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The Surviving Sepsis Campaign

sepsis_logo_smThe Surviving Sepsis Campaign 

In response to recent publications both in the medical literature and the lay press questioning the validity of recent Surviving Sepsis Campaign (SSC) guidelines, the leadership of ACEP appointed a working group of members with special interest and expertise in this area to reassess the college’s position in supporting the SSC generally, and reviewing the specific recommendations.

The group unanimously and enthusiastically supports the SSC as representing an important positive advance in promoting the early recognition and aggressive resuscitation of patients suffering from severe sepsis and septic shock. Recent efforts have helped decrease hospital mortality. Emergency physicians play a key role in early recognition of this patient population and are critically important in initiating early and aggressive resuscitation, primarily with large volume fluid infusions. The relative importance of individual elements of “Early Goal Directed Therapy,” including titration of pressors, iontropes, blood transfusion, and fluids with the use of continuous central venous saturation monitoring represent one method, but the need for each step remains controversial. Similarly, other SSC recommendations, including “tight” glycemic control, and the use of “stress doses” of steroids are also controversial. Nonetheless, we believe that the principles of the SSC are valid – recognize and treat shock early, focusing on protocolized resuscitation, monitoring of vital signs plus other measures of perfusion (lactate and oxygen saturation), and timely administration of an appropriate antibiotics regimen are supported by available data.

Minor variations in practice based on the individual circumstances of the local environment are to be expected. Specific recommendations will be altered as emerging data refine optimal care, and new innovations and interventions will undoubtedly be incorporated into the guidelines as they are developed and tested.

Most importantly, we recognize the key role of emergency physicians in the care of and knowledge advancement for critically ill patients – our actions can improve the outcomes of those most in need.

Early Goal Directed Therapy for Sepsis: Show Me the Data!
Meta-analysis of randomized sepsis trials showed mortality benefit with early goal-directed, therapy.

New SSC 2008 guidelines and pocket card 

The increasing incidence of severe sepsis, septic shock, and mortality inspired ACEP to join with 10 other international societies in a Surviving Sepsis Campaign in 2005. The goal was to decrease the mortality from sepsis by 25% percent in five years. In this section, please see the 2008 guidelines, free access to the pocket card, the letter to ACEP membership regarding ACEPs participation in the SSC, and the editorial chronicling ACEPs involvement.

Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008; 36(1):296-327.

SSC 2008 guidelines pocket card  

ACEP’s commitment to quality of care for septic patients - Letter to ACEP membership regarding the Surviving Sepsis Campaign, March 2006

Annals editorial on ACEP involvement with SSC (Osborn TM, Nguyen HB, Rivers EP. Emergency medicine and the Surviving Sepsis Campaign: An international approach to managing severe sepsis and septic shock. Ann Emerg Med. 2005; 46(3):228-231.)

In 2007 an opinion was published in the New England Journal of Medicine regarding the genesis of the Surviving Sepsis Campaign and commitment to patient care. Please find below alternate views to balance the discussion. 

  1. Dellinger RP, Durbin CG. Separating practice guidelines from pharmaceutical marketing. Crit Care Med. 2007;35(12):2878-2880. 
  2. SCCM Pod-49 Responding to NEJM's Article on the SSC
    Mitchell Levy, MD, FCCM, discusses a perspectives article published in the October 19, 2006, issue of the New England Journal of Medicine, titled “Surviving Sepsis - Practice Guidelines, Marketing Campaigns, and Eli Lilly,” which criticizes the campaign and its major funding source, Eli Lilly. NEJM 2006; 355(16):1640-1642.
  3. Barie PS. An opinion too far – The campaign against the Surviving Sepsis Campaign . Surg Infect. 2006;7(6):485-488.

Putting together a sepsis program: Getting Started 

What to consider before starting a sepsis improvement program – understanding the process on how to improve

Get institutional buy in 

How to collect data and measure outcome 

Access SSC chart review database, and more at:
http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Tools/ 

Putting it all together – protocols, orders and flowsheets.

IHI Improvement stories – learn from those who have put programs together

Mitchell LevySepsis Education Section 

Interview with Mitchell M. Levy, MD, FCCM
Dr. Levy talks about the recent work in the area of sepsis, and for his thoughts on what he’d like to see the website accomplish.

Surviving Sepsis: Improving Mortality with New Therapies
Lecture, Scientific Assembly 2007
Faculty: Peter W. DeBlieux, MD, FACEP

Course Description: Sepsis remains the leading cause of death in critically ill patients in the US. Each year 750,000 people will develop sepsis and more than 210,000 of them will die. As increasing numbers of septic patients present to EDs, identifying those who will benefit from early implementation of selected therapies is important. The speaker will review sepsis pathophysiology and discuss the latest updates in sepsis and SIRS therapies.

Emergency Department Management of Septic Shock: Defining Care or Delaying Progress?Lecture, Scientific Assembly 2005
Faculty: Emmanuel Rivers, MD, MPH, David T. Huang, MD, MPH, H. Bryant Nguyen, MD, MS, and Tiffany M. Osborn, MD.

