BUNDLES IN 2013: SURVIVING SEPSIS

CAMPAIGN

R. Phillip Dellinger MD, MSc, MCCM

Professor of Medicine

Cooper Medical School of Rowan University

Professor of Medicine

University Medicine and Dentistry of New Jersey

Director Critical Care Medicine

Cooper University Hospital

Camden NJ USA

Potential Conflicts of Interest

• No potential financial conflict of interest as to any material

presented in this presentation

• Leadership position in Surviving Sepsis Campaign

DEBATING (SEPSIS) GUIDELINES

• Bundles in 2013: Surviving Sepsis - P. Dellinger

• Surviving Sepsis Guidelines: where they went wrong - J.

Kahn

• Surviving Sepsis Guidelines: what they got right - J-L.

Vincent

• Doubts about Bundles - B. Kavanaugh

Phil and the Lion’s Den

Dellinger’s Last Stand

DEBATING (SEPSIS) GUIDELINES

• Bundles in 2013: Surviving Sepsis - P. Dellinger

• Surviving Sepsis Guidelines: where they went wrong - J.

Kahn

• Surviving Sepsis Guidelines: what they got right - J-L.

Vincent

• Doubts about Bundles - B. Kavanaugh

R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig

Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung, Ivor S.

Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R.

Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus, Clifford S.

Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb,

Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis

Campaign Guidelines Committee including the Pediatric Subgroup.

Crit Care Med 2013; 41:580-637

Intensive Care Medicine 2013; 39: 165-228

Surviving Sepsis Campaign: International guidelines for

management of severe sepsis and septic shock: 2012

Currently Funded with a Gordon and Betty

Moore Foundation Grant

(Intel family).

Surviving Sepsis Campaign

Current Surviving Sepsis Campaign Guideline Sponsors (2010/11

Update)

• American Association of Critical-Care Nurses

• American College of Chest Physicians

• American College of Emergency Physicians

• Australian and New Zealand Intensive Care

Society

• Asia Pacific Association of Critical Care Medicine

• American Thoracic Society

• Brazilian Society of Critical Care(AIMB)

• Canadian Critical Care Society

• Chinese Society of Critical Care Medicine –

Chinese Medical Society

• Chinese Society of Critical Care Medicine

• Emirates Intensive Care Society

• European Respiratory Society

• European Society of Clinical Microbiology and

Infectious Diseases

• European Society of Intensive Care Medicine

• European Society of Pediatric and Neonatal

Intensive Care

• Infectious Diseases Society of America

• Indian Society of Critical Care Medicine

• International Pan Arab Critical Care Medicine Society

• Japanese Association for Acute Medicine

• Japanese Society of Intensive Care Medicine

• Pediatric Acute Lung Injury and Sepsis Investigators

• Society Academic Emergency Medicine

• Society of Critical Care Medicine

• Society of Hospital Medicine

• Surgical Infection Society

• World Federation of Critical Care Nurses

• World Federation of Pediatric Intensive and Critical

Care Societies

• World Federation of Societies of Intensive and Critical

Care Medicine

Participation and endorsement:

German Sepsis Society

Latin American Sepsis Institute

Guidelines Are Not Enough

• Protocols

• Performance Improvement Programs

• Audit and Feedback

SSC Performance Improvement

Program

Partnership with Institute of Healthcare Improvement

(IHI)

• Key elements of guidelines identified

• Goals established based on those chosen

recommendations – can be graded easily as yes or no for

achievement based on chart review

• Sepsis Change Bundle(s)

• 2005 - 6 and 24 hours

• 2013 – 3 and 6 hours

Primary Advantage of Bundle Care

• Structuring of care to promote consistency in

the management of clinical conditions

(standardization of care)

Critics of Bundled Care

• Cookbook medicine

• Supplanting clinical judgment

• Complacency

• Effect on medical education

Bundles should not negate deviations when

particular patient scenario warrants

Converting Goals to

Measurable Indicators

Bundled Care

• Indicators of care retrievable from chart review

Early Screening and a Performance

Improvement Program (1C)

Surviving Sepsis Campaign 2013

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation

to maintain a mean arterial pressure [MAP] 65 mm Hg)

6) In the event of persistent arterial hypotension despite volume resuscitation (septic

shock) or initial lactate ≥4 mmol/L (36 mg/dL):

- Measure central venous pressure (CVP)

- Measure central venous oxygen saturation (ScvO2)

7) Remeasure lactate if initial lactate was elevated

Why measure lactate?

