7 out of 8 patients &#40;87&#46;5&#37;&#41; did present positive SIRS criteria&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Furthermore&#44; the authors&#44; in the paper on new sepsis definitions&#44; affirmed that SIRS does not represent a dysregulated systemic response compromising host survival for the diagnosis of sepsis anymore&#46; The concept of SIRS&#44; such as expressed by Bone et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> is a clear one and refers to non-specific inflammatory response of the host to an injury&#46; The theory of &#8220;CHAOS&#8221; proposed by Bone &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; masterfully develops the different interactions between the pro and anti-inflammatory response of the host taking into account a translational view&#44; which has elucidated the different phases or states of patients with sepsis&#46; Moreover&#44; several studies have found a direct association between SIRS severity and clinical progression&#46; Rangel-Frausto et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> showed that mortality significantly increased from 7&#37; to 17&#37; based on the number of SIRS criteria &#40;from two to four respectively&#41;&#46; Interestingly&#44; Napolitano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> observed in trauma patients the relative risk &#40;RR&#41; of mortality increased from 3&#46;46 &#40;interquartile range &#91;IQR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;48&#8211;8&#46;11&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41; with a SIRS score<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#8211;6&#46;88 &#91;1&#46;81&#8211;22&#46;8&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004 for SIRS<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46; In addition&#44; Barie and Hydo<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> reported that the change in SIRS score within the first 24<span class="elsevierStyleHsp" style=""></span>h of treatment was significantly associated with mortality &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Moreover&#44; to define sepsis based on organ dysfunction may have serious limitations&#46; The SOFA score was designed to estimate more objectively organ dysfunction associated with sepsis<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> and its use is common in intensive care units &#40;ICUs&#41;&#44; but not in other health care settings&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> where a more large number of patients with sepsis are screened&#46; This is by far the area of detection and Sepsis Code activation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the other hand&#44; it important to highlight that with the previous definitions and international campaigns implementations based on such&#44; mortality of sepsis has dramatically decreased&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> As other authors have previously acknowledged it&#44; SIRS and MOF are not syndromes but merely concepts&#46; SIRS criteria are non-specific physiological responses to an aggression to the host&#46; Whilst SIRS should be promptly identified&#44; MOF should be considered a delayed failure to an inadequate clinical response&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Another important aspect of the recently launched definitions of sepsis is the proposal of &#8220;quick SOFA&#8221; as a criterion for suspected sepsis if there are two of the three criteria chosen &#40;systolic blood pressure &#60;100<span class="elsevierStyleHsp" style=""></span>mmHg&#44; tachypnea &#62;22<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">&#8211;1</span> or altered mentation &#91;derived from Glasgow Coma Score &#60;13&#93;&#41; while SIRS &#40;including tachycardia &#62;90 and tachypnea &#62;20&#41; criteria is deleted&#46; Unfortunately&#44; there is a potential exclusion of physiopathology concept&#46; Vasoconstriction and tachycardia are physiological mediated responses aimed to keep adequate oxygen transport and metabolism&#46; This phenomenon has been extensively studied showing a good correlation between shock index &#40;heart rate&#47;systolic blood pressure ratio&#41; and mortality&#46; This concept is extremely valid and useful in young patients or patients without chronic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">10&#8211;12</span></a> Moreover&#44; based on new definitions&#44; to have chosen just hypotension or altered sensorium for sepsis detection&#44; may &#40;a&#41; delay essential therapeutic measures such as early administration of antibiotics and &#40;b&#41; accepting organ failure establishment as the first sign of detection&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As a common rule&#44; the choice of one or other clinical indicator should be related to the goal to be achieved&#46; Thus&#44; if the goal is to detect promptly a wide number of patients at risk &#40;even with the risk of over diagnosis&#41; of one event &#40;sepsis&#41;&#44; a very sensitive indicator should be chosen even when less associated specificity&#46; The recent definitions focus on a more specific goal&#44; organ dysfunction&#44; which will somehow jeopardize the detection of patients with sepsis with both lack or delayed identification of patients at risk&#46; Like in other diseases &#40;i&#46;e&#46; stroke&#44; myocardial infarction&#41;&#44; the efforts have been made in early detection campaigns rather than very specific approaches&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We have to acknowledge the limitations of the former definitions especially severe sepsis and the new interpretation of septic shock&#46; Now&#44; shock is defined&#44; as a clinical condition associated to vasopressor requirement to maintain a mean arterial pressure of 65<span class="elsevierStyleHsp" style=""></span>mm Hg or greater and serum lactate level greater than 2<span class="elsevierStyleHsp" style=""></span>mmol&#47;L &#40;&#62;18<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; in the absence of hypovolemia&#46; This is something that might be applicable only within the first hours of resuscitation to identify patient&#39;s response but not to define a clinical state&#46; It is true that different recent clinical trials have shown an unexpected low mortality in some patients with septic shock&#46; However&#44; there is a lack of timing with this very important change in the concept&#46; For instance&#44; if a patient has a sustained high lactate level&#44; would this define a terminal event after a failure in resuscitation instead&#63;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary&#44; we consider that new definitions must foster to adequately characterize identification&#44; management and stratification with an integrative clinical and pathophysiological approach&#46; We wonder&#44; after a careful review of the new definitions&#44; if they are just a confusing episode of research or they bring anything truly needed to improve current clinical practice&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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ISSN: 02105691
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