Sepsis mortality must be reduced

Sepsis is widely acknowledged by intensive care professionals to be one of the most challenging conditions to manage, yet it is the leading cause of death in the non-coronary ICU and estimated to kill 1,400 people worldwide, every day. Symptoms can vary widely and are often similar to those