The Surviving Sepsis Campaign: A Critical Analysis

7/30/2019 The Surviving Sepsis Campaign: A Critical Analysis

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The Surviving Sepsis Campaign

A Critical Analysis

Andrew A. Quartin, M.D., M.P.H.

Professor of Clinical Medicine

Division of Pulmonary and Critical Care

University of Miami Miller School of Medicine

Miami, Florida


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First released in 2004, updated in 2008

2nd revision published in February 2013

Simultaneous release in Critical Care Medicine and Intensive Care

Medicine

68 experts, 58 pages, 88 recommendations


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Surviving Sepsis CampaignImproving Survival

0.00

0.05

0.10

0.15

0.20

0.25

0.30

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

SepsisMor

talityRate


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Surviving Sepsis CampaignOops Wrong Time Period!

0.00

0.05

0.10

0.15

0.20

0.25

0.30

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992

SepsisMor

talityRate

Martin, NEJM 2003


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Surviving Sepsis CampaignStart With Appropriate Skepticism

When you see this . . .

Mortali ty by quarter at 165 sitesafter implementing SSC protocols

Levy, Crit Care Med 2010


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Surviving Sepsis CampaignStart With Appropriate Skepticism

Martin, NEJM 20

When you see this . . . Remember this . . .



Trends in sepsis mortality in theU.S. over 20 years before SSC


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Surviving Sepsis CampaignApplying a Little Skepticism



Only the most enthusiastic si teswould have 7-8 quarters of data


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Surviving Sepsis Campaign (2004)Strength of Recommendations

Grade A Supported by at least 2 large randomized tr ials with clearcut results

Grade B Supported by 1 large randomized tr ial with clearcut results

Grade C Supported by small randomized trials with uncertain results

Grade D Supported by at least one non-randomized study using

contemporaneous controls

Grade E Even less case series, use of historical controls, expert opinion


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Surviving Sepsis Campaign (2004)

Recommendations and Evidence Grades

No High DoseSteroids

DVTDrug Prophylaxis

Vent WeaningSBT Protocol

Grade A

Ant ithrombinNot Recommended

EPONot Recommended

Transfuse at Hgb 7 g/dLIf Not Hypoperfusing

rhAPC for Patients At High Risk of Death

Do Not Use Renal Dose Dopamine

EGDT SCVO270% Goal

(Hct to 30%, dobutamine)

EGDT Basic GoalsMAP65, CVP 8-12

Grade B

SemirecumbentBody Position

Low-Dose SteroidIf On Pressors

Grade C

Cultures Before

Grade D

26 Really Weakly

Supported

Recommendations

Grade E

No SupranormalO2 Delivery Goal

PUD ProphylaxisFor All Patients

ALI Venti lat ionLow Vt/Pplat Strategy

SedationProtocol With Goal

SedationIntermittent or Daily Wake

Renal ReplacmentIHD or CRRT Okay

Crystalloids orColloids Okay

High PCO2 Okay ifNeeded for Low Vt

No BicarbonateFor pH>7.15

Ant ib io tics to Cover

Norepi or Dopamine

Glucose


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Grade A

EGDT SCVO270% Goal


Grade B Grade C Grade D Grade E



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Grade A

EGDT SCVO270% Goal




How does one achieve

Supranormal O2 Delivery?

Transfuse PRBCs

Dobutamine


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Grade A

EGDT SCVO270% Goal




How does one achieve

Supranormal O2 Delivery?

Transfuse PRBCs

Dobutamine

Conflict!


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DVTDrug Prophylaxis


Grade A

Ant ithrombinNot Recommended

EPONot Recommended

Transfuse at Hgb 7 g/dLIf Not Hypoperfusing


Do Not Use Renal Dose Dopamine

EGDT SCVO270% Goal



Grade B



Grade C

Cultures Before

Grade D

26 Really Weakly

Supported

Recommendations

Grade E






Renal ReplacmentIHD or CRRT Okay

Crystalloids orColloids Okay

High PCO2 Okay ifNeeded for Low Vt

No BicarbonateFor pH>7.15


Norepi or Dopamine

Glucose


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Surviving Sepsis Campaign (2004)Positive Recommendations To Do Something


DVTDrug Prophylaxis


Grade A


EGDT SCVO270% Goal



Grade B



Grade C

Cultures Before

Grade D

20 Really Weakly

Supported

Recommendations

Grade E






Norepi or Dopamine

Glucose


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Surviving Sepsis Campaign (2004)Sepsis Specific Positive Recommendations


Grade A


EGDT SCVO270% Goal



Grade B


Grade C

Cultures Before

Grade D

11 Really Weakly

Supported

Recommendations

Grade E


Norepi or Dopamine

Ant ib io tics

Suspect Bugs

As 1st Line Pressor


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Surviving Sepsis CampaignRevised Grading for 2008 and 2012

A numeric score for strength of recommendation 1: Strongly recommended, thought very likely to improve outcome

We recommend . . .

