Sepis and lactic acidosis
My favorite topic!
I would appreciate any feedback on Severe sepsis based on lactic acidosis. For example, pt comes in with fever, elevated HR, elevated bands, + infection. Sepsis is diagnosed. Lactic acid checked in ER 2.5, fluids given and lactic acid rechecked 4 hours later and is normal. No other evidence of organ dysfunction. Documentation also notes pt severely dehydrated. No other pertinent history or diagnoses during this admission.
Would you query for severe sepsis?
Would you code severe sepsis if its documented?
We are challenged by this- especially as lactic acid is not part of the Sepsis 3 criteria.
Thanks!
Comments
I believe the decision to query depends greatly upon your facilities accepted indications for Severe Sepsis. (If you have said published indicators, do these state that 'elevated lactate' may be one indicator for acute organ dysfunction associated with Sepsis)? Yes, I know this is not an indicator per Sepsis 3, but neither is a Type II AMI in the setting of infection, nor is critical illness myopathy.
Per H&P, progress notes, the patient is septic and there is noted concern for lactic acid of 4.0. The patient is noted to be 'acidotic', and septic bundle provided, to include IV antibiotics and fluid bolus.
Query:
Please indicate the clinical significance of the noted lactate level, if any
Lactic Acidosis
Lactic Acidosis 2/2 Sepsis
Lactic Acidosis 2/2 other cause (please state)
Not Significant
Unable to Determine
Other Condition
P. Evans
I'm curious your comments from this perspective:
Severe sepsis cannot be coded unless a specific organ dysfunction is identified. Lactic acid is a sign of potential organ dysfunction. Unless an organ is identified (acute kidney failure, resp failure, etc) severe sepsis will not be coded based on Lactic acidosis alone.
From a Sepsis 3 perspective, I concur. Not all endorse Sepsis 3. Hence, the need for medical staff to provide detailed input as to what they wish to 'define, document, and defend' as severe sepsis.
Criteria not the same between Sep-1, Surviving Sepsis and Sepsis 3.
RE: Sepsis 3...does not state that a Type NSTEMI in setting of sepsis is 'an acute organ dysfunction'..nor does it recognize critical illness myopathy as a consequence of Severe Sepsis? I have a problem with this.
Yet, the 'coding' rules clearly state we are compelled to code R65.20, Severe Sepsis, when acute organ dysfunction is present. Not stating I have the answer, as I believe this concept is still evolving. Personally I like some of the elements and concepts of SOFA, but it ain't perfect, either. I think we all have to stay tuned.