Viewpoint
Sepsis: older and newer concepts

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Summary

Sepsis is a common complication in patients in intensive care units and a frequent reason for intensive care unit admission. Sepsis is a major cause of morbidity and mortality and, without specific antisepsis therapies, management relies on infection control and organ support. For these interventions to be most effective, they must be started early, which highlights the need for all health-care workers to be aware of sepsis so that diagnosis can be made as early as possible. In this Viewpoint, we discuss some of the earlier terms used to characterise and define sepsis, and point out some of their limitations. We then introduce some aspects of new consensus definitions, proposed by an expert panel, which highlight in particular the importance of organ dysfunction. These definitions should help provide a more standardised approach to the identification of patients with suspected sepsis in both clinical practice and clinical research.

Introduction

Sepsis is hard to define. The word sepsis has been around for centuries, and was used as early as the time of the ancient Greeks (σηψiς) to describe decomposition or putrefaction.1 The term thus existed long before anything was known about the microorganisms and immunological responses responsible for this often lethal condition. Although the clinical picture of sepsis has not changed much since those early days, our ability to support failing organs has altered how we manage sepsis, such that individuals can now survive severe infections that would previously have been fatal. With these advances in organ support, many aspects of the immunological response have been unravelled, and our understanding of the basic pathogenesis and pathophysiology of sepsis has improved. Along with these changes, the realisation of the importance of early diagnosis and management, and the need to identify appropriate patient groups for clinical research,2 has come a need to define sepsis more precisely.

Section snippets

Older concepts

A North American consensus definitions conference held in 19913 caused considerable controversy when the participants attempted to simplify the concept by proposing that sepsis represented the association between infection and signs of the systemic inflammatory response syndrome. The presence of infection is certainly essential for a diagnosis of sepsis. Some patients might have a sepsis-like state without evidence of an infection4—a good example is a patient who develops a hyperkinetic state

Newer concepts

In 2001, an attempt was made to revisit the systemic inflammatory response syndrome criteria,11 but the resultant list of signs and symptoms of sepsis was too long to be widely accepted, and the systemic inflammatory response syndrome criteria, however inadequate, continued to be used. In 2014, the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine put together a group of experts (including J-LV, one of the coauthors of this Viewpoint) from different

Conclusion

So, is this new consensus a big step? Not really, but it is a welcome and necessary update. The systemic inflammatory response syndrome was a (long) hiccup in the history of sepsis, and we are now heading back towards a more representative and realistic definition. Just as monitoring alone cannot improve outcomes,17 altered definitions cannot be said to represent major progress in terms of patient management. Introduction of the new Berlin definitions of acute respiratory distress syndrome18

Search strategy and selection criteria

We selected relevant literature published in English based largely on our personal knowledge of developments in sepsis research.

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