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Learning Objectives Respiratory Failure Acute Respiratory Failure Sepsis: 1, 2, 3, RAC Attack! Respiratory Failure: Definition and Sequencing Guidelines William Haik, MD, FACCP, CDIP, AHIMA‐Approved ICD‐10‐CM/PCS Trainer Director DRG Review, Inc. Fort Walton Beach, FL1 Learning Objectives • At the completion of this educational activity, the learner will be able to: – Identify the clinical elements that validate the reporting of acute respiratory failure – Identify the clinical criteria that support Sepsis‐1, Sepsis‐2, and Sepsis‐3 definitions 2 Respiratory Failure Severe Hypoxia ↓ Pulmonary Acute Respiratory Insufficiency Insufficiency → Respiratory ← Failure ↑ Respiratory Acidosis 3 2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 1 These materials may not be copied without written permission. Respiratory Failure • Respiratory failure should be specified as acute, chronic, or acute on chronic (hypoxemic/hypercapneic). Acute Respiratory Failure • Respiratory failure is a condition categorized by inadequate exchange of oxygen and/or carbon dioxide by the lungs. • The diagnosis of respiratory failure is a life‐threatening disorder requiring aggressive management and monitoring. A patient with acute respiratory failure usually exhibits evidence of increased work of breathing (rapid respiratory rate, use of accessory muscles of respiration) or possibly cyanosis and/or paradoxical breathing. • Treatment includes frequent respiratory therapy and possibly support with either invasive mechanical ventilation or noninvasive modalities such as CPAP/BiPAP and/or high flow oxygen therapy (HFT). The absence of mechanical ventilation, however, does not exclude the diagnosis of acute respiratory failure. 4 Respiratory Failure 4. Arterial blood gas determinations are helpful in determining acute respiratory failure. a) A patient with acute respiratory failure with previously normal lungs • pO2 < 60 mmHg, pCO2 > 50 mmHg, pH < 7.35 on room air (FiO2 = 21%) • Hemoglobin oxygen saturation < 90% on room air (FiO2 = 21%) • P/F ratio (pO2/FiO2) < 300 (Example: pO2 of 90 mmHg on 32% oxygen) P/F = 90/0.32 = 281 b) Acute respiratory failure in a patient with previously abnormal lungs such as chronic obstructive lung disease • pH < 7.35 with a pCO2 > 50 mmHg • Generally, in a patient with chronic lung disease, the arterial blood pH is a more useful criteria than simply efollowing th pCO2 • A change in the pO2 < 60 mmHg representing a drop of 10–15 mmHg from the previous "normal" pO2 5 Respiratory Failure c) Oxygen delivery device conversion to FiO2 (estimate based on normal tidal volume) • Nasal O2 1 L 24% 2 L 28% 3 L 32% 4 L 36% 5 L 40% 6 L 44% 6 2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 2 These materials may not be copied without written permission. Respiratory Failure • Simple mask 5–8 LPM FiO2 0.35 to 0.55 • Venturi mask Variable LPM FiO2 0.24 to 0.50 • Partial rebreather 10 LPM FiO2 0.50 to 0.70 • Non‐rebreather 15 LPM FiO2 0.70 to 1.0 7 7 Respiratory Failure d) Hemoglobin oxygen saturation conversion to pO2* Hemoglobin oxygen Partial pressure of saturation oxygen 50% 27 mmHg 75% 40 mmHg 88% 55 mmHg 90% 60 mmHg 98% 100 mmHg *Hemoglobin oxygen saturation conversion to pO2 is only an approximation as several factors such as pH, temperature, and DPG content may impact it. References: Murray and Nadel’s Textbook of Respiratory Medicine, Sixth Edition, pp. 1723, 1740. Guyton and Hall Textbook of Medical Physiology, 12th Edition, Chapter 39. 8 Respiratory Failure • Chronic Respiratory Failure – No significant deviation from baseline ABGs – pO2 < 60 mmHg – Without significant increase in work of breathing – Continuous oxygen use or ventilatory support – P/F ratio not useful • The cause(s) of the respiratory failure such as COPD, intestinal lung disease, bronchiectasis, etc. should be clearly stated. 9 2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 3 These materials may not be copied without written permission. Respiratory Failure Sequencing Guidelines • Do not code acute respiratory failure as the principal diagnosis when there is a chapter‐specific coding guideline (sepsis, obstetrics, poisoning, HIV, newborn) or an Alphabetic Index or Tabular List directive that takes precedence over the general respiratory failure guidelines and examples listed above. Examples: – Acute respiratory failure, secondary to Pneumocystis carinii pneumonia in a patient with HIV. The human immunodeficiency virus (B20) is reported as the principal diagnosis. – Patient is admitted with acute respiratory failure secondary to Valium overdose. The poisoning (Valium overdose) is reported as the principal diagnosis. – A patient is admitted with aspiration pneumonia with associated sepsis and acute respiratory failure. Sepsis is reported as the principal diagnosis. 