2: Weakly recommended, less confident that benefits exceed risks

We suggest . . .

A letter score for quality of evidence A: High B: Moderate C: Low D: Very Low

Some play in this

Randomized trials usually graded A, but may be downgraded for

concerns over reporting bias, limitations in implementation, etc.

Observational studies are usually graded C, but may be

upgraded if the magnitude of effect is particularly large

A score of UG (ungraded) added for 2012

S i i S i C i E l ti


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Surviving Sepsis Campaign EvolutionEGDT and Resuscitation

2004 2008 2012

A B C D E

SCVO270% Goal(Hct to 30%, dobutamine)

Basic GoalsMAP65, CVP 8-12 1C

Start resusci tation before

ICU if BP low or lactate high

1C

Goals: MAP65, CVP 8-10*,

and UO0.5 mL/kg/hr

*12-15 recommended on vent

2C

If SCVO2


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Surviving Sepsis Campaign EvolutionEGDT and Resuscitation

2004 2008 2012

A B C D E

SCVO270% Goal(Hct to 30%, dobutamine)

Basic GoalsMAP65, CVP 8-12 1C

Start resusci tation before

ICU if BP low or lactate high

1C

Goals: MAP65, CVP 8-10*,

and UO0.5 mL/kg/hr

*12-15 recommended on vent

2C

If SCVO2


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Surviving Sepsis Campaign EvolutionActivated Protein C (Xigris)

2004 2008 2012

A B C D E

2B

rhAPC for Patients

At High Risk of Death

APACHE 25

Or

Multiple Organ Failures

rhAPC for Patients


1A

Do Not Use rhAPC for

Patients

At Low Risk of Death

APACHE < 20

And

0-1 Organ Failures

Drug Off Market

S i i S i C i E l ti


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Surviving Sepsis Campaign EvolutionActivated Protein C (Xigris)

2004 2008 2012

A B C D E

2B

rhAPC for Patients


APACHE 25

Or

Multiple Organ Failures

rhAPC for Patients


1A

rhAPC NOT for Patients

At Low Risk of Death

APACHE < 20

And

0-1 Organ Failures

Drug Off Market

What evidence came out between the 2004 and 2008 guidelines to downgrade

the quality of the orig inal PROWESS trial of rhAPC?

Surviving Sepsis Campaign Evolution


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Surviving Sepsis Campaign EvolutionCorticosteroids

2004 2008 2012

A B C D E

1A No High Dose Steroids

Low-Dose SteroidIf Pressor Dependent


Do Not Treat Sepsis With

Steroids if Not Shock

Stop Steroid i f ACTH

Response Intact

Wean Steroid Dose as

Pressor Dose Declines

Add Fludrocorti sone

To Hydrocort isone

2CConsider Low-Dose Steroid If

Vasopressor Dependent

2B

If Steroid Used,

Hydrocortisone Preferred

1DDo Not Treat Sepsis With


2B Do Not Use ACTH Response

2D

Wean Steroids Only When

Off Pressors

2CAdd Fludrocortisone to

Hydrocortisone

2COnly Use Steroid If Fluid

and Pressors Ineffectiv

2D

Use Continuous Infusio

Hydrocortisone (200 mg/d

1DDo Not Treat Sepsis Wi


2B Do Not Use ACTH Respo

2D

Wean Steroids Only Wh

Off Pressors

Surviving Sepsis Campaign Evolution


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Surviving Sepsis Campaign EvolutionCorticosteroids

2004 2008 2012

A B C D E

1A No High Dose Steroids

Low-Dose SteroidIf Pressor Dependent


Do Not Treat Sepsis With


Stop Steroid i f ACTH

Response Intact

Wean Steroid Dose as

Pressor Dose Declines

Add Fludrocorti sone

To Hydrocort isone

2CConsider Low-Dose Steroid If

Vasopressor Dependent

2B

If Steroid Used,

Hydrocortisone Preferred

1DDo Not Treat Sepsis With


2B Do Not Use ACTH Response

2D

Wean Steroids Only When

Off Pressors

2CAdd Fludrocortisone to

Hydrocortisone

2COnly Use Steroid If Fluid

and Pressors Ineffectiv

2D

Use Continuous Infusio

Hydrocortisone (200 mg/d

1DDo Not Treat Sepsis Wi


2B Do Not Use ACTH Respo

2D

Wean Steroids Only Wh

Off Pressors

Corticosteroids Reduced to Salvage Therapy

The Surviving Sepsis Campaign: A Critical Analysis

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