Surviving Sepsis Campaign Recommendations Research Articles

Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department.

The impact on patient survival of an infectious disease (ID) team dedicated to the early management of severe sepsis/septic shock (SS/SS) in Emergency Department (ED) has yet to be assessed. A quasiexperimental pre-post study was performed at the general ED of our hospital. During the pre phase (June 2013-July 2014), all consecutive adult patients with SS/SS were managed according to the standard of care, data were prospectively collected. During the post phase (August 2014-October 2015), patients were managed in collaboration with a dedicated ID team performing a bedside patient evaluation within 1 hour of ED arrival. Overall, 382 patients were included, 195 in the pre phase and 187 in the post phase. Median age was 82 years (interquartile range, 70-88). The most common infection sources were lung (43%) and urinary tract (17%); in 22% of cases, infection source remained unknown. During the post phase, overall compliance with the Surviving Sepsis Campaign (SSC) bundle and appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P < .001) and from 30% to 79% (P < .001), respectively. Multivariate analysis showed that predictors of all-cause 14-day mortality were quick sepsis-related organ failure assessment ≥2 (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.15-2.45; P = .007), serum lactate ≥2 mmol/L (HR, 2.13; 95% CI, 1.39-3.25; P < .001), and unknown infection source (HR, 2.07; 95% CI, 1.42-3.02; P < .001); being attended during the post phase was a protective factor (HR, 0.64; 95% CI, 0.43-0.94; P = .026). Implementation of an ID team for the early management of SS/SS in the ED improved the adherence to SSC recommendations and patient survival.

Interprofessional Collaboration to Improve Sepsis Care and Survival Within a Tertiary Care Emergency Department

ProblemSepsis is a leading cause of death in the United States; however, health care providers struggle with timely recognition, diagnosis, and treatment of patients. Both the Centers for Medicare and Medicaid Services and the National Quality Forum have identified this diagnosis as a priority. Presently, many patients with sepsis are identified late, resulting in significant morbidity and death. MethodsIn this project, a collaborative, interprofessional approach was created for screening and early identification of ED patients with possible sepsis. The department has 38 beds with annual patient volumes of more than 40,000 visits. Education was provided about the symptoms and treatment of patients with sepsis. A screening and management algorithm tool was instituted that consisted of early identification triggers and how to intervene according to Surviving Sepsis Campaign recommendations. The tool allowed for assessment of the patient by the ED team; the team worked to determine if sepsis was present and the extent of the illness. ResultsDuring the first 4 months after implementation, more than 240 patients were screened, assessed, and treated according to the algorithm. Project outcomes resulted in an increase in staff knowledge of sepsis, a decrease in length of stay by 3 hours, and a significant decrease in mortality when compared with the previous year’s coded data. Implications for PracticeThis project demonstrates that sepsis education and team collaboration are an integral part of identifying and treating patients with sepsis. An interprofessional collaborative approach could be implemented in other institutions to combat the life-threatening complications of sepsis.Image 1

Treatment of Pediatric Septic Shock With the Surviving Sepsis Campaign Guidelines and PICU Patient Outcomes.

The Surviving Sepsis Campaign recommends rapid recognition and treatment of severe sepsis and septic shock. Few reports have evaluated the impact of these recommendations in pediatrics. We sought to determine if outcomes in patients who received initial care compliant with the Surviving Sepsis Campaign time goals differed from those treated more slowly. Single center retrospective cohort study. Emergency department and PICU at an academic children's hospital. Three hundred twenty-one patients treated for septic shock in the emergency department and admitted directly to the PICU. None. The exposure was receipt of emergency department care compliant with the Surviving Sepsis Campaign recommendations (delivery of IV fluids, IV antibiotics, and vasoactive infusions within 1 hr of shock recognition). The primary outcome was development of new or progressive multiple organ dysfunction syndrome. Secondary outcomes included mortality, need for mechanical ventilation or vasoactive medications, and hospital and PICU length of stay. Of the 321 children studied, 117 received Surviving Sepsis Campaign compliant care in the emergency department and 204 did not. New or progressive multiple organ dysfunction syndrome developed in nine of the patients (7.7%) who received Surviving Sepsis Campaign compliant care and 25 (12.3%) who did not (p = 0.26). There were 17 deaths; overall mortality rate was 5%. There were no significant differences between groups in any of the secondary outcomes. Although only 36% of patients met the Surviving Sepsis Campaign guideline recommendation of bundled care within 1 hour of shock recognition, 75% of patients received the recommended interventions in less than 3 hours. Treatment for pediatric septic shock in compliance with the Surviving Sepsis Campaign recommendations was not associated with better outcomes compared with children whose initial therapies in the emergency department were administered more slowly. However, all patients were treated rapidly and we report low morbidity and mortality. This underscores the importance of rapid recognition and treatment of septic shock.

