The Pre-brief
Sepsis is a dysregulated inflammatory response to infection that can lead to severe consequences, such as organ dysfunction and death. It had a global incidence of 437 per 100,000 person-years between the years 1995 and 2015 and its rates have only increased, likely due to advancing age, immunosuppression, and multi-drug resistant infection. Fortunately for us, the Surviving Sepsis Campaign has put together a list of easy to follow guidelines and recommendations that help us treat our patients in an evidence-based method.
On the Mercy St. Vincent EM Residency Blog, I summarized the 2016 SSC Guidelines1 into a *relatively* short post. While some of these recommendations have lots of supporting data, many of them are still very contentious. The guidelines were meant to provide a general framework of treatment, and individualized care is crucial for optimal patient care.
2018 SSC Update
In 2018, the Surviving Sepsis Campaign released an update to the guidelines. The 3-hour and 6-hour bundles were combined into a single “Hour-1 Bundle” with the explicit intention of beginning resuscitation and management immediately.2 The concept of the “bundle” is extremely controversial, especially when the government mandates these as requirements; but that’s a topic for another day. For now, here are the updates from 2018:
- Measure lactate level. Remeasure if initial lactate is >2mmol/L (Weak recommendation, low quality of evidence)
- Obtain blood cultures prior to administration of antibiotics (Best practice statement)
- Administer broad-spectrum antibiotics (Strong recommendation, moderate quality of evidence)
- Begin rapid administration of 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L (Strong recommendation, low quality of evidence)
- Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥65mmHg (Strong recommendation, moderate quality of evidence)
The Debrief
The 2018 Surviving Sepsis Guidelines Update converts the 3- and 6-hour bundles into an “Hour-1 Bundle” for sepsis patients
References
- Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377. doi: 10.1007/s00134-017-4683-6. Epub 2017 Jan 18. PMID: 28101605.
Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med. 2018 Jun;44(6):925-928. doi: 10.1007/s00134-018-5085-0. Epub 2018 Apr 19. PMID: 29675566.
