The critical care community has long been plagued by a series of antiquated, overbearing guidelines created by the Surviving Sepsis Campaign (SSC). The campaign was originally sponsored by Eli Lilly and Edwards Life Sciences, as a commercial marketing campaign. The backbone of the original guidelines was a single center trial by Rivers, which has failed to be replicated. Nonetheless, despite new evidence, the guidelines have been highly resistant to change, often causing them to lag several years behind modern sepsis care.
The Surviving Sepsis Campaign spawned the SEP-1 core measures for sepsis, an arcane set of goals which frequently pressures physicians to act against their best clinical judgement. To make matters even worse, the 2018 SSC update doubled down on prior measures by mandating that fluids and antibiotics be administered within sixty minutes of emergency department triage. Due to a subsequent backlash among the clinical community, this update was temporarily suspended, but then quietly reinstated. It has become increasingly clear that the Surviving Sepsis Campaign poses a threat to patient care, leading to a petition to retire the campaign that received over six thousand signatures.
It’s hard to remove something without a suitable replacement. One reason the Surviving Sepsis Campaign has continued to persist is that it was adopted by numerous societies, thereby discouraging the creation of alternative guidelines. Fortunately, the 2018 SSC update was so ridiculous that it stimulated the American College of Emergency Physicians (ACEP) to create a new policy on the management of sepsis. This policy was likely conceived in part to push back against the wholly unrealistic 1-hour timeframe proposed for initial sepsis management.
The ACEP consensus-based task force report was just published. Although spearheaded by ACEP, the report is also endorsed by the Society of Hospital Medicine (SHM) and the Society of Critical Care Medicine (SCCM):
The resulting task force report describes a modern, evidence-based, and sensible approach to sepsis. Comparison to the Surviving Sepsis Campaign shows how the ACEP recommendations are consistently superior (table below). The ACEP report corrects several longstanding myths perpetuated by the Surviving Sepsis Campaign guidelines (as previously discussed here).
The ACEP task force report represents a dramatic improvement over the Surviving Sepsis Campaign guideline. As such, ACEP guidance provides an excellent replacement for the antiquated and harmful Surviving Sepsis Campaign.
going further: the surviving sepsis saga
- Fresh ACEP task force report on sepsis.
- From the EMCrit crew –
- 8/2014 – The fallacy of time-to-intervention studies
- 6/2015 – We are complicit – A glimpse into the current state of Severe Sepsis/Septic Shock quality measures
- 1/2017 – Six myths promoted by the new Surviving Sepsis Campaign guidelines
- 3/2018 – Petition to retire the surviving sepsis campaign guidelines
- 2/2019 – The Surviving Sepsis campaign 1-hour bundle is… back?
- 10/2019 – The case of the Hurried Objective
- Additional discussion:
- Marik et al. Pro-Con debate: Should the Surviving sepsis campaign guidelines be retired? CHEST 2019; 155:12-20.
- Kalantari A and Rezaie SR. Challenging the one-hour sepsis bundle. Western Journal of Emergency Medicine.
- Spiegel R et al. The 2018 Surviving Sepsis Campaign's Treatment Bundle: When guidelines outpace the evidence supporting their use. Annals of Emergency Medicine, 2018.
- Anand Swaminathan (RebelEM Blog) – Are antibiotics for sepsis in one hour feasible in the ED?
- PulmCrit Hot Take: Steroid for severe pneumonia (CAPE COD trial) - March 21, 2023
- PulmCrit Blogitorial – SIESTA syndrome: Sedation Induced EEG Suppression with Transient Agitation - December 19, 2022
- PulmCrit Hot Take – Acetazolamide plus furosemide for decongestion of heart failure (ADVOR trial) - August 27, 2022
Wow. Thank you and AMEN AMEN. Is there such a position statement that exists for our colleagues in critical care? (read: ICU) As a nurse working in ED, ICU/COVID ICU and critical care transport, I function in a variety of environments. Frequently I utilize EBM to engage/spark critical thinking discussions- fondly referred to as “doctor fights”- in which we nurses are unwilling to administer the mandated sepsis drowning bolus (and other elements of said bundle at inordinate times) based on system launched parameters unquestioned by the hospitalist o’ the day. One pushback is “well that was in the ED, now… Read more »
ICU always can say “large volume crystalloid bolus not infused due to concerns for volume overload”. I often don’t give the 30cc/kg bolus because it’s ridiculous. I just have to document why or else the sepsis police come after me. You can still meet SEP-1 without drowning your patients as long as you document properly!!
yeah
that is unfortunately a false statement
My understanding is you get dinged even if you justify it, even if you say they’re floridly volume overloaded, etc. Is that not correct?
Yes. It’s correct. You may be fortunate enough to work at a hospital where the medical director is bright enough or principled enough to have your back even if it means the hospital gets dinged. But that sure as hell ain’t everywhere.
It’s great you work in an environment where that can be done. But that’s not everywhere. Ultimately, hospital payment is tied to compliance with these bundles. And it’s therefore inevitable that physician performance will be similarly measured. This is happening where I work in particular. I’ve been told several times, “you can just intubate” the patient if you push them into respiratory failure. As long as hospital performance, and therefore payment, is tied to this, and as long as residents are somehow being taught this is “evidence based”, then this will only get worse. I honestly cannot think of any… Read more »
right…because nothing bad happens after a patient gets intubated…
I really hope the SCC guidelines are history soon… I’m tired of seeing overloaded patients with hypoalbuminemia and saline-induced metabolic acidosis
Goodnight. Would it be possible to make the consensus available in full?
Physician
This is wonderful. The only thins is if you truly want to replace the surviving sepsis guidelines, there has to be something measured. Something that can be turned into a metric. That’s what the marketing people at Eli Lilly and Edwards realized when they created the bundles. CMS needs metrics to measure hospital performance and these bundles gave them something to use. If we want to retire surviving sepsis, and most like myself certainly do, somehow we need appropriate bundles of care that CMS can use as a measure of performance.
Sometimes I think CMS wants metrics hospitals can fail so they can deny full reimbursement, but you are right. They, and hospital executives, want numbers, expressed in percentages, that easily convey adherence to a standard
I thought they shouldve been tougher on not giving people the full bolus. They said it, but not forcefully, and didnt specifically mention the patient population of heart failure pts who shouldnt get more than a few hundred CC’s
After many years of practice seeing the little progress that we have achieved in sepsis / septic shock, I finally had to get off the horse and realize that in medicine 2 plus 2 may actually be 64, and that I first needed to understand that a biological system like the body is a .non-linear Non-Equilibrium Dissipative System. This system uses metabolism to maintain the biological system at a critical distance from equilibrium, .My point is that to begin to have a vague idea where I was standing when confronted with something so complex as sepsis or septic shock. I… Read more »