Prognostic Value of Timing of Antibiotic Administration in Patients With Septic Shock Treated With Early Quantitative Resuscitation

BackgroundThe Surviving Sepsis Campaign recommends initiating broad-spectrum antibiotic treatment within 1 hour of septic shock recognition. However, there is controversy regarding this owing to contradictory studies. This study investigated the relationship between the antibiotic administration interval and 28-day mortality in septic shock patients treated with an early quantitative resuscitation protocol in an emergency department (ED). Methods715 consecutive septic shock patients were prospectively collected from January 2010 to December 2012. Of these, 426 patients developed shock at or after initial assessment, and the time of initial antibiotic administration was recorded. The primary outcome was 28-day mortality. ResultsThe median antibiotic administration interval was 91.5 (47.0–158.0) minutes, and the 28-day mortality was 20.0%. Mortality did not change with hourly delays in antibiotic administration up to 5 hours after shock recognition: 1 hour (odds ratio [OR]: 0.81, 95% confidence interval [CI]: 0.45–1.45), 2 hours (OR: 0.72, 95% CI: 0.40–1.29) and 3 hours (OR: 0.61, 95% CI: 0.30–1.25). However, inability to achieve early resuscitation goals (OR: 1.94, 95% CI: 1.07–3.51), sequential organ failure assessment score (OR: 1.30, 95% CI: 1.17–1.44) and lactic acid concentration (OR: 1.66, 95% CI: 1.11–2.49) were significantly associated with an increased risk of 28-day mortality. ConclusionsAmong septic shock patients who underwent early quantitative resuscitation in an ED, mortality did not increase with hourly delays in antibiotic administration. These data call into question the strength of the association between hourly delays in antibiotic administration and mortality in septic shock patients.

Reply by the Authors

As pointed out by Dr. Turunc, emphysematous pyelonephritis (EPN) is a life-threatening condition characterized by the presence of gas in renal parenchyma, collecting systems, and/or adjacent tissues. A timely diagnosis and adequate identification of prognostic factors are crucial to decision-making process and selection of optimal treatment. Unfortunately, in our opinion, radiographic appearance is not as accurate as needed to determine the prognosis of a patient with EPN. Recently, our group published a multicenter series of 62 patients with EPN. 1 Olvera-Posada D. Armengod-Fischer G. Vazquez-Lavista L. et al. Emphysematous pyelonephritis: multicenter clinical and therapeutic experience in Mexico. Urology. 2014; 83: 1280-1284 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Surprisingly, we found that there was no difference in mortality rates when comparing Huang's classification 2 Huang J.J. Tseng C.C. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000; 160: 797-805 Crossref PubMed Scopus (508) Google Scholar categories (P = .55). Instead, a thorough clinical workup supported by radiographic evaluation is recommended. Previously, we have demonstrated that impaired consciousness, multiple organ failure, hyperglycemia, and elevated leukocyte count are independent predictors of poor outcome. 3 Olvera-Posada D. Garcia-Mora A. Culebro-Garcia C. et al. Prognostic factors in emphysematous pyelonephritis. Actas Urol Esp. 2013; 37: 228-232 Crossref PubMed Scopus (12) Google Scholar Moreover, in our opinion, initial approach and treatment guided by strict criteria such as Surviving Sepsis Campaign recommendations 4 Dellinger R.P. Levy M.M. Carlet J.M. et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008; 36: 296-327 Crossref PubMed Scopus (3942) Google Scholar is more reliable than radiologic criteria alone. The Management of Emphysematous Pyelonephritis and Importance of Minimally Invasive TreatmentUrologyVol. 84Issue 4PreviewEmphysematous pyelonephritis (EPN) is one of the most common clinical form of emphysematous infections of upper urinary tract.1 EPN is an acute, severe, necrotizing infection of the renal parenchyma and perirenal tissue, which causes gas within the renal parenchyma, collecting system, or perinephric tissue.2 It usually affects one kidney and occurs mostly in diabetic patients.1,3 The combination of the presence of gas-producing microorganisms, a high tissue glucose concentration, and impaired tissue perfusion favors the development of the emphysematous infections of the urinary tract. Full-Text PDF

Time to Administration of Antibiotics among Inpatients with Severe Sepsis or Septic Shock.

