Q&A: Non-infectious SIRS Criteria
Q: I have a patient with alcohol-induced pancreatitis. In this case, the documentation notes a lactate level of 2.9 mmol/L with acute kidney injury (AKI). I have always learned that systemic inflammatory response syndrome (SIRS) is defined as two or more of the following criteria:
- Pulse greater than 90 beats per minute
- Respirations greater than 20/min or PaCO2 greater than 32 mm Hg
- Temperature less than 38 or greater than 36°C
- White blood cell count greater than 12,000 or less than 4,000 cells/mm3 or greater than 10% immature neutrophils (bands)
When I research the evidence-based clinical decision support information, this still seems to be the case. The 2016 CDI Pocket Guide also lists a large number of SIRS criteria for sepsis. However, I have been unable to locate any definition of noninfectious SIRS. I am concerned that the documentation currently available on this case is not enough to support a non-infectious SIRS diagnosis or query. Do you have any other reference material or information I might be missing?
A: The four SIRS criteria you refer to come from the original 1991 sepsis definition by the ACCP/SCCM Consensus Conference Committee. SIRS criteria were substantially modified and expanded by the 2001 Sepsis Definition Conference, published in 2003, and are listed in Table 1 of that publication.
As pointed out in The 2016 CDI Pocket Guide, an essential, but often overlooked, 2001 provision is the very clear admonition that when a provider applies the criteria for making a diagnosis of sepsis, only findings that cannot be easily explained by other causes should be included. For example, pulse and respiratory heart failure alone almost never justify a diagnosis of sepsis, because they can be caused by many other conditions in hospitalized patients.
The 2001 definition does not simply define sepsis— it represents the current authoritative definition of SIRS, and then further defines sepsis as SIRS due to confirmed or suspected infection. There are no other authoritative definitions of SIRS. In the 2016 CDI Pocket Guide’s key references for non-infectious SIRS, we mention that the SIRS criteria are identical for both infectious (sepsis) and noninfectious causes
While it is ultimately up to the clinician’s professional judgement, in the particular situation you describe, the presence of a lactate level of 2.9 mmol/L with AKI does, in my opinion, seem to justify a diagnosis of non-infectious SIRS if they could not be easily explained by other causes, as required by the 2001 definition.
The presence of AKI seems to also represent acute organ failure indicative of severe SIRS. If the lactate rose above 4.0 mmol/L, that would represent progression to hemodynamic shock, indisputable evidence of severe SIRS.
Editor’s note: Richard D. Pinson, MD, FACP, CCS, principal of Pinson & Tang LLC, and author of the CDI Pocket Guide answered this question. Contact him at info@pinsonandtang.com.