Sepsis

Definitions

According to the 2005 International Pediatric Sepsis Consensus Conference:

Sepsis = systemic inflammatory response syndrome (SIRS) + suspected or proven infection. This is the definition currently used by CMS (Medicaid).

According to the CDC, sepsis is the body’s extreme response to an infection and can 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.

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 TWO or more following criteria (ONE of which MUST BE abnormal temperature or leukocyte count).

Pediatric criteria (see table for normal vitals per age):

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.
- OR or 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

  
    Age-Specific Vital Sign and Laboratory Thresholds
    
        Age Group
        Tachycardia (bpm)
        Bradycardia (bpm)
        Resp Rate (breath/min)
        Leukocyte Count (Leuks x 103/mm3)
        Systolic BP (mm Hg)
      

    
        0 days to 1 wk
        >180
        <100
        >50
        >34
        <65
      

        1 wk to 1 mo
        >180
        <100
        >40
        >19.5 or <5
        <75
      

        1 mo to 1 year
        >180
        <90
        >34
        >17.5 or <5
        <100
      

        2-5 years
        >140
        N/A
        >22
        >15.5 or <6
        <94
      

        6-12 years
        >130
        N/A
        >18
        >13.5 or <4.5
        <105
      

        13 to <18 years
        >110
        N/A
        >14
        >11 or <4.5
        <117
      

  

Severe Sepsis/ Multiple Organ Dysfunction Syndrome

Severe sepsis = Sepsis PLUS one of the following:

Cardiovascular organ dysfunction OR
Acute respiratory distress syndrome (ARDS) OR
At least 2 other organ dysfunctions (i.e. neuro, hematologic, renal, hepatic)

Septic shock = severe sepsis + circulatory failure

Organ Dysfunction Criteria*

System	Criteria
Cardiovascular dysfunction	Despite administration of isotonic intravenous fluid bolus ≥40 mL/kg in 1 hr: 1. Decrease in BP (hypotension) <5th percentile 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 torr or 20 mm Hg over baseline PaCO2 OR Proven need or > 50% FIO2 to maintain saturation ≥92% OR Need for nonelective 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

Neonatal/Infant Sepsis

Neonatal sepsis is a systemic infection occurring in the first 28 days of life caused by bacterial, viral, or fungal organisms, associated with hemodynamic changes and clinical manifestations resulting in substantial morbidity and mortality**.

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

Sepsis should be considered for neonates and infants ≤ 60 days old*** when:

Febrile (Rectal temperature greater than 38°C or 100.4° F)
Hypothermic (Rectal temperature less than 36°C or 96.8°F)
Appears ill regardless of age
Presenting with exam findings suggestive of HSV infection (mucocutaneous vesicles, seizures, or focal neurologic findings)
Younger than 22 days of age, even if an identifiable etiology for infection
Younger than 29 days of age if positive UA, abnormal inflammatory markers (IM’s), or CSF pleocytosis or uninterpretable.

A temperature of >38.5°C (101.3°F) is considered an inflammatory marker (IM) for risk stratification of febrile infants 22-28 days old, where it serves as a predictor of invasive bacterial infection.

**The Lancet 2017; 390(10104):1770-1780. DOI: 10.1016/S0140-6736(17)31002-4

***Pediatrics 2021; 148(2):e2021052228. DOI: 10.1542/peds.2021-05222

Neonatal Fever

Neonatal fever may be coded as neonatal fever or rule out sepsis during the stay of a baby in the hospital. Can document “treating for neonatal sepsis” or “possible neonatal sepsis”.

If symptoms resolved, document “sepsis resolved” and a REASON for the sepsis (i.e. viral syndrome) on discharge summary.
If sepsis ruled-out (i.e. environmental hypothermia), document “sepsis ruled-out”. In this case, the diagnosis CANNOT be coded.

Tips For Documentation

When unsure but managing a patient for sepsis, these are the BEST ways to document:
- ‘Treating for sepsis,’ ‘Probable sepsis,’ ‘Suspected sepsis’
When known, LINK the underlying systemic type
- Viral vs bacteria (with specific organism if known)
- e.g. Viral sepsis due to Norovirus gastroenteritis
When patient has severe sepsis, document “severe” or show organ dysfunction
If circulatory failure & sepsis are related, document septic shock
If bacterial sepsis is suspected but cultures are negative, document culture-negative sepsis.
Try to clarify if sepsis is present on admission, or developed during the admission
- Considered present on admission (POA) if symptoms present within 6 hours of the Inpatient admit order (not OBS)
Add the sepsis diagnosis to the diagnosis list and carry the diagnosis to the discharge summary.

Documentation to AVOID

AVOID writing “rule-out sepsis”, “concern for sepsis” or “meets sepsis criteria’
- These CANNOT be used by the coding team to equate a diagnosis of sepsis
Urosepsis is not a ICD-10 code and only captures UTI, not sepsis
- Better: Sepsis due to E.coli pyelonephritis
Bacteremia is bacteria in the blood. Within coding guidelines, bacteremia does not convey the same level of acuity within documentation as sepsis.

Quick Tips!

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 chart)
If cultures are negative, document “Culture negative sepsis” or “Viral sepsis” if that is suspected

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

  
        SIRS Criteria (Systemic Inflammatory Response Syndrome)
      
        Core temperature > 38.5°C OR <36°C
      
        Tachycardia (HR>2SD) for age
OR
Bradycardia (HR<10th %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

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