LAUSR

Critical Care Medicine www.ccmjournal.org 1567 Cognitive perspective—Early sepsis identification and intervention improve outcomes (15). The identification of patients at risk causes activation of the “septic cognitive process.” The possibility of a septic process induces a series of immediate physician actions with subsequent ramifications to be considered. This process, when engaged early, benefits patients. This cognitive process is continuous, and the different stages of the disease are by nature linked: “This patient is sick, is he infected?” to “this patient has an infection, is there also organ dysfunction?” to “this patient has organ dysfunction, I should move quickly to avoid shock.” The Sepsis-1 stages of SIRS/sepsis/severe sepsis/septic shock are intimately linked and in constant flux in the physicians’ cognitive process, a link which is truncated in Sepsis-3. Communication perspective—The use of a lactate threshold greater than or equal to 2 mmol/L for the Sepsis-3 septic shock criteria is troublesome. On rounds, what should a patient with infection, organ dysfunction, and hypotension requiring vasopressors but normal lactate be called? The Sepsis-3 authors referred to these patients as preshock (16). Fluid resistant hypotensive septic patients requiring vasopressors but with lactate levels less than or equal to 2 mmol/L and a mortality of 30% (6) deserve the diagnosis of septic shock and not preshock. We propose a middle road that takes advantage of the strengths of each definition. The Sepsis-1 and Sepsis-3 criteria should be used according to the intended purpose of the user, choosing the one that best fits the user’s objective. We believe that Sepsis-1 should continue to be used for clinical practice and communication. We suggest that Sepsis-3 is best suited for epidemiology and certain research projects and the Sepsis-3 nomenclature be reconciliated with the Sepsis-1 terms to avoid confusion. Future research will probably require both definitions.