Sepsis has been a big topic of research over the years (understatement), and the last 18 months have seen the publication of data that has made us, once again, rethink how we approach these critically ill patients. If you are reading this blog then it is highly likely that you are aware of the 2001 Rivers study which encouraged early goal directed therapy (EGDT). You will also most likely be aware of the ProMISe, ProCESS and ARISE trials and their collective findings; the lack of evidence for increased survival with aggressive goal-directed therapy over “standard care”.
What you may not be aware of is the update in care bundles published by the Surviving Sepsis Campaign (SSC) in response to this new evidence. You can find their revised recommendations here.
The SSC is a progressive bunch of people and the campaign group has been happy to change the care bundles that they recommend on the back of these three trials. They previously advocated the use of a central venous catheter (CVC) to monitor central venous pressure (CVP) and central venous oxygen saturation (ScvO2) in all patients with severe sepsis or septic shock, or those with a lactate greater than 4 mmol/L.
So what’s new?
The SSC has broken down their recommendations into two time-limited bundles of care; within 3 hours and within 6 hours. Here’s a summary…
Then, within 6 hours:
We are advised to assess volume status and tissue perfusion using one of following methods:
- Repeat focused clinical examination
OR two of the following
- Bedside cardiovascular US
- Dynamic fluid challenge (IV bolus/passive leg raise)
The 3 hour care bundle is unchanged and unaffected by the results of the triad of ProMISe, ProCESS and ARISE. It is interesting to note that the SSC update does not separate administration of antibiotics into a “first hour” category but rather leaves this in the 3 hour bundle. I know I aim to ensure antibiotic provision within 60 minutes, and this is the practice I see my colleagues aspiring to.
It is in the 6 hour bundle where we can find some significant changes. We are still advised to aim for a MAP of at least 65mmHg, but we now no longer have a targeted ScvO2 or CVP to aim for. In fact, even measuring these parameters is now optional! The new bundles allow more freedom for the treating clinician.
For patients with refractory hypotension we can either perform a thorough clinical examination or choose to insert a central venous catheter to measure ScvO2 or CVP, or perform an ultrasound, or perform a fluid challenge or any combination of these tests! Phew. That was hard work to type. So what combination is best? I imagine, skill set permitting, that most clinicians will do all or most of these investigations for the shocked septic patient. It will be interesting to see how this translates into clinical practice.
All the components of the EGDT are still in the care bundles, however there are no longer targets to work towards. We no longer have to aim for a CVP of 8-12mmHg or ScvO2 ≧ 70%. We don’t even have to measure them. In my experience, patients that require vasopressors usually end up with a CVC. If you need vasopressors then you are working on the 6 hour care bundle. If you are starting vasopressors for refractory hypotension then you also need to reassess volume status. If you already have a CVC in for point 5, then for point 6 why not just measure CVP/ScvO2? Or will you just use the CVC for vasopressors and rely on your clinical examination and ultrasound skills? Is the 6 hour bundle simply EGDT without the ‘G’? I guess the important thing to appreciate is that the SSC has downplayed the importance of CVP/ ScvO2 but still acknowledges the role it plays in the assessment of volume status in the hypotensive septic patient.
— Henry Morriss (@hrmorriss) April 4, 2015
Will this change what I do?
At first glance the changes to the care bundle appears to give more freedom to the clinician. It appears to give clinicians the flexibility to assess volume status without the rigid targets proposed by Rivers. In fact, aside from a MAP ≧ 65, the bundles do not suggest any goals of therapy.
From a personal perspective I imagine that the sickest, hypotensive septic patients I look after will have a CVC inserted for vasopressor administration, and that I may or may not measure CVP/ScvO2 (but I probably will), and that I’ll be utilising a combination of the assessments of volume status.
I would love to hear how/if this will change your practice, so please leave a comment below!