BUNDLES IN 2013: SURVIVING SEPSIS

CAMPAIGN

R. Phillip Dellinger MD, MSc, MCCM

Professor of Medicine
Cooper Medical School of Rowan University
Professor of Medicine
University Medicine and Dentistry of New Jersey
Director Critical Care Medicine
Cooper University Hospital
Camden NJ USA

Potential Conflicts of Interest

No potential financial conflict of interest as to any material
presented in this presentation
Leadership position in Surviving Sepsis Campaign

DEBATING (SEPSIS) GUIDELINES

Bundles in 2013: Surviving Sepsis - P. Dellinger

Surviving Sepsis Guidelines: where they went wrong - J.

Kahn
Surviving Sepsis Guidelines: what they got right - J-L.
Vincent
Doubts about Bundles - B. Kavanaugh

Phil and the Lions Den

Dellingers Last Stand

DEBATING (SEPSIS) GUIDELINES

Bundles in 2013: Surviving Sepsis - P. Dellinger

Surviving Sepsis Guidelines: where they went wrong - J.
Kahn
Surviving Sepsis Guidelines: what they got right - J-L.

Vincent
Doubts about Bundles - B. Kavanaugh

Surviving Sepsis Campaign: International guidelines for

management of severe sepsis and septic shock: 2012

R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig

Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung, Ivor S.
Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R.
Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus, Clifford S.
Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb,
Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis
Campaign Guidelines Committee including the Pediatric Subgroup.
Crit Care Med 2013; 41:580-637
Intensive Care Medicine 2013; 39: 165-228

Surviving Sepsis Campaign

Currently Funded with a Gordon and Betty
Moore Foundation Grant
(Intel family).

Current Surviving Sepsis Campaign Guideline Sponsors (2010/11

Update)

American Association of Critical-Care Nurses

American College of Chest Physicians
American College of Emergency Physicians
Australian and New Zealand Intensive Care
Society
Asia Pacific Association of Critical Care Medicine
American Thoracic Society
Brazilian Society of Critical Care(AIMB)
Canadian Critical Care Society
Chinese Society of Critical Care Medicine
Chinese Medical Society
Chinese Society of Critical Care Medicine
Emirates Intensive Care Society
European Respiratory Society
European Society of Clinical Microbiology and
Infectious Diseases
European Society of Intensive Care Medicine
European Society of Pediatric and Neonatal
Intensive Care

Infectious Diseases Society of America

Indian Society of Critical Care Medicine
International Pan Arab Critical Care Medicine Society
Japanese Association for Acute Medicine
Japanese Society of Intensive Care Medicine
Pediatric Acute Lung Injury and Sepsis Investigators
Society Academic Emergency Medicine
Society of Critical Care Medicine
Society of Hospital Medicine
Surgical Infection Society
World Federation of Critical Care Nurses
World Federation of Pediatric Intensive and Critical
Care Societies

World Federation of Societies of Intensive and Critical

Care Medicine
Participation and endorsement:
German Sepsis Society
Latin American Sepsis Institute

Guidelines Are Not Enough

Protocols
Performance Improvement Programs
Audit and Feedback

SSC Performance Improvement

Program
Partnership with Institute of Healthcare Improvement
(IHI)
Key elements of guidelines identified
Goals established based on those chosen
recommendations can be graded easily as yes or no for
achievement based on chart review

Sepsis Change Bundle(s)

2005 - 6 and 24 hours
2013 3 and 6 hours

Primary Advantage of Bundle Care

Structuring of care to promote consistency in

the management of clinical conditions
(standardization of care)

Critics of Bundled Care

Cookbook medicine

Supplanting clinical judgment

Complacency
Effect on medical education

Bundles should not negate deviations when

particular patient scenario warrants

Converting Goals to
Measurable Indicators

Bundled Care

Indicators of care retrievable from chart review

Early Screening and a Performance

Improvement Program (1C)

Surviving Sepsis Campaign 2013

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation
to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume resuscitation (septic
shock) or initial lactate 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated

Why measure lactate?

Diagnose severe sepsis with elevated lactate
as a diagnosis of tissue hypoperfusion
Trigger for quantitative resuscitation if lactate
is 4 mg/dL or more

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation
to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume resuscitation (septic
shock) or initial lactate 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated

Blood Cultures

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation
to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume resuscitation (septic
shock) or initial lactate 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated

Antibiotic Therapy
We recommend that intravenous antibiotic
therapy be started as early as possible and
within the first hour of recognition of septic
shock (1B) and severe sepsis without septic
shock (1C).
Remark: Judged to be best practice but not standard of care

Antibiotic Therapy
Cover broad initially
Reassess antibiotic regimen daily for deescalation

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation
to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume resuscitation (septic
shock) or initial lactate 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated

Fluid therapy
Initial fluid challenge in sepsis-induced tissue
hypoperfusion (hypotension or elevated lactate)
with suspicion of hypovolemia to be a minimum
of 30ml/kg of crystalloids(a portion of this may
be
albumin
equivalent).
More
rapid
administration and greater amounts of fluid,
may be needed in some patients ( 1B)

Surviving Sepsis Campaign 2013

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation
to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume resuscitation (septic
shock) or initial lactate 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated

Resuscitation of Sepsis Induced Tissue

Hypoperfusion
Recommend MAP 65 mm Hg
Grade 1C

Surviving Sepsis Campaign 2013

Potential Conflicts of Interest

No potential financial conflict of interest as to any material
presented in this presentation
Leadership position in Surviving Sepsis Campaign

Sepsis Induced Tissue Hypoperfusion

Requirement for vasopressors after

fluid challenge
Lactate 4 mg/dL

Protocolized Quantitative Resuscitation

Protocolized
Care

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation
to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume resuscitation (septic
shock) or initial lactate 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated

Why Measure CVP and ScvO2?

Can be accomplished within the critical first 6 hours
Are these variables perfect?
No
Trials ongoing that seek better quantitative resuscitation
targets
Attempts at pushing newer technologies to the critical first 6
hours

Are these variables useful for decision making?

Yes, when integrated into total clinical picture

Also may choose to use:

Systolic pressure variation (if mechanically ventilated)
Inferior vena cava ultrasound (if technology and expertise
available)
Echocardiography(if technology and expertise available)
Stroke volume and stroke volume variation (if technology
and expertise available)

SURVIVING SEPSIS CAMPAIGN BUNDLES

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation
to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume resuscitation (septic
shock) or initial lactate 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated*

Hospital Mortality and Length of Stay

Jones, A. E. et al. JAMA 2010;303:739-746.

Am J Respir Crit Care Med. 2010 Sep 15;182(6):752-61.

In Summary, ICU Bundles:

Are not perfect

Are still evolving and always will be
Attempt to provide the best quality for the
typical patient in the ICU with the matched
disorder
Will never replace clinical decision-making
Allow audit, feedback, and behavior change
Offer education and team-building capability

www.survivingsepsis.org

Thank You