Advanced Practice - New Sepsis Guidelines Ignite Controversy!
The major changes to the sepsis bundle:
- Initiation of bundle should be within one hour of patient arrival to the ED, including:
- Initiation of broad spectrum antibiotics
- 30 ml/kg of crystalloid fluid, with vasopresor initiation if MAP fails to reach 65 mm Hg
- blood culture draw and lactate measurement
The controversy is in the requirement that these tasks be accomplished within one hour of ED arrival, not based on any evidence that this improves outcomes but rather because, as the authors state, "We believe this reflects the clinical reality at the bedside of these seriously ill patients with sepsis and septic shock—that clinicians begin treatment immediately, especially in patients with hypotension, rather than waiting or extending resuscitation measures over a longer period."
The potential pitfalls include:
- Lack of specificity in selecting patients for the bundle, reflecting the challenges in identifying subtle cases of sepsis as well other pathologies which trigger sepsis alert pathways, resulting in many patients being exposed to large volume fluid resuscitation and broad spectrum antibiotics unnecessarily
- Inappropriate usage of broad spectrum antibiotics will result in the rise of resistant organisms as well as the attendant risks of exposing patients to unnecessary antibiotics
- Inappropriate large volume resuscitation in patients without sepsis, especially in the obese patients with CHF or renal failure, may result in harm from volume overload, possibly resulting in unnecessary intubation and mechanical ventilation
- Lack of any physician judgement incorporated into the bundle, which force ED physicians to implement sepsis pathways by mandated protocols even when deemed clinically inappropriate, essentially replacing the doctor at the bedside with a computer algorithm that makes patient care decisions for us
You can read the full summary of the updates here.
The Infectious Disease Society of America declined to endorse the Surviving Sepsis Campaign Guidelines partially due to concerns of indiscriminate and unnecessary exposure of patients to broad spectrum antibiotics, you can read their statement here.
Motivated individuals can sign a petition calling for retraction of the 2018 guideline here.