Didn’t we just learn the sepsis guidelines? It didn’t seem that long ago; however, the Society of Critical Care Medicine (SCCM) has been busy studying the evidence and ensuring that the best care possible can be delivered to those suspected of having sepsis. For many, reading through the 93 recommendations for 2021 can be cumbersome and confusing. How do they differ? Why are we changing them? Here are some of the highlights.
In terms of general recommendations, there are two updates. First, SCCM is recommending not only a performance improvement model, but also a standard operating system for the identification and treatment of sepsis. This may include identification tools, as well as standard order sets to facilitate implementation of the guidelines. The second may be surprising: SCCM no longer endorses the use of qSOFA as a single identification tool for those at risk for sepsis, in favor of multivariate instruments such as MEWS, SIRS, and NEWS. As a simple tool, qSOFA gained popularity, but there is strong evidence to support use of other tools that take other factors into consideration.
Now on to resuscitation. Fluid boluses of 30mL/kg within 3 hours are now suggested
, rather than recommended
. Why? Some patients, such as those with heart or renal failure, are not always the best candidates for these boluses. The language was adjusted to allow for clinical decisions based on individual patients. There is also a new suggestion to utilize capillary refill time to guide resuscitation, in addition to other assessments.
There have been some updates to how infection or suspected infection is to be treated. The new strategy seems to steer away from nonjudicious use of antibiotics, in favor of “time-limited” close monitoring for those with low risk of infection and deferring antibiotics in those patients. For those in septic shock or high suspicion of sepsis the recommendation remains antimicrobials be administered within one hour of identification, with a change in terminology from “sepsis without shock” to “high likelihood for sepsis.” For patients with a high risk of MRSA, antimicrobials with MRSA coverage are recommended over those without. For those patients with a low risk of MRSA, the suggestion is antimicrobials without MRSA coverage. In the same fashion, SCCM recommends those patients at high risk for fungal infection to be covered for same and suggests against antifungal coverage in those at low risk of fungal infection.
Moving on to hemodynamic management, SCCM has updated their position as a suggestion to use a balanced crystalloid approach, as opposed to normal saline; and suggests against using gelatin for resuscitation. For those with hypotension and cardiac dysfunction with persistent hypoperfusion despite euvolemia and adequate mean arterial pressures, SCCM is suggesting against the use of levosimendan due to low quality of evidence to support its use. When hypotension is present, SCCM suggests starting vasopressors peripherally rather than delay for central venous access. There has also been an about-face regarding hydrocortisone in those with adequate fluid volume and persistent hypotension despite vasopressors, now suggesting IV corticosteroids.
For those with sepsis-induced acute hypoxemic respiratory failure, high flow nasal oxygen is favored over conventional non-invasive positive pressure ventilation such as BiPAP. In those patients with sepsis-induced moderate to severe ARDS, Veno-Venous (VV) ECMO is recommended, provided the facility has the experience and resources to do so. This, of course, may not be available and transport may not be possible depending on the degree of hypoxemia.
Finally, there are two new recommendations regarding additional therapies that may be used in sepsis. PolymyxinB hemoperfusion and infusions of vitamin C in those with sepsis or septic shock originally had no recommendation. A low quality of evidence prompted SCCM to suggest against both practices.
The Society of Critical Care Medicine has continued to evaluate the evidence to improve the care of patients with suspected and confirmed sepsis. Although the changes may seem cumbersome, many involve a language change to better serve patients who may not always benefit from the full recommendation. In other cases, evidence supports a change in practice or advising against a practice. Another example of how evidence-based practice impacts our best patient care.
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 1–67. Advance online publication. https://doi.org/10.1007/s00134-021-06506-y