title: Are you Ernest Shackleton,the polar explorer? Refining the criteria for delirium and brain dysfunction in sepsis.
abstract: The Third International Consensus Definitions for Sepsis and Septic Shock has recently defined sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunctions in this consensus definition were identified as an organ-specific Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score ≥ 2 points. The quick SOFA (qSOFA) considers altered mentation indicating brain dysfunction when the Glasgow Coma Scale (GCS) score is ≤13 or ≤14. However, concern has been expressed that the revised criteria may lead to a failure in recognizing the signs of potentially lethal organ dysfunction and thus sepsis. Patients with delirium have a fluctuating course, and GCS can be normal or only slightly reduced at the time when signs of delirium are already present. We here report an illustrative case showing how an acute, initially unrecognized, urinary tract infection caused acute brain dysfunction with profound behavioral and cognitive dysfunction despite normal GCS, hence not meeting the criteria for sepsis.
authors.affiliation: Department of Anesthesiology, Critical Care Medicine and Emergency, Division of Neurocritical Care, Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy.|Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
authors.forename: Frank Anthony
authors.initials: FA
authors.lastname: Rasulo
authors.affiliation: Geriatric Research Group, Brescia, Italy.|School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.|Geriatric Unit, San Gerardo Hospital, Monza, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Bellelli
authors.affiliation: Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN USA.|Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN USA.|Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN USA.|Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN USA.
authors.forename: Eugene Wesley
authors.initials: EW
authors.lastname: Ely
authors.affiliation: Geriatric Research Group, Brescia, Italy.|Department of Rehabilitation and Aged Care of the Fondazione Camplani, Ancelle Hospital, Cremona, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Morandi
authors.affiliation: Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, Nashville, USA.|Anesthesia Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, USA.
authors.forename: Pratik
authors.initials: P
authors.lastname: Pandharipande
authors.affiliation: Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.|Department of Anesthesiology, Critical Care Medicine and Emergency, Spedali Civili University Hospital, Brescia, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Latronico
keywords: Brain dysfunction; Delirium; Glasgow Coma Scale (GCS) score; Quick Organ Failure Assessment (qSOFA) score; Sepsis; Third International Consensus Definitions for Sepsis and Septic Shock