• Diagnose severe sepsis with elevated lactate

as a diagnosis of tissue hypoperfusion

• Trigger for quantitative resuscitation if lactate

is 4 mg/dL or more

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation

to maintain a mean arterial pressure [MAP] 65 mm Hg)

6) In the event of persistent arterial hypotension despite volume resuscitation (septic

shock) or initial lactate ≥4 mmol/L (36 mg/dL):

- Measure central venous pressure (CVP)

- Measure central venous oxygen saturation (ScvO2)

7) Remeasure lactate if initial lactate was elevated

Blood Cultures

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation

to maintain a mean arterial pressure [MAP] 65 mm Hg)

6) In the event of persistent arterial hypotension despite volume resuscitation (septic

shock) or initial lactate ≥4 mmol/L (36 mg/dL):

- Measure central venous pressure (CVP)

- Measure central venous oxygen saturation (ScvO2)

7) Remeasure lactate if initial lactate was elevated

Antibiotic Therapy

We recommend that intravenous antibiotic

therapy be started as early as possible and

within the first hour of recognition of septic

shock (1B) and severe sepsis without septic

shock (1C).Remark: Judged to be best practice but not standard of care

Antibiotic Therapy

Cover broad initially

Reassess antibiotic regimen daily for de-

escalation

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation

to maintain a mean arterial pressure [MAP] 65 mm Hg)

6) In the event of persistent arterial hypotension despite volume resuscitation (septic

shock) or initial lactate ≥4 mmol/L (36 mg/dL):

- Measure central venous pressure (CVP)

- Measure central venous oxygen saturation (ScvO2)

7) Remeasure lactate if initial lactate was elevated

Fluid therapy

Initial fluid challenge in sepsis-induced tissue

hypoperfusion (hypotension or elevated lactate)

with suspicion of hypovolemia to be a minimum

of 30ml/kg of crystalloids(a portion of this may

be albumin equivalent). More rapid

administration and greater amounts of fluid,

may be needed in some patients ( 1B)

Surviving Sepsis Campaign 2013

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation

to maintain a mean arterial pressure [MAP] 65 mm Hg)

6) In the event of persistent arterial hypotension despite volume resuscitation (septic

shock) or initial lactate ≥4 mmol/L (36 mg/dL):

- Measure central venous pressure (CVP)

- Measure central venous oxygen saturation (ScvO2)

7) Remeasure lactate if initial lactate was elevated

Resuscitation of Sepsis Induced Tissue

Hypoperfusion

• Recommend MAP 65 mm HgGrade 1C

Surviving Sepsis Campaign 2013

Potential Conflicts of Interest

• No potential financial conflict of interest as to any material

presented in this presentation

• Leadership position in Surviving Sepsis Campaign

Sepsis Induced Tissue Hypoperfusion

Requirement for vasopressors after

fluid challenge

Lactate ≥ 4 mg/dL

Protocolized

Care

Protocolized Quantitative Resuscitation

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation

to maintain a mean arterial pressure [MAP] 65 mm Hg)

6) In the event of persistent arterial hypotension despite volume resuscitation (septic

shock) or initial lactate ≥ 4 mmol/L (36 mg/dL):

- Measure central venous pressure (CVP)

- Measure central venous oxygen saturation (ScvO2)

7) Remeasure lactate if initial lactate was elevated

Why Measure CVP and ScvO2?

• Can be accomplished within the critical first 6 hours

• Are these variables perfect?

• No

• Trials ongoing that seek better quantitative resuscitation

targets

• Attempts at pushing newer technologies to the critical first 6

hours

• Are these variables useful for decision making?

• Yes, when integrated into total clinical picture

Also may choose to use:

• Systolic pressure variation (if mechanically ventilated)

• Inferior vena cava ultrasound (if technology and expertise

available)

• Echocardiography(if technology and expertise available)

• Stroke volume and stroke volume variation (if technology

and expertise available)

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation

to maintain a mean arterial pressure [MAP] 65 mm Hg)

6) In the event of persistent arterial hypotension despite volume resuscitation (septic

shock) or initial lactate ≥4 mmol/L (36 mg/dL):

- Measure central venous pressure (CVP)

- Measure central venous oxygen saturation (ScvO2)

7) Remeasure lactate if initial lactate was elevated*

Jones, A. E. et al. JAMA 2010;303:739-746.

Hospital Mortality and Length of Stay

Am J Respir Crit Care Med. 2010 Sep 15;182(6):752-61.

In Summary, ICU Bundles:

• Are not perfect

• Are still evolving and always will be

• Attempt to provide the best quality for the

“typical” patient in the ICU with the matched

disorder

• Will never replace clinical decision-making

• Allow audit, feedback, and behavior change

• Offer education and team-building capability

www.survivingsepsis.org

Thank You