June 13, 2016

Organ Dysfunction versus Organ Failure

By
EDITOR’S NOTE: The late Robert S. Gold, MD tackled the issue of sepsis even before the advent of the 1992 SIRS criteria. He made certain that healthcare professionals should be aware that capturing the true clinical picture should be first and foremost on the agenda. This is the second in a series of articles on the subject of sepsis. Dedicated to Dr. Gold’s memory, this series has been written by Cesar M. Limjoco, MD, vice president of clinical services for DCBA, Inc., a consulting firm co-founded by Dr. Gold.                                               

These two terms in the headline have been used, overused, and abused for ages. Many providers use them synonymously. But are they? Organ dysfunction is defined as an abnormality or impairment in the function of a specified bodily organ or system.

Organ failure is defined as dysfunction to such a degree that normal homeostasis cannot be maintained without external clinical intervention. Think of dysfunction as a continuum going from mild to extreme, of which failure would be the extreme outcome. 

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Now, what would be considered "life-threatening?" Let's use a non-medical situation. A bomb would be considered life-threatening because it could detonate at any time. What about a dagger? A gun? Does it have to depend on the circumstances? In medicine, there is a wide range of life-threatening situations. Sepsis in itself is life-threatening, but so is acute blood loss, acute asthma, and/or acute heart failure (systolic/diastolic). 

Consider cardiac catheterization and echocardiogram reports with findings of left ventricular dysfunction with ejection fractions of less than or equal to 40 percent. Truly, this represents systolic heart failure. What if it was 50 percent? Does this mean the patient is not in failure? Maybe not in systolic failure, but could the patient be in diastolic failure? 

Creating a distinction between organ dysfunction and failure has proven to be quite an enigma. In certain circumstances, the terms are synonymous; but at other times, they may indicate differences in severity. Recent Coding Clinic editions have come out with appropriate guidelines that speak to the two scenarios mentioned above in order to help facilitate the capture of the clinical truth. 

Heart failure with reduced ejection fraction (HFrEF) and heart failure with reduced systolic function now can be coded to systolic heart failure. Heart failure with preserved ejection fraction (HFpEF) or heart failure with preserved systolic function now can be coded to diastolic heart failure. Two documentation issues that remain pertain to acuity (acute, chronic, or exacerbation) in situations of combined systolic/diastolic dysfunctions.  

With sepsis, the term "organ dysfunction" takes a confusing turn. The third definition of sepsis was a reaction to the overuse of the term brought about by the 1992 systemic inflammatory response syndrome (SIRS) criteria in the first definition, which the second definition, issued in 2001, was unable to curb. Thus the term "life-threatening." It was a direct retort to prevent folks to diagnose sepsis on everyone who came in with fever and leukocytosis, or any other combination falling under the second definition. But this also brought about confusion. The issue of whether life-threatening organ dysfunction meant organ failure became a point of contention.

There are codes for sepsis without organ dysfunction (A41); and if organ dysfunction is present, additional codes are needed (A41. plus R65.20, plus specific organ dysfunction or failure codes). But the current sepsis definition indicates that life-threatening organ dysfunction should be present. This is what confuses most folks because it implies that with sepsis, there is already organ dysfunction. Hence, A41 should always be reported with the R65.20 code and a specific organ dysfunction (or organ failure) code. 

This leads to the question: is there no sepsis, just severe sepsis? Please refer to the LinkedIn article "Is Sepsis Now Severe Sepsis?" for the full discussion. But to recap, organ dysfunction that is innate in sepsis is a continuum that starts from organ(s) starting to be dysfunctional and culminates in organ failure. At the outset, before it becomes severe sepsis, there will be signs and symptoms of impending organ failure, i.e., alteration of mental status, hypotension (before full septic shock occurs), lactic acidosis, renal insufficiency (before it meets parameters for full acute renal failure, which is 1.5 times from patient's baseline creatinine), etc.

A caveat that needs to be mentioned is that these findings (i.e., altered mental state, hypotension, and abnormal renal function) may be caused by other conditions (e.g., medication side effects, overdose, poisoning, and other comorbidities), of which hypovolemia (dehydration) is notorious in the elderly. Dehydration in the elderly is well-known to cause altered mental status, hypotension, and a dip in renal function. All of these return to the baseline once volume is replete.

A discerning provider will see the change with the patient's return to baseline (within four to six hours) and rule out sepsis ("sepsis ruled out" needs to be documented in next day's progress note). This is why medicine is called an art and a science. 

Things are rarely black or white. There are lots of shades of gray.
Cesar M Limjoco, MD

Dr. Limjoco has more than 25 years of experience as a consultant with significant expertise in the capture of severity of illness in clinical documentation.  He serves as vice president of clinical services of DCBA, Inc. a position he has held since 2005. Dr. Limjoco is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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