Do the Surviving Sepsis Campaign Guidelines Work?

What Are Bundles?

The development and publication of guidelines seldom lead to changes in clinical behavior, and guidelines are rarely integrated into bedside practice in a timely fashion. Bundles are a group of evidence-based interventions that, when instituted together, may provide an impact greater than any single intervention alone. Ideally, a bundle provides a simple and uniform way to implement best practices.

Need for Bundles in Severe Sepsis and Septic Shock

Sepsis accounts for 20% of all admissions in noncardiac intensive care units (ICUs) and is the leading cause of death in such units. There are approximately 750,000 new sepsis cases in the United States every year, and the overall mortality rate remains close to 30%. It is the single most expensive condition treated in the United States, exceeding $20 billion annually. Mortality and health-care costs associated with sepsis can be reduced by the coordinated and timely application of a group of evidence-based interventions. Thus sepsis is a syndrome that is particularly amenable to bundle-based management.

Recognizing the global impact of sepsis and the growing evidence for interventions that would improve outcomes, the Surviving Sepsis Campaign (SSC) Guidelines were published initially in 2004, incorporating the best available evidence at that time. Beyond the guidelines, the SSC developed an international collaborative initiative to increase awareness of sepsis and to apply bundles as a means of translating the available evidence into improved patient outcomes on a global scale.

Over the last 10 years, the SSC has progressed in phases with multiple goals: building awareness, educating health-care professionals, and improving the management of sepsis. Thus the SSC structured itself into an international practice improvement project, with in-depth collection of performance data and a goal of reducing sepsis mortality by 25% within 5 years (2004-2009). During this time, the bundles themselves have been adapted in response to an evolving evidence base and data collected from the SSC itself ( Table 43-1 ).

Table 43-1

Surviving Sepsis Campaign Care Bundles

Original Bundle (2005)	Updated Bundle (2012)
Resuscitation bundle (to be completed within the first 6 hr) • Serum lactate measured • Blood cultures obtained before antibiotic administration • Broad spectrum antibiotics administered within 3 hr for ED admissions, 1 hr for non-ED admissions • If hypotensive or if lactate ≥ 4 mmol/L, initial bolus of 20 mL/kg crystalloid (or colloid equivalent) administered; if MAP still <65 mm Hg, vasopressors applied • If hypotension or hyperlactemia persists, CVP >8 mm Hg and S cv O ₂of >65% achieved (or MV o ₂>65%)	To be completed within 3 hr • Serum lactate measured • Blood cultures obtained before antibiotic administration • Broad-spectrum antibiotics administered • 30 mL/kg of crystalloids administered for hypotension or lactate ≥ 4 mmol/L
Management bundle (to be completed within the first 24 hr) • Low-dose steroids administered for septic shock • Drotrecogin alpha (activated) administered • Glucose control maintained between lower limit of normal and <150 mg/dL • Inspiratory plateau pressures maintained <30 cm water for patients who are mechanically ventilated	To be completed within 6 hr • Vasopressors applied for refractory hypotension to maintain MAP ≥ 65 • If initial lactate >4 mmol/L or if hypotension persists after volume resuscitation, measure CVP and S cv O ₂ • Remeasure lactate if initial lactate was elevated

Original Bundle (2005)

Updated Bundle (2012)

Resuscitation bundle (to be completed within the first 6 hr)

•

Serum lactate measured
•

Blood cultures obtained before antibiotic administration
•

Broad spectrum antibiotics administered within 3 hr for ED admissions, 1 hr for non-ED admissions
•

If hypotensive or if lactate ≥ 4 mmol/L, initial bolus of 20 mL/kg crystalloid (or colloid equivalent) administered; if MAP still <65 mm Hg, vasopressors applied
•

If hypotension or hyperlactemia persists, CVP >8 mm Hg and S cv O ₂of >65% achieved (or MV o ₂>65%)

To be completed within 3 hr

•

Serum lactate measured
•

Blood cultures obtained before antibiotic administration
•

Broad-spectrum antibiotics administered
•

30 mL/kg of crystalloids administered for hypotension or lactate ≥ 4 mmol/L

Management bundle (to be completed within the first 24 hr)

•

Low-dose steroids administered for septic shock
•

Drotrecogin alpha (activated) administered
•

Glucose control maintained between lower limit of normal and <150 mg/dL
•

Inspiratory plateau pressures maintained <30 cm water for patients who are mechanically ventilated

To be completed within 6 hr

•

Vasopressors applied for refractory hypotension to maintain MAP ≥ 65
•

If initial lactate >4 mmol/L or if hypotension persists after volume resuscitation, measure CVP and S cv O ₂
•

Remeasure lactate if initial lactate was elevated

CVP, central venous pressure; ED, emergency department; MAP, mean arterial pressure; MV o ₂, myocardial oxygen consumption; S cv O ₂, central venous oxygen saturation.

Adapted from Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med . 2013;41:580–637; and from Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med . 2010;38(2):368.

Is There Evidence That Application of the SSC Bundles Improves Outcomes?

Although the components of the bundles themselves have generated ample debate since their development, there is little doubt that the SSC bundles have been effective. Ferrer et al. published the results of a national, SSC-based educational effort in Spain. The effort, based on the SSC guidelines, resulted in a reduction of in-hospital and 28-day mortality from severe sepsis or septic shock by 11% and 14%, respectively ( Fig. 43-1 ). Improvement in outcomes was greatest in hospitals with the poorest initial performance. The key to improving outcomes, however, seemed to lie in persistent and penetrating education. The postin-tervention cohort still had a compliance rate of only 10% to 15%, and during long-term follow-up, compliance with the resuscitation bundle returned to baseline.