May 022018

In their 2018 update, the Surviving Sepsis Campaign's guidelines attempt to accelerate care delivery for sepsis, advising that within one hour, physicians and health care teams should collect blood cultures and lactate, begin 30 ml/kg fluid resuscitation for hypotension or lactatemia, and start vasopressors for selected patients. Previously, these interventions were advised within three- and six-hour timeframes.

The authors cite no new evidence for such a significant change, merely stating "we believe this reflects the clinical reality at the bedside of these seriously ill patients with sepsis and septic shock—that clinicians begin treatment immediately, especially in patients with hypotension, rather than waiting or extending resuscitation measures over a longer period." They seem buoyed by New York state's reported sepsis outcomes after regulating care (although NY's experience doesn't clearly support anything besides giving antibiotics within a few hours).

The new guidelines try to push back the recently-invented sepsis clock to start the moment a patient is first seen in the ED:

"Time zero” or “time of presentation” is defined as the time of triage in the emergency department or, if referred from another care location, from the earliest chart annotation consistent with all elements of sepsis (formerly severe sepsis) or septic shock ascertained through chart review."

But an important fact goes unmentioned. There is no accurate and reliable test for sepsis, so any "sepsis trigger" will necessarily be based on error-prone heuristics (SIRS, qSOFA, procalcitonin, etc) with high false positive rates. Over-treatment will result, especially in the enormous population of patients with lactatemia without hypotension.

The backlash has already begun: on PulmCrit, an influential companion blog to EMCrit, more than 20 academic physicians and thought leaders (including Dr. Paul Marik) have co-signed a statement strongly criticizing the Surviving Sepsis Campaign and its guidelines. An online petition has gathered hundreds of signatures in the day or so since it was created.

This comes in the wake of prior criticism of the increasing pressure to deliver bundled sepsis care within the 3-hour timeframe, as voiced by sepsis experts interviewed on NPR and editorializing in major journals. Sepsis bundles are increasingly mandated internally by hospitals, in response to the SEP-1 core measure from CMS and its reporting requirements. New York enshrined the 3- and 6-hour bundle timeframes into law, and other states are considering doing so.

Emergency department physicians express concern about feeling forced to deliver three- or four-liter crystalloid boluses to obese patients with hypertension, end-stage renal disease or congestive heart failure who have no evidence of organ hypoperfusion, simply because they have lactatemia and a "sepsis alert" triggered by the electronic medical record.

Intensive care physicians are dismayed when receiving such patients, who anecdotally are more likely to progress to frank respiratory failure requiring mechanical ventilation, or to require extended hospital stays with high doses of supplemental oxygen and diuretics. None of these unintended consequences are being measured or reported, to PulmCCM's knowledge.

A one-hour timeframe will virtually eliminate thoughtful clinical decision-making by emergency physicians, forcing their teams to scramble into protocolized over-treatment of tens of thousands of non-septic patients per year in the U.S. alone. For patients with hypotension, this might carry a justifiable harm-to-benefit ratio. For patients with isolated lactatemia, normal or high blood pressure, relative contraindications to fluid boluses, and a weakly positive "sepsis screen," it borders on mandated malpractice.

Interested physicians can review the online petition here.

Source: Intensive Care Medicine

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2018 Update to Surviving Sepsis Guidelines: Cue Backlash