10 Sepsis • None of these SIRS terms code to ↓ sepsis • Blood cultures do not define sepsis • SIRS has infectious Bacteremia Urosepsis as well as non‐ → Sepsis ← infectious etiologies • “SIRS due to infection” does not ↑ equate to sepsis in Sepsis ICD‐10‐CM Syndrome 11 Sepsis A. Infection (B99.9): Invasion of normally sterile tissue, fluid, or body cavity by pathogenic microorganisms B. Bacteremia (R78.81): A laboratory finding of viable bacteria in the blood without evidence of a systemic inflammatory response. C. Systemic Inflammatory Response Syndrome (SIRS) (R65.10): A syndrome defined by the presence of two or more of the following features of systemic inflammation: 1. Fever (core temperature > 38.3°C or 100.9°F) or hypothermia (core temperature < 36°C or 96.8°F) 2. Leukocytosis (white count > 12,000) or leukopenia (white count < 4,000 or > 10% bands) 3. Tachycardia (> 90 beatsr pe minute or more than two SD above the normal value for age) 4. Tachypnea (respiratory rate > 20 breaths per minute or a pCO2 of < 32 mmHg) 12 2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 4 These materials may not be copied without written permission. Sepsis D. Sepsis (A41.9): An infection‐induced syndrome defined by the presence of at least two unexplained features of systemic inflammation: 1. Fever (core temperature > 38.3°C or 100.9°F) or hypothermia (core temperature < 36°C or 96.8°F) 2. Leukocytosis (white count > 12,000) or leukopenia (white count < 4,000 or > 10% bands) 3. Tachycardia (> 90 beats per minute or more than two SD above the normal value for age) 4. Tachypnea (respiratory rate > 20 breaths per minute or a pCO2 of < 32 mmHg) 5. Altered mental status 6. Significant edema or positive fluid balance (> 20 mL per kg over 24 hours) 7. Hyperglycemia, unexplained (glucose > 140 mg/dL in the absence of diabetes) 8. Evidence of hypoperfusion [hyperlactatemia (> 1 mmol/L)] or decreased capillary refill or mottling 9. Ileus (absent bowel sounds) 10. Arterial hypoxemia (PaO2/FiO2 < 300) 11. Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs, despite adequate fluid resuscitation) 12. Creatinine increase > 0.5 mg/dL or 44.2 umol/L 13. Hyperbilirubinemia (> 2 mg/dL)* 14. Plasma C‐reactive protein more than two SD above the normal value 15. Plasma procalcitonin more than two SD above the normal value 13 Sepsis E. Septicemia (A41.9): An antiquated, ambiguous term that has been used nonspecifically in the past to imply either bacteremia or sepsis; therefore, should be eliminated from current medical usage. F. Severe sepsis (R65.20): Defined as sepsis‐induced tissue hypoperfusion or organ dysfunction (any one of which due to infection): 1. Sepsis‐induced hypotension [systolic blood pressure (SBP) < 90 mmHg, mean arterial pressure (MAP) < 70 mmHg, or an SBP decrease by > 40 mmHg in adults or less than two SD below normal for age] 2. Lactate above upper limits of laboratory normal 3. Acute oliguria (urine output < 0.5 mL/kg/hrr fo more than 2 hrs, despite adequate fluid resuscitation) 4. Creatinine increase > 2.0 mg/dL 5. Platelet count < 100,000/uL 6. Coagulopathy (international normalized ratio > 1.5) 7. Acute lung injury with PaO2/FiO2 < 250 in the absence of pneumonia as an infection source 8. Acute lung injury with PaO2/FiO2 < 200 in the presence of pneumonia as an infection source 9. Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL*) 14 Sepsis G. Septic shock (R65.21): Severe sepsis with hypotension (systolic blood pressure < 90 mmHg or a 40 mmHg drop from the previous normal blood pressure) unresponsive to fluid resuscitation, requiring vasopressor intervention. *Personal email communication with Mitchell M. Levy, MD, on May 14, 2013. Bilirubin levels for sepsis and severe sepsis were reversed with additional modifications to the clinical elements also ebased on th communication. References: Dillinger, Levy, et al., “Surviving Sepsis Campaign, 2012,” Critical Care Medicine, 2013;41(2). Levy, M.D., M.M., “International Sepsis Definition Conference, 2001,” Critical Care Medicine, 2003;31:1250–1256. Bone, M.D., R.C., “ACCP/SCCM Consensus Conference,” Chest, 1992;101:1044–1055. 15 2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 5 These materials may not be copied without written permission. The Third International Consensus Definition for Sepsis and Septic Shock (Sepsis‐3) • Since the previous consensus definitions of sepsis1, 2 and its related terminology (sepsis syndrome, septicemia, severe sepsis, and septic shock), there have been considerable advances in pathobiology • Therefore, a third international consensus definition representing experts from the
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