Surviving Sepsis SlidesLecture, Scientific Assembly 2005
Faculty: Tiffany M. Osborn, MD

Dr. Osborn has graciously granted her permission to others to use her PowerPoint slides to present information to others on the Surviving Sepsis Campaign.

Related Articles 

Key IHI sepsis literature 

The Importance/Burden of Sepsis to Emergency Medicine 

Early Resuscitation Clinical Effectiveness 

Early Resuscitation Cost-Effectiveness 

  • Huang DT, Clermont G, Dremsizov TT, et al. Implementation of early goal-directed therapy for severe sepsis and septic shock: A decision analysis. Crit Care Med. 2007; 35(9):2090-2100. http://www.ncbi.nlm.nih.gov/pubmed/17855823
  • Shorr AF, Micek ST, Jackson WL Jr, et al. Economic implications of an evidence-based sepsis protocol: can we improve outcomes and lower costs? Crit Care Med. 2007; 35(5):1257-1262. http://www.ncbi.nlm.nih.gov/pubmed/17414080

Barriers/Considerations for Implementation of Early Resuscitation Strategy 

Review Articles 

SSC Pod Casts 

SCCM Pod-77 CCM: Sepsis Bundles Associated With Decreased Mortality
H. Bryant Nguyen, MD, associate professor of emergency medicine at Loma Linda University in California, discusses an article published in the April 2007 edition of Critical Care Medicine, Implementation of a Bundle of Quality Indicators for the Early Management of Severe Sepsis and Septic Shock is Associated with Decreased Mortality. (Crit Care Med. 2007;35(4):1105).

Congress Special: Epinephrine Versus Norepinephrine for Septic Shock
Djillali Annane, MD, discusses a study on epinephrine versus norepinephrine for septic shock he presented during the 36th Critical Care Congress.

Responding to NEJM’s Article on the Surviving Sepsis Campaign
Mitchell Levy, MD, FCCM, discusses a perspectives article published in the October 19, 2006, issue of the New England Journal of Medicine, titled "Surviving Sepsis—Practice Guidelines, Marketing Campaigns, and Eli Lilly," which criticizes the campaign and its major funding source, Eli Lilly. N Engl J Med. 2006;355(16):1640-1642.

Revising the Surviving Sepsis Guidelines
Phillip Dellinger, MD, FCCM, professor of medicine at Robert Wood Johnson Medical School and director of the critical care section at Cooper University Hospital, and Roman Jaeschke, MD, a clinical professor at McMaster University discuss an article published in the August issue of Critical Connections. The article, "Revising the Surviving Sepsis Guidelines: A Closer Look," details the guideline revision process. Crit Conn. 2006;5(4):20.

Implementing the Surviving Sepsis Campaign
Michael Gropper, MD, PhD, is director of critical care medicine for the University of California San Francisco Medical Center and professor of medicine and anesthesiology at the medical school. He is one of the many healthcare professionals who have found success in implementing the Surviving Sepsis Campaign guidelines and discusses the strategies for implementation as well as the challenges his institution faced.

Early Indicators of Sepsis Survival
Mitchell Levy, MD, FCCM, and Jean-Louis Vincent, MD, PhD, FCCM, discuss their article in the October 2006 issue of Critical Care Medicine. The article, "Early Changes in Organ Function Predict Eventual Survival in Severe Sepsis," can help clinicians identify variables associated with good outcomes in sepsis. The authors explain that if patients with sepsis are not getting better at the end of 24 hours, they may be getting worse. Crit Care Med. 2005;33(10):2194-2201.

PCCM: The 1st International Sepsis Forum on Sepsis in Infants and Children with Dr. Adrienne Randolph
Adrienne Randolph, MD, MSc, served as guest editor for the May 2005 supplement of Pediatric Critical Care Medicine. Dr. Randolph shares her thoughts on the importance of the 1st International Sepsis Forum on Sepsis in Infants and Children and the Pediatric Acute Lung Injury and Sepsis Investigator’s (PALISI) Network. She also highlights the most important aspects from the supplement, which she played such an instrumental role in producing. Ped Crit Care Med. 2005;6(3) (Suppl S1-S2)

 

Etomidate and septic shock – out of step or perfect rhythm?

Walls RM, Osborn TM. Special report: Should Etomidate be used as an induction agent for patients with sepsis?J Watch Emerg Med. February 1, 2008.

Related Links 

Selected Journal Watch articles: 

Intensive Insulin Therapy, Pentastarch Resuscitation Linked to Adverse Events in Septic Shock

Adjunctive Therapy in Septic Shock and Severe Sepsis:

Intensive Insulin Therapy for Patients with Severe Sepsis? Not So Fast:

Managing Sepsis – Early Goal-Directed Therapy Saves Lives, Again

Early Goal-Directed Therapy Can Save Lives (and Money)

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