Current evidence suggests that administration of appropriate antibiotic therapy within 1 h after the onset of hypotension significantly improves mortality rates among patients with severe sepsis and septic shock. To determine the interval from recognition of severe sepsis or septic shock in inpatients to initial administration of antibiotic and to assess institutional compliance with the Surviving Sepsis Campaign's recommendation for early antibiotic therapy. A 6-month retrospective chart analysis was conducted to determine the interval from documented onset of hypotension to initial administration of antibiotic for patients with severe sepsis or septic shock. Patients who were admitted to a general medicine ward, a surgery ward, or the intensive care unit (ICU) of a 475-bed university-affiliated hospital and who met the criteria for severe sepsis or septic shock were eligible for inclusion. Patients who received antibiotics before meeting the criteria for severe sepsis or septic shock were excluded. Charts for 100 patients with severe sepsis or septic shock were reviewed. The mean age was 69.0 years (standard deviation 18.7 years), and 56% were men. The median interval from onset of severe sepsis or septic shock to administration of antibiotic was 4.00 h (interquartile range [IQR] 1.80-6.45 h). The median interval from the time a physician ordered an antibiotic to administration of the drug was 1.28 h (IQR 0.57-3.05 h). The interval between ordering and administration differed significantly for patients on the wards (5.67 h), those with onset in the ICU (4.00 h), and those with onset in the emergency department (3.28 h) (p = 0.039). The overall survival rate was 56%. At the study hospital, the interval from onset of severe sepsis or septic shock to initial administration of antibiotic to inpatients exceeded the 1-h period recommended by the Surviving Sepsis Campaign. These results will be used as a baseline for future quality assurance and improvement initiatives aimed at minimizing the time to antibiotic administration for this group of patients, who are at high risk of death.

High versus Low Blood-Pressure Target in Patients with Septic Shock

BackgroundThe Surviving Sepsis Campaign recommends targeting a mean arterial pressure of at least 65 mm Hg during initial resuscitation of patients with septic shock. However, whether this blood-pressure target is more or less effective than a higher target is unknown.MethodsIn a multicenter, open-label trial, we randomly assigned 776 patients with septic shock to undergo resuscitation with a mean arterial pressure target of either 80 to 85 mm Hg (high-target group) or 65 to 70 mm Hg (low-target group). The primary end point was mortality at day 28.ResultsAt 28 days, there was no significant between-group difference in mortality, with deaths reported in 142 of 388 patients in the high-target group (36.6%) and 132 of 388 patients in the low-target group (34.0%) (hazard ratio in the high-target group, 1.07; 95% confidence interval [CI], 0.84 to 1.38; P=0.57). There was also no significant difference in mortality at 90 days, with 170 deaths (43.8%) and 164 deaths (42.3%), respectively (hazard ratio, 1.04; 95% CI, 0.83 to 1.30; P=0.74). The occurrence of serious adverse events did not differ significantly between the two groups (74 events [19.1%] and 69 events [17.8%], respectively; P=0.64). However, the incidence of newly diagnosed atrial fibrillation was higher in the high-target group than in the low-target group. Among patients with chronic hypertension, those in the high-target group required less renal-replacement therapy than did those in the low-target group, but such therapy was not associated with a difference in mortality.ConclusionsTargeting a mean arterial pressure of 80 to 85 mm Hg, as compared with 65 to 70 mm Hg, in patients with septic shock undergoing resuscitation did not result in significant differences in mortality at either 28 or 90 days. (Funded by the French Ministry of Health; SEPSISPAM ClinicalTrials.gov number, NCT01149278.)

Differences in compliance with Surviving Sepsis Campaign recommendations according to hospital entrance time: day versus night

