The most important thing a health care provider can do is recognize sepsis and septic shock early and take immediate action, according to new guidelines released at the Society of Critical Care Medicine’s (SCCM) 46th Critical Care Congress.
“I think it is important to recognize that sepsis and septic shock are medical emergencies,” said Andrew Rhodes, FRCP, FRCA, FFICM, co-chair of the guidelines committee. Early resuscitation should begin with early antibiotics and fluids, as well as the identification of the source of infection.
In addition, Dr. Rhodes said, the new guidelines say a health care provider who is trained and skilled in the management of sepsis should reassess the patient frequently at the bedside. “It is not the initial assessment, but the frequent reassessment that will make a difference,” he said.
In many ways, the guidelines will change the paradigm of management, he said.
The guidelines were jointly released by the SCCM and the European Society of Intensive Care Medicine (ESICM) and comprised of a consensus committee of 55 international experts updated the 2012 Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock recommendations to help guide clinicians caring for their adult patients with sepsis and septic shock. The 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%,” Dr. Rhodes said. “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.”
Sepsis is the leading cause of death from infection, and its reported incidence is on the rise, the SCCM said in a statement.
Laura E. Evans, MD, FCCM, the co-chair of the committee, reiterated the importance of early recognition and quick action. “We continue to make a strong recommendation that hospitals and health care 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.”
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 of the guidelines in 2012 are those addressing initial resuscitation and antimicrobial therapy.
Regarding the 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.
Dr. Rhodes said a number of actions that many clinicians now take have changed the management of sepsis for the better, which is why the recommendations for central venous pressure and central venous oxygen saturation have changed.
“A number of the things we do in tandem have changed,” he said, such as early fluids and antibiotics that have produced better outcomes for patients. “The overall management of sepsis has changed, I think to the better,” he said.
The guidelines have a strong recommendation that for the resuscitation from sepsis-induced hypoperfusion, at least 30 mL/kg IV crystalloid fluid be given within the first three hours.
Following the initial fluid resuscitation, additional fluids should be guided by frequent reassessment of hemodynamic status, which was a best practice statement.
The new guidelines, however, recommend frequent clinician reassessment as a priority over specific targets. “We need to be there at the bedside, we need to assess the patient. We don’t just leave the patient once we prescribe the fluid, but we frequently reassess,” he said.
“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 regarding 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.”
The guidelines include a strong recommendation from the committee to administer antibiotics, ideally within the first hour, for patients at risk for sepsis and septic shock. This recommendation was present in the previous guidelines for septic shock, but more recent data give greater strength to the recommendation and expand the recommendation to include both sepsis and septic shock.
“We recommend that a specific anatomic diagnosis of infection requiring emergent source control be identified or excluded as rapidly as possible in patients with sepsis or septic shock, and that any required source control intervention be implemented as soon as medically and logistically practical after the diagnosis is made,” Dr. Rhodes said.
They recommend that administration of IV antibiotics be initiated as soon as possible after recognition and within one hour for both sepsis and septic shock. In addition, they recommend that empiric broad-spectrum antibiotics with one or more antimicrobials to cover all likely pathogens be delivered.
“If we are looking at the initial resuscitation, I think there are three key components to think about: getting control of the source of the infection; giving early antibiotics; getting on with the resuscitation and sometimes, all three elements will have to happen in parallel,” Dr. Rhodes said.
Mitchell M. Levy, MD, MCCM, of Brown University in Providence, RI, who was one of the founders of the campaign in 2000 said the guidelines emphasize the need for antibiotic stewardship in hospitals. “We recommend that appropriate routine microbiologic cultures, including blood, be obtained before starting antimicrobial therapy,” he said.
“The reason why we feel good about making that recommendation is by marrying it to antibiotic stewardship” and as soon as the results are available, one can narrow the spectrum.
“We recommend that empiric antibiotics be narrowed once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted,” he said. “We all know that it is not uncommon to have people on antibiotics longer than necessary because the order to stop antibiotics simply goes undone.”
The panel suggests that a duration of seven to 10 days is adequate for most serious infections with sepsis and septic shock and said patients should be assessed daily to determine if antibiotics should be de-escalated.
“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 guidelines took four years to revise, according to Dr. Evans. “One of the big challenges that faced this group is that the sepsis-3 definitions were co-published by the SCCM and the ESICM. They redefined sepsis as a life-threatening organ dysfunction caused by dysregulated host response to infection and septic shock subset of sepsis with circulatory and cellular metabolic dysfunction associated with a higher risk of mortality. The eliminated the term ‘severe sepsis.’
“Our panel was faced mid-guidelines process with how do we incorporate these new definitions into this process, and what we ended up doing was-clearly the new definition of sepsis is very similar to the old definition of severe sepsis with organ dysfunction associated with infection-so, we replaced severe sepsis in these guidelines with the new sepsis 3 definition and terminology of sepsis,” Dr. Evans said.
“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 challenge today is how can we do better,” he said.