Evidence-Based Guidelines Issued to Detect and Treat Sepsis

June 12, 2007 — A review in the June issue of the Southern Medicine Journal provides evidence-based guidelines to help detect and treat sepsis. These treatment guidelines are endorsed by 11 professional societies representing multispecialty groups.
"If you could reduce the mortality rate by one quarter in a patient population afflicted with a condition with mortality rates of 30 to 50%, and which affects 750,000 people annually in the US, would you?" write Douglas Schlichting, RN, MS, MPA, and Jill Shwed McCollam, PharmD, BS, BCPS, from Eli Lilly and Co in Indianapolis, Indiana. "The condition is severe sepsis. Evidence-based guidelines and tools are available now that can help you achieve reductions in mortality and reduce length of stay."
The authors performed a literature review concerning the epidemiology and pathophysiology of severe sepsis, including alterations in inflammation, coagulation, and impaired fibrinolysis occurring during the course.
Severe sepsis is common, with about 750,000 cases each year in the United States. Although the mortality rate for severe sepsis is 30% to 50%, this climbs to 80% to 90% for septic shock with multiple organ dysfunction.
In terms of the pathophysiology of severe sepsis, a cascade of inflammation and activation of the coagulation system associated with impaired fibrinolysis causes changes in microvascular circulation associated with organ dysfunction, severe sepsis, multiple organ dysfunction syndrome, and death.
The Institute for Healthcare Improvement (IHI) has highlighted sepsis as an area of focus and has identified several deficiencies that may cause suboptimal care of patients with severe sepsis.
These deficiencies include inconsistency in the early diagnosis of severe sepsis and septic shock, frequent inadequate volume resuscitation without defined endpoints, late or inadequate use of antibiotics, frequent failure to support the cardiac output when depressed, frequent failure to control hyperglycemia adequately, frequent failure to use low tidal volumes and pressures in acute lung injury, and frequent failure to treat adrenal inadequacy in refractory shock.
To address these deficiencies, the Surviving Sepsis Campaign and IHI have revised and added to the Surviving Sepsis Guidelines and created 2 sepsis treatment bundles (resuscitation and management) to guide therapy for patients with severe sepsis.
"Implicit in the use of the bundles is the need to adopt all the elements contained in the bundle," the authors write. "One cannot choose to apply only selected items from the bundle and expect to achieve comparable benefit. The IHI sepsis website also provides tools to screen patients for severe sepsis, as well as to measure success with adherence to implementing the bundles (http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/)."
The sepsis resuscitation bundle, which should be accomplished as soon as possible and scored during the first 6 hours, includes the following:
Measure serum lactate level.
Obtain blood cultures before antibiotic administration.
From the time of presentation, administer broad-spectrum antibiotics within 3 hours for emergency department admissions and within 1 hour for non–emergency department intensive care unit (ICU) admissions.
In the event of hypotension and/or lactate level greater than 4 mmol/L (36 mg/dL), deliver an initial minimum dose of 20 mL/kg of crystalloid (or colloid equivalent); use vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure of 65 mm Hg or greater.
In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate level greater than 4 mmol/L (36 mg/dL), achieve central venous pressure of 8 mm Hg or greater and achieve central venous oxygen saturation of 70% or greater or a mixed venous oxygen saturation of 65% or greater.
"Timely recognition and diagnosis of severe sepsis is the first step," the authors write. "Applying the evidence-based guidelines created under the auspices of the Surviving Sepsis Campaign is the second step. Following up by measuring adherence to the guidelines is equally important to successfully implement change."
The sepsis management bundle, which should be accomplished as soon as possible and scored during the first 24 hours, includes the following:
Low-dose steroids should be administered for septic shock, following a standardized ICU protocol.
Activated drotrecogin alfa should be administered following a standardized ICU protocol.
Glucose control should maintain glucose level at or above the lower limit of normal, but less than 150 mg/dL (8.3 mmol/L).
For mechanically ventilated patients, inspiratory plateau pressures should be maintained at less than 30 cm H2O.
"Tools are available for use today that will guide the clinician in providing comprehensive and evidence-based care to the patient suffering from severe sepsis," the authors conclude. "Hopefully, once the patient is identified, multidisciplinary teams will rapidly and appropriately apply a series of evidence-based interventions. If the interventions are applied in a systematic fashion and adherence to standardized guidelines is followed and measured, then we will know if the Surviving Sepsis Campaign's goal of a 25% reduction in mortality from sepsis by the year 2009 had been obtained."
The authors are employees of Eli Lilly and Co, the maker of drotrecogin alfa (activated).
South Med J. 2007;100:594-600.