IntroductionHigher compliance with Surviving Sepsis Campaign (SSC) recommendations has been associated with lower mortality. The authors evaluate differences in compliance with SSC 6-hour bundle according to hospital entrance time (day versus night) and its impact on hospital mortality.MethodsProspective cohort study of all patients with community-acquired severe sepsis admitted to the intensive care unit of a large university tertiary care hospital, over 3.5 years with a follow-up until hospital discharge. Time to compliance with each recommendation of the SSC 6-hour bundle was calculated according to hospital entrance period: day (08:30 to 20:30) versus night (20:30 to 08:30). For the same periods, clinical staff composition and the number of patients attending the emergency department (ED) was also recorded.ResultsIn this period 300 consecutive patients were included. Compliance rate was (night vs. day): serum lactate measurement 57% vs. 49% (P = 0.171), blood cultures drawn 59% vs. 37% (P < 0.001), antibiotics administration in the first 3 hours 33% vs. 18% (P = 0.003), central venous pressure >8 mmHg 45% vs. 29% (P = 0.021), and central venous oxygen saturation (SvcO2) >70%, 7% vs. 2% (P = 0.082); fluids were administered in all patients with hypotension in both periods and vasopressors were administered in patients with hypotension not responsive to fluids in 100% vs. 99%. Time to get specific actions done was also different (night vs. day): serum lactate measurement (4.5 vs. 7 h, P = 0.018), blood cultures drawn (4 vs. 8 h, P < 0.001), antibiotic administration (5 vs. 8 h, P < 0.001), central venous pressure (8 vs. 11 h, P = 0.01), and SvcO2 monitoring (2.5 vs. 11 h, P = 0.222). The composition of the nursing team was the same around the clock; the medical team was reduced at night with a higher proportion of less differentiated doctors. The number of patients attending the Emergency Department was lower overnight. Hospital mortality rate was 34% in patients entering in the night period vs. 40% in those entering during the day (P = 0.281).ConclusionCompliance with SSC recommendations was higher at night. A possible explanation might be the increased nurse to patient ratio in that period. Adjustment of the clinical team composition to the patients' demand is needed to increase compliance and improve prognosis.

Initial resuscitation guided by the Surviving Sepsis Campaign recommendations and early echocardiographic assessment of hemodynamics in intensive care unit septic patients

To compare therapeutic interventions during initial resuscitation derived from echocardiographic assessment of hemodynamics and from the Surviving Sepsis Campaign guidelines in intensive care unit septic patients. Prospective, descriptive study in two intensive care units of teaching hospitals. The number of ventilated patients with septic shock who were studied was 46. Transesophageal echocardiography was first performed (T1<3 hrs after intensive care unit admission) to adapt therapy according to the following predefined hemodynamic profiles: fluid loading (index of collapsibility of the superior vena cava≥36%), inotropic support (left ventricular fractional area change<45% without relevant index of collapsibility of the superior vena cava), or increased vasopressor support (right ventricular systolic dysfunction, unremarkable transesophageal echocardiography study consistent with sustained vasoplegia). Agreement for treatment decision between transesophageal echocardiography and Surviving Sepsis Campaign guidelines was evaluated. A second transesophageal echocardiography assessment (T2) was performed to validate therapeutic interventions. Although transesophageal echocardiography and Surviving Sepsis Campaign approaches were concordant to manage fluid loading in 32 of 46 patients (70%), echocardiography led to the absence of blood volume expansion in the remaining 14 patients who all had a central venous pressure<12 mm Hg. Accordingly, the agreement was weak between transesophageal echocardiography and Surviving Sepsis Campaign for the decision of fluid loading (κ: 0.37 [0.16;0.59]). With a cut-off value<8 mm Hg for central venous pressure, κ was 0.33 [-0.03;0.69]. Inotropes were prescribed based on transesophageal echocardiography assessment in 14 patients but would have been decided in only four patients according to Surviving Sepsis Campaign guidelines. As a result, the agreement between the two approaches for the decision of inotropic support was weak (κ: 0.23 [-0.04;0.50]). No right ventricular dysfunction was observed. No patient had anemia and only three patients with transesophageal echocardiography documented left ventricular systolic dysfunction had a central venous oxygen saturation<70%. A weak agreement was found in the prescription of fluid loading and inotropic support derived from early transesophageal echocardiography assessment of hemodynamics and Surviving Sepsis Campaign guidelines in patients presenting with septic shock.

What is next in sepsis: current trials in sepsis

17th International Symposium on Infections in the Critically Ill PatientBarcelona, Spain, 3–4 February 2012International experts reviewed and updated the most recent and relevant scientific advances on severe sepsis during the 17th International Symposium on Infections in the Critically Ill Patients in Barcelona (Spain) in February 2012. All new pharmacological therapeutic strategies have failed to demonstrate a survival benefit. Despite the large variability among countries and hospitals, the improvement of standard care according to the Surviving Sepsis campaign recommendations reduced the 28-day mortality to 24%. These results may have implications for future clinical trials in which much larger samples sizes of patients at high risk of death will be necessary. The identification of novel proinflammatory endogeneous signals and pathways may lead to the discovery of new drugs to reduce inflammatory reactions and end-organ dysfunction in critically ill patients with sepsis. Extracorporeal blood purification stem or progenitor cells have received increasing interest for the treatment of inflammation and organ injury. A better understanding of how these therapies work is essential and its benefit should be confirmed in future prospective randomized studies.

