After much anticipation the new surviving sepsis guidelines have been published in critical care medicine.
There will no doubt be much conversation, debate and discussion about this in the coming weeks and I’ll bet Scott Weingart will be all over it already. I’m really looking forward to the inevitable podcasts on this from my expert ICU colleagues.
This post is really just a quick heads up on what’s happening. If you are an ED/Intensivist you really should be going through all 58 pages yourself. This is important stuff which will probably influence practice for years to come. If 58 pages is too much for you then there are some more accessible guides here at the surviving sepsis website. What I would like to see is a nice diagram though – I like pictures!
So what about the ED docs? What’s new for us in the first read through? Here are a few notable points from the document –
- Definitions of severe sepsis are clear and defined across a range of clinical and laboratory investigations (see the table above).
- Outcomes for initial resuscitation within 6 hours mandate
- CVP 8-12
- MAP >65mmHg
- Urine output >o.5ml/Kg
- ScVO2 or mixed venous O2 of 70% or 65% respectively.
- Normalisation of lactate as a resuscitation goal.
3. Dobutamine and/or Red cells for patients with persistently low venous O2 s
4. Priority to antibiotics within first hour, 2 sets of cultures so long as antibiotics not delayed by more than 45 mins.
5. Priority to search for source of infection – early imaging helpful (my thoughts)
So, no reduction in the number of central lines that need placing in the ED then and a re-iteration of the need for early antibiotics. CVP is still advocated to guide resuscitation which is interesting (though the limitations of this are mentioned in the full article). Starch has gone (as we have been saying for a while here at St.Emlyn’s).
The guideline has been put into two bundles. One to be delivered within three hours and one within 6 hours. Cynically I notice that this straddles the 4-hour target in the UK (but perhaps that is too cynical).
|1. Complete within 3 hours|
|2. Complete within 6 hours|
– Measure central venous pressure (CVP)*
– Measure central venous oxygen saturation (ScVO2)
*Targets for quantitative resuscitation included in the guidelines are CVP of _8 mm Hg, ScvO2 of 70%, and normalization of lactate.
So what do you think? My initial thoughts are that the guideline is pretty conservative and may arguably be behind the current thinking in some units.
What do you think?