The incidence of severe sepsis (sepsis with organ dysfunction) is increasing.1 The initial diagnosis and management of severe sepsis may occur in the ED, the ICU, or the hospital ward.
Several recently published studies have demonstrated decreased mortality and morbidity as a result of interventions and therapeutics applied to patients with sepsis.2-5 These new data, resulting from rigorously performed, randomized controlled trials, combined with previous data for beneficial interventions not specific to sepsis management (such as DVT and stress ulcer prophylaxis) and consensus opinion where no evidence exists lend significant weight to the belief that critical care clinicians can now significantly reduce mortality in patients with severe sepsis and septic shock.6-9
Protocolized care now exists for heart attack and stroke, which is based on recent advances as demonstrated by the medical literature. Until now there has been no attempt to reproduce such an approach in severe sepsis. The Surviving Sepsis Campaign hopes to change that.
The Surviving Sepsis Campaign is administered by the Society of Critical Care Medicine (SCCM), the European Society of Intensive Care Medicine (ESICM), and the International Sepsis Forum (ISF) and is open to all industry for funding through unrestricted educational grants. Contributors to date include Baxter, Edwards, and Eli Lilly.
The first phase was the introduction of the campaign at several major international critical care medicine conferences, the ESICM meeting in Barcelona in 2002, and the SCCM meeting in 2003. The stated goal of the campaign is to decrease the mortality from severe sepsis by 25% in five years.
Phase 2 of the campaign was aimed at producing guidelines for the management of sepsis. In 2003, critical care and infectious disease experts representing 11 international organizations developed evidence-based management guidelines for severe sepsis and septic shock for practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign.
Pediatric considerations were provided to contrast adult and pediatric management. The resulting recommendations represent an attempt to facilitate a rapid change in the standard of care for management of sepsis, based on the quality of available published data and expert opinion where no literature guidance is available. The guidelines manuscript was published in both Critical Care Medicine and Intensive Care Medicine.10,11 The publication of this manuscript represents an historic step for critical care worldwide. These guidelines represent an international consensus on the best available standard for management of sepsis.
Key recommendations (listed by category and not by hierarchy) include:
- Early goal-directed resuscitation of the septic patient during the first six hours after recognition;
- Appropriate diagnostic studies to ascertain causative organisms before starting antibiotics;
- Early administration of broad-spectrum antibiotic therapy;
- Reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate;
- A usual seven to 10 days of antibiotic therapy guided by clinical response;
- Source control with attention to the method that balances risks and benefits;
- Equivalence of crystalloid and colloid resuscitation;
- Aggressive fluid challenge to restore mean circulating filling pressure;
- Vasopressor preference for norepinephrine and dopamine;
- Cautious use of vasopressin pending further studies;
- Avoidance of low-dose dopamine administration for renal protection;
- Consideration of dobutamine inotropic therapy in some clinical situations;
- Avoidance of supranormal oxygen delivery as a goal of therapy;
- Stress-dose steroid therapy for septic shock;
- Use of recombinant activated protein C in patients with severe sepsis and high risk for death;
- Resolution of tissue hypoperfusion and targeting a hemoglobin of 7-9 g/dL in the absence of coronary artery disease or acute hemorrhage;
- Appropriate use of fresh frozen plasma and platelets;
- A low tidal volume and limitation of inspiratory plateau pressure strategy for acute lung injury and acute respiratory distress syndrome;
- Application of a minimal amount of positive end expiratory pressure in acute lung injury/acute respiratory distress syndrome;
- A semi-recumbent bed position unless contraindicated;
- Protocols for weaning and sedation/analgesia, using either intermittent bolus sedation or continuous infusion sedation with daily interruptions/lightening;
- Avoidance of neuromuscular blockers, if at all possible;
- Maintenance of blood glucose <150 mg/dL after initial stabilization;
- Equivalence of continuous veno-veno hemofiltration (CVVH) and intermittent hemodialysis;
- Lack of utility of bicarbonate use for pH 7.15 or greater;
- Use of DVT/stress ulcer prophylaxis; and
- Consideration of limitation of support where appropriate.