Improving Door-to-Antibiotic Time in Severely Septic Emergency Department Patients

BackgroundThe Surviving Sepsis Campaign (SSC) guidelines recommend that broad-spectrum antibiotics be administered to severely septic patients within 3 h of emergency department (ED) admission. Despite the well-established evidence regarding the benefit of timely antibiotics, adoption of the SSC recommendation into daily clinical practice has been slow and sporadic. Study ObjectiveTo study the impact of storing broad-spectrum antibiotics in an ED automated dispensing cabinet (ADC) on the timeliness of antibiotic administration in severely septic patients presenting to the ED. MethodsRetrospective observational study of timeliness of antibiotic administration in severely septic patients presenting to a community ED before and after adding broad-spectrum antibiotics to the ED ADC. Data on 56 patients before and 54 patients after the intervention were analyzed. The primary outcome measure was mean order-to-antibiotic time. Secondary outcome measures included mean door-to-antibiotic time and percentage of patients receiving antibiotics within 3h. ResultsThe final analysis was on 110 patients. Order-to-antibiotic administration time was reduced by 29min post-intervention (55min vs. 26min, 95% confidence interval [CI] 12.5–45.19). Mean door-to-antibiotic time was also reduced by 70min (167min vs. 97min, 95% CI 37.53–102.29). The percentage of severely septic patients receiving antibiotics within 3h of arrival to the ED increased from 65% pre-intervention to 93% post-intervention (95% CI 0.12–0.42). ConclusionStoring key antibiotics in an institution’s severe sepsis antibiogram in the ED ADC can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3h of ED arrival.

Steroid treatment for patients with severe sepsis and septic shock

Dear Editor, We read with interest the recent article by Kalil and Sun [1] describing the use of Bayesian statistics to resolve the controversy regarding the use of low-dose steroids for severe sepsis and septic shock. The authors used only three recent meta-analyses. We wonder if the authors’ conclusions would change or remain the same after also analyzing two other recent papers, the meta-analysis by Sligl [2] and the Bayesian metaanalysis by Moran [3]. We have just published [4] an evaluation of recent conflicting studies [5, 6] and meta-analyses, emphasizing the problems with metaanalyses and providing recommendations for practice. These recommendations were that without a strong signal for a mortality decrease with corticosteroid therapy, steroids should not be used for all septic shock patients [4]. We believe steroids should only be used in patients meeting the severe septic shock entry criteria in the Annane et al. study [5] of a systolic blood pressure less than 90 mmHg for greater than 1 h where steroids improved survival and were the basis for the original 2004 Surviving Sepsis Campaign recommendations for the use of steroids in septic patients requiring vasopressors despite fluid therapy requirements [4]. We, however, understand why physicians might use steroids for septic shock patients identified to be poorly responsive to fluid resuscitation and vasopressor therapy based on the recent updated Surviving Sepsis Campaign’s recommendations [7]. Patients with severe sepsis not in shock or patients with septic shock stabilized with fluid and vasopressor therapy should not receive steroid therapy [4, 7].

Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self-reported, continent-wide survey of anaesthesia providers

IntroductionIt is unknown whether resources necessary to implement the Surviving Sepsis Campaign guidelines and sepsis bundles are available in Africa. This self-reported, continent-wide survey compared the availability of these resources between African and high-income countries, and between two African regions (Sub-Sahara Africa vs. South Africa, Mauritius and the Northern African countries).MethodsThe study was conducted as an anonymous questionnaire-based, cross-sectional survey among anaesthesia providers attending a transcontinental congress. Based on the respondents' country of practice, returned questionnaires were grouped into African and high-income countries. The questionnaire contained 74 items and evaluated all material resources required to implement the most recent Surviving Sepsis Campaign guidelines. Group comparisons were performed with the Chi2, Fisher's Exact or Mann Whitney U test, as appropriate.ResultsThe overall response rate was 74.3% (318/428). Three-hundred-seven questionnaires were analysed (African countries, n = 263; high-income countries, n = 44). Respondents from African hospitals were less likely to have an emergency room (85.5 vs. 97.7%, P = 0.03) or intensive care unit (73.8 vs. 100%, P < 0.001) than respondents from high-income countries. Drugs, equipment, and disposable materials required to implement the Surviving Sepsis Campaign guidelines or sepsis bundles were less frequently available in African than high-income countries. Of all African and Sub-Saharan African countries, 1.5% (4/263) and 1.2% (3/248) of respondents had the resources available to implement the Surviving Sepsis Campaign guidelines in entirety. The percentage of implementable recommendations was lower in African than in high-income countries (72.6 (57.7 to 87.7)% vs. 100 (100 to 100)%, P < 0.001) and lower in Sub-Saharan African countries than South Africa, Mauritius, and the Northern African countries (72.6 (56.2 to 86.3)% vs. 90.4 (71.2 to 94.5)%, P = 0.02).ConclusionsThe results of this self-reported survey strongly suggest that the most recent Surviving Sepsis guidelines cannot be implemented in Africa, particularly not in Sub-Saharan Africa, due to a shortage of required hospital facilities, equipment, drugs and disposable materials. However, availability of resources to implement the majority of strong Surviving Sepsis Campaign recommendations and the sepsis bundles may allow modification of current sepsis guidelines based on available resources and implementation of a substantial number of life-saving interventions into sepsis care in Africa.

Impact of Time to Antibiotics on Survival in Patients with Severe Sepsis or Septic Shock in whom Early Goal-directed Therapy was Initiated in the Emergency Department

Given that early goal-directed therapy (EGDT) has demonstrated a 16% absolute reduction in in-hospital mortality for septic patients without specific antibiotic guidelines, and the Surviving Sepsis Campaign recommends that antibiotics be administered within 1h of recognition of severe sepsis of shock, this study investigated the impact of time to antibiotic therapy in the emergency department on the in-hospital mortality of septic patients. The authors conducted a retrospective analysis of patients with severe sepsis and septic shock treated with EGDT at a single institution.

The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before-and-after intervention study

Background In 2004, the Surviving Sepsis Campaign (SSC), a global initiative to reduce mortality from sepsis, was launched. Although the SSC supplies tools to measure and improve the quality of care for patients with sepsis, effective implementation remains troublesome and no recommendations concerning the role of nurses are given. Objectives To determine the effects of a multifaceted implementation program including the introduction of a nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback. Design and setting A prospective before-and-after intervention study conducted in the emergency department (ED) of a university hospital in the Netherlands. Participants Adult patients (≥16 years old) visiting the ED because of a known or suspected infection to whom two or more of the extended systemic inflammatory response syndrome (SIRS) criteria apply. Methods We measured compliance with six bundled SSC recommendations for early recognition and treatment of patients with sepsis: measure serum lactate within 6 h, obtain two blood cultures before starting antibiotics, take a chest radiograph, take urine for urinalysis and culture, start antibiotics within 3 h, and hospitalize or discharge the patient within 3 h. Results A total of 825 patients were included in the study. Compliance with the complete bundle significantly improved from 3.5% at baseline to 12.4% after our entire implementation program was put in place. The completion of four of six individual elements improved significantly, namely: measure serum lactate (improved from 23% to 80%), take a chest radiograph (from 67% to 83%), take urine for urinalysis and culture (from 49% to 67%), and start antibiotics within 3 h (from 38% to 56%). The mean number of performed bundle elements improved significantly from 3.0 elements at baseline to 4.2 elements after intervention [1.2; 95% confidence interval = 0.9–1.5]. Conclusions Early recognition of sepsis in patients presenting to the ED and compliance with SSC recommendations significantly improved after the introduction of a predominantly nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback.

