Surviving Sepsis Update – Insane or Just Crazy?

May 26, 2018

Written by Thomas Davis

Spoon Feed
The Surviving Sepsis Campaign has issued a new 1-hour bundle beginning at the time of triage in the emergency department. This replaces the current 3- and 6-hour bundles.

Why does this matter?
Although the 2016 Surviving Sepsis Campaign guidelines state that “Recommendations from these guidelines cannot replace the clinician’s decision-making capacity when presented with a patient’s unique set of clinical variables,” the regulatory reality is less deferential to your clinical acumen. The Centers for Medicare and Medicaid Services (CMS) has adopted the 3- and 6-hour bundles as rigid core measures, which severely impact hospital reimbursement. Just as you may be getting used to the current bundles, you may want to read the 1-hour bundle summary below as this will likely be the new CMS standard.

Patient checked in 45 minutes ago. You have 15 minutes remaining.
The following bundle should be initiated within 1 hour of ED triage. The published document implies that the bundle is intended for patients with sepsis or septic shock using the Sepsis-3 definition.

1. Measure lactate level. If lactate > 2 mmol/L, re-measure within 2-4 hours.
2. Obtain blood cultures prior to antibiotics. Of course, “administration of appropriate antibiotic therapy should not be delayed in order to obtain blood cultures.”
3. Administer broad spectrum antibiotics.
4. Rapidly administer 30 mL/kg crystalloid for hypotension or lactate >/= 4 mmol/L. Fluids should be completed within 3 hours
5. Apply vasopressors if the patient is hypotensive during or after fluid resuscitation to maintain MAP >/= 65 mmHg.

Instead of re-organizing the bundles using data, three authors justify their move by stating that, “we believe this reflects the clinical reality at the bedside of these seriously ill patients.” However, all three authors are non-emergency physicians and demonstrate little understanding of the clinical reality in the emergency department.

1. Behind from the start – Getting SOFA labs (Sepsis-3 definition) back in time for the 1-hour bundle will be nearly impossible. Simpler scoring systems exist, but the false positive rate will be high. Will every case of likely strep throat or flu get a slug of empiric piperacillin-tazobactam in the waiting room just because they are SIRS positive based on triage vitals?

2. Low quality evidence – The Surviving Sepsis Campaign (SSC) admits to shoving mostly low quality evidence into its guidelines. Just take a look at its summary below.

3. Observational data – The SSC pats itself on the back for the success of bundles based largely on observational data from the New York experience—even though it showed no benefit to faster administration of IV fluid.  A RCT in Lancet showed no benefit to prehospital antibiotics.

4. Everybody else is doing it – Despite the admitted paucity of data on optimal IV fluid volume and rate, the SSC says we should give a 30 ml/kg crystalloid bolus because that’s what recent landmark studies in ProCESS, ARISE, and PROMISE have shown to be usual care for the average patient. For example, ARISE patients received 34.7 +/- 20.1 ml/kg of crystalloid during the initial resuscitation period. The SSC argues that since the average patient is getting 30 ml/kg of crystalloid, every patient should therefore get at least the average. It’s somewhat analogous to how everybody thinks they’re a better-than-average driver. That’s just statistical nonsense, since not every patient should receive the average fluid volume.

5. Read the fine print – The guidelines emphasize that it’s better to give antibiotics than to delay blood cultures. However, we all know that’s not true. If you read the fine print of the government mandate, fail this measure and you fail it all.

Another Spoonful
This new 1-hour bundle has started a firestorm in the #FOAMed world. Listen to Scott Weingart rant and read Josh Farkas explain his discontent.  Then sign the petition to dismantle the Surviving Sepsis Campaign if you agree. Or read about what some of our critical care colleagues think at PulmCCM.

Source
The Surviving Sepsis Campaign Bundle: 2018 update.  Intensive Care Med. 2018 Apr 19. doi: 10.1007/s00134-018-5085-0. [Epub ahead of print]

Peer reviewed by Clay Smith