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In this corner, the Surviving Sepsis Campaign (SSC), a Society of Critical Care Medicine and European Society of Intensive Care Medicine collaboration “committed to reducing mortality and morbidity from sepsis and septic shock worldwide.” See http://bit.ly/survive-sepsis.
And in this corner, thousands petitioning the 2018 Surviving Sepsis Campaign Bundle, asking SSC not be used for hospital-specific guidelines/protocols, government interventions, or mandated care. See http://bit.ly/SSC-petition.
I don’t need to tell you how big a deal sepsis is. It accounts for ~15% of in-hospital deaths (JAMA).
Supporters say, “The most important change is… the 3-hour and 6-hour bundles have been combined into a single “hour-1 bundle” with the explicit intention of beginning resuscitation and management immediately… [so] clinicians begin treatment immediately, especially in patients with hypotension, rather than waiting or extending resuscitation measures over a longer period.”
Dissenters say the guidelines are “arbitrary, dangerous… unsupported… and infantilize clinicians by prescribing a rigid set of bundles which mandate specific interventions within fixed time frames. Nonetheless, the guidelines have been adopted by the Centers for Medicare & Medicaid Services as a core measure (SEP-1). This pressures physicians to administer treatments despite their best medical judgment (e.g. fluid bolus for a patient with clinically obvious volume overload).”
I don’t know the right answer but think this is an important topic for your consideration.
If you are knowledgeable on the topic, please weigh in and educate us.
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Make it a great week.
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Having said this (and I am far, far, far from an expert here), I’m somewhat familiar with the notion of fluid overload. My medical device marketing client ImaCor has technology that helps clinicians avoid it.
In its simplest terms, if you give fluid to someone whose heart can’t use it, the extra fluid goes into the lungs which almost invariably leads to complications.
So to say in a blanket statement, “if sepsis, give fluid” sounds, to my under-educated ear, a bad idea.
Your link is 15-20 year old information and no longer a game-changer. What is needed is the ability to anticipate sepsis and intervene earlier to reduce that likelihood that full-blown sepsis ever develops. (1 of 2)
Marty: Perhaps, but I think it more a reflection of the limitation of guidelines. It takes years before proven interventions make it into the guidelines.
Guidelines are among the least valuable resources for making personalized healthcare decisions. They are usually developed through a majority vote of a committee, influence by very subjective criteria and plagued with delays.
Guidelines are also diagnosis-focused rather than patient-focused.
For example, do you give the same fluid treatment to a patient who is pulmonary edema as well as sepsis?
Personally, I consider the guideline process (as it is typically developed) as an obstacle to personalized healthcare.
But provider adherence was less in the early goal directed therapy group than in the standard care group.
It is unclear if the lack of mortality difference was 2/2 good recognition and response to sepsis, lack of effect of intervention, or other factors e.g. timing of prognosis assessment and withdrawal of care.
Clinicians continue to disagree on the relative utility of SIRS vs SOFA vs qSOFA
But it is unclear if the lack of mortality difference is due to good recognition and response to sepsis, lack of effect of the intervention, or its brief duration (i.e., 6 h of a multiday hospital stay).
They have yielded conflicting results. The first trial was a single center trial conducted at Detroit Receiving Hospital. http://bit.ly/Rivers-NEJM-GDT
First, the marked escalation in the reported incidence likely reflects better recognition and reporting, which is due in part to increase knowledge of providers about the need to recognize sepsis, as well as targetted reimbursement of sepsis by Medicare.
Ronda Cobb, BSME
I can’t imagine clinicians being forced to implement guidelines that are contraindicated for a specific patient. I also don’t believe that every physician is aware of best practices.Is there a middle ground here?
Rush E. Simonson
Lisa Ann Wade
Rodney Chin, PhD, BSC, MA
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