The Little ICU Book of Facts and Formulas

Books now compete with web-based electronic resources, and the challenge for authors and publishers is how to provide accurate and timely information with sufficient depth and breadth to be useful in the workplace. A book of this type therefore has to compromise between size and detail, demonstrate balance in selection of material, and appeal to a globalised world. In many respects, Paul Marino succeeds in this task. The book is a condensed version of 'The ICU Book' by the same author. Intended as a compact bedside reference, it is presented as 15 chapters, each with up to 5 sub-sections. Chapters cover diverse subjects with an appendix of conversion tables, normal values and formulae. Algorithms are well referenced using current evidence. However, these strengths are offset by some notable omissions and imbalances. The haemodynamic monitoring section is exclusively based on the pulmonary artery flotation catheter (PAFC), disregarding other forms of monitoring – for example, oesophageal Doppler, LiDCO™ or PiCCO™. No reference is made to evidence regarding lack of clinical utility of the PAFC. The section on haemodynamic drugs lacks breadth, omitting discussion of epinephrine, vasopressin (mentioned briefly in the septic shock chapter), phosphodiesterase inhibitors or levosimendan. Sodium nitroprusside, however, receives four pages. The chapter on vascular access mentions the importance of aseptic technique, stating that handwashing, sterile gloves and full barrier precautions are 'recommended' for central venous catheter (CVC) insertion. A simple table mandating such measures would have greater impact, including the use of alcoholic chlorhexidine and a catheter cart facilitating prior preparation. There is no reference to the use of ultrasound guided CVC insertion. Conversely, there is an unnecessary page describing peripheral intravenous cannulation. The toxicology chapter omits important aspects of self-poisoning, namely tricyclic antidepressants and drugs of abuse. The chapter on antimicrobial therapy would have been improved by repeating the Surviving Sepsis Campaign recommendations in the septic shock section and by referencing the website, rather than the now outdated 2004 recommendations. Daily review and early termination of antimicrobials should be emphasised. The sequences of chapters and topic choices are disjointed. Topics including illness severity scoring, morbidity, mortality and treatment withdrawal would have been useful. Non-SI units in many equations make conversions inconveniently necessary for the European reader. The book is positioned as a primer in the basics of North American intensive care medicine. It is not entirely harmonised with European practice and readers may consider alternatives. That said, trainees would find it a handy reference at the ICU workstation.

The new Surviving Sepsis Campaign recommendations on glucose control should be reconsidered

Sir: Dellinger et al. are to be congratulated on their new Surviving Sepsis Campaign recommendations as published recently in this journal [1]. The efforts of Dellinger and his group are of great value for all of us who take care of patients with sepsis. Indeed, guidelines like those from the Surviving Sepsis Campaign, an initiative of the European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine, are very much welcomed and appreciated by the intensive care community. They have been and continue to be an important tool in improving care of septic patients globally. However, in our opinion, the new recommendations are flawed with respect to glucose control. The new recommendations for septic patients advise maintaining the blood glucose concentration (BGC) below 150 mg/dl (8.3 mmol/l) instead of adhering to the more strict thresholds as in the two randomized controlled trials by van den Berghe et al. (BGC 80–110 mg/dl, 4.0–6.1 mmol/l) [2, 3]. The Surviving Sepsis Campaign justifies this departure on several grounds: new studies show conflicting results incidence of severe hypoglycemia with lower BGC thresholds, with a presumed association between severe hypoglycemia and death. We disagree with the advised thresholds, and argue against the reasoning for not retaining the original stricter BGC thresholds. First, the evidence. Simply, there are no studies that provide evidence for glucose control in sepsis using the now recommended threshold of 150 mg/dl. Using the 150 mg/dl upper limit, more septic patients will be in the higher BGC range. However, with more successful glucose control (i. e., BGC closer to 80 mg/dl) more benefit is achieved [4, 5]. Indeed, the lowered BGC rather than the insulin dose is related to reduced mortality, critical illness polyneuropathy, bacteremia, and inflammation [4]. Second, the conflicting information that comes from new (yet unpublished) studies [6, 7]. Unfortunately, the multicenter VISEP trial on glucose control in Germany by the SepNet group was discontinued prematurely because of identical mortality rates in the treatment groups but a higher incidence of hypoglycemia in the glucose control group (12.1% vs. 2.1%) [6]. Another study, the European GLUControl trial, was also stopped before inclusion was completed [7]. As in the VISEP study, the primary reason for stopping inclusion of patients was the relatively high incidence of hypoglycemia in the glucose control group. Due to the early termination of these studies we are left with two underpowered randomized controlled trials which can by no means be used as evidence in the discussion on potential benefit of glucose control. Third, blood glucose control with insulin carries the risk of hypoglycemia. Indeed, the incidence of severe hypoglycemia (defined as a blood glucose concentration < 40 mg/dl) is 5 to 10 times higher than with a conventional blood glucose strategy [2, 3]. Thus, the rise in incidence of hypoglycemia in the glucose control groups in the two newer studies as mentioned above was not surprising. Similar findings came from numerous other studies reporting on some form of glucose control (merely studies with a before–after design) [8]. Fear of severe hypoglycemia has, at least in part, hampered broad implementation of glucose control [8]. Although many ICUs have adopted some form of glucose control, frequently the applied glucose control regimens have higher thresholds than those used in the original studies. Of note, with higher BGC thresholds, the incidence of severe hypoglycemia does not differ greatly from that with more strict BGC thresholds [8]. Fourth, the assumed association between hypoglycemia and poor outcome. We recently analyzed the short-term consequences (seizures, coma, and death) of hypoglycemia [9]. The hazard ratio for in-hospital death was 1.03 (95% confidence interval 0.68–1.56; P = 0.88) in patients with a first occurrence of hypoglycemia relative to the controls without hypoglycemia. Results were corrected for duration of intensive care unit admittance before hypoglycemia, age, sex, and Acute Physiology, Age and Chronic Health Evaluation II score at admission. In addition, no cases of hypoglycemia-associated death were reported. Although the evidence for glucose control with strict thresholds does not yet support a grade A recommendation (based on the highest level of evidence), it does appear to be stronger than the evidence in support of a strategy of tolerating higher BGC thresholds. Most importantly, however, the only evidence we have supports a BGC threshold of 110 mg/dl, not 150 mg/dl.

