A consensus committee of 55 international experts in sepsis has updated recommendations to help guide clinicians caring for their adult patients with sepsis and septic shock.
The release of the guidelines is a joint collaboration between the European Society of Intensive Care Medicine (ESICM) and the Society of Critical Care Medicine.
Committee members say the updated guidelines, available at survivingsepsis.org/Guidelines
, offer important advancements for clinicians caring for patients with sepsis and septic shock, starting with the need to identify at-risk patients sooner.
“Despite advances in treatment, septic shock still has a mortality rate of approximately 40 percent,” said Andrew Rhodes, FRCP, FRCA, FFICM, co-chair of the committee. “Even for those who survive a sepsis event, it causes considerable long-term health issues. Getting the right management early in the disease process is vital to improving the chances of a good outcome.”
“The big bottom line remains on early recognition of infection and organ dysfunction,” said Laura E. Evans, MD, FCCM, co-chair of the committee. “We continue to make a strong recommendation that hospitals and healthcare systems implement programs that help identify at-risk patients early. There’s implicit recognition that just being a good clinician is probably not enough; you need a system in place to help recognize patients early.”
Sepsis is the leading cause of death from infection, and its reported incidence is on the rise. The committee’s revised guidelines encompass 21 categories—from initial resuscitation to setting goals of care. Two categories with important advancements for clinicians since the last iteration in 2012 are those addressing initial resuscitation and antimicrobial therapy.
In regard to initial resuscitation, the new guidelines address what some clinicians had considered a controversial issue in the 2012 guidelines—giving specific targets for fluid resuscitation, including central venous pressure and central venous oxygen saturation. The new guidelines, however, recommend frequent clinician reassessment as a priority over specific targets.
“There have been several large studies published since the 2012 revisions that find no difference in patient outcomes using those specific targets versus basic clinician reassessment,” Dr. Evans said. “Our new recommendation reflects the belief that clinician reassessment is very important in regard to patient outcomes. This recommendation may be a little controversial because it’s a bit more vague than having specific targets, but it’s where the data took us this time.”
In regard to antimicrobial therapy, the guidelines include a strong recommendation from the committee to administer antibiotics, ideally within the first hour, for patients at risk of sepsis and septic shock. This recommendation was present in the previous guidelines for septic shock, but more recent data gives greater strength to the recommendation and expands the recommendation to include both sepsis and septic shock.
“The revised guidelines increase the quantitative evidence supporting our recommendation and not just for patients at risk for septic shock, but sepsis as well,” Dr. Evans said. “Another important change is recommending combination therapy for patients with septic shock. It’s a weak recommendation, based on low-quality evidence currently, but it’s a big change.”
A broader change in the current guidelines is the absence of pediatric considerations for sepsis. Dr. Evans said this change reflects the fact that “pediatrics deserves its own separate guidelines and not a subset of adult guidelines.” Work to develop these guidelines is in process and will be available at a later date.
Overall the committee identified 93 statements on early management and resuscitation of patients with sepsis or septic shock. The results yielded 32 strong recommendations, 39 weak recommendations and 18 best practice statements. No recommendation was provided for four questions.
All statements were generated using Population, Intervention, Comparison, and Outcome (PICO) questions. Subsequently, the committee applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence supporting the statements from high to very low, and to formulate recommendations as strong or weak. For the first time since the guidelines were initiated in 2004, the committee introduced best practice statements for strong recommendations that are ungraded.
The revised guidelines offer just the next step forward in the evolving study of sepsis. Important further steps include helping hospitals and healthcare systems implement the guidelines and using the current guidelines to identify existing gaps in the research so they can be studied.
“The guidelines provide great direction, but if they are not implemented, they will not do much,” Dr. Evans said. “Another part of the campaign will be looking at these revised guidelines to determine if changes need to be made to the Surviving Sepsis Campaign bundles used to help facilitate implementation.”
“This is the continuation of a huge process that began in 2004,” Dr. Rhodes added. “As more and more data on sepsis accumulates, we are able to refine the recommendations and offer more evidence to support them. These guidelines will enable clinicians to provide the best treatment possible for these very sick patients and ultimately help save many lives.”
The revised guidelines culminate more than a year of work by the committee convened by SCCM and the European Society of Intensive Care Medicine. The group’s 55 members represent 25 international organizations. The guidelines are being published in Critical Care Medicine and Intensive Care Medicine.
In the session centered on the guidelines, Drs. Evans and Rhodes, and Mitchell M. Levy, MD, MCCM, FCCP, reviewed the methodology and what's new in the Surviving Sepsis Campaign Guidelines. Special guests Lauren Epstein, MD, from the Centers for Disease Control and Prevention and R. Phillip Dellinger, MD, MCCM, from Cooper University Hospital were also on hand to offer special live commentary.
All of the late-breaking literature releases from the 46th Critical Care Congress are available at www.sccm.org/literature. Keep the conversation going about the new sepsis guidelines by using #SCCMLive.