The new Surviving Sepsis Campaign recommendations on glucose control: reply to Schultz et al.

The new Surviving Sepsis Campaign recommendations on glucose control: reply to Schultz et al.

Guidance in sepsis management: navigating uncharted waters?

A platypus is a duck designed by a committee. (Australian aphorism) Practice guidelines should be enormously helpful to our patients. We offer another view, however, to that expressed by authors of the Surviving Sepsis Campaign (SSC) [1]. Traditionally, clinical decisions have been informed by peers, but committees such as the SSC seek to drive, rather than reflect, consensus. Is criticism of this new approach justified? Guidelines can influence physicians to act against their better judgement. For example, while only 47% of surveyed intensivists believed that central venous pressure should guide resuscitation, 86% used it because of the SSC recommendation [2]. Protocols may improve care, but what should one do when audited patient outcomes are already better than those achieved by guideline interventions – such as early goal-directed therapy for severe sepsis [3]? Guidelines for high-income countries may be inappropriate elsewhere, where assigning resources to guideline compliance might preclude other interventions. Such prioritisation is better determined by clinicians in response to local circumstances than by international expert panels. When guidelines become a standard of care, equipoise for confirmatory trials can be lost. Enrolment in the Cortico-steroid Therapy of Septic Shock (CORTICUS) trial [4], for example, may have been unsustainably low because cortico-steroids had the SSC imprimatur. Guidelines are increasingly used in malpractice litigation despite contrary recommendations. Finally, without the assent of clinicians, inappropriately formulated guidelines risk being ignored. We suggest an alternative. Guidelines should define broad goals rather than dictate exact replication of process. For example, instead of recommending rigorous early goal-directed therapy implementation, a guideline could summarise the evidence, and then discuss the merits of approaches (such as fluid therapy, blood transfusion, and inotropic support) targeting central venous oxygen saturation >70%. Rather than recommending strict glycaemic control, a guideline might discuss the populations in which trials have been performed and advise that, pending further evidence, a reasonable strategy might be to control glucose to a degree, but not so intensively as to cause hypoglycaemia. Furthermore, as patrician democracy has given way to universal suffrage, we envisage polls to gain the assent of practising intensivists, such that guidelines reflect true consensus rather than expert opinion. Quality assurance standards – the broadly agreed minimum – should be specifically distinguished from such guidelines. We sense unease, inside and outside the profession [5], at the list of directions presented by the 'cartographer' experts of the SSC – made more contentious because the geographic features are incompletely known. Our suggestion is analogous to replacing a recommended course with the entire map, marked with areas of certainty and uncertainty (Figure ​(Figure1).1). Experience, local conditions, and resources should determine the course of competent practitioners. Figure 1 Carte reduite de L'Australasie (Smaller map of Australia) by Robert Gilles de Vaugondy, published in 1756. More than a list of directions, declaring the unknown as well as the known aids safety and stimulates discovery. National Library of Australia, ...

Advances in the management of sepsis: the randomised controlled trials behind the Surviving Sepsis Campaign recommendations

The Surviving Sepsis Campaign is the first international, multiorganisation, multidisciplinary attempt to reduce the appalling morbidity and mortality related to sepsis. Under the auspices of the campaign, guidelines have been published that cover more than 50 aspects of care of the septic patient. Campaign guidelines on antimicrobial therapy cover very general aspects of antibiotic policy and are mostly supported by expert opinion rather than randomised controlled trials. However, these ‘common sense’ recommendations on antibiotic therapy have been included in this review. The core areas of the Surviving Sepsis Campaign guidelines have been crystallised into resuscitation and management ‘bundles’. This review focuses on the most important clinical trials that form the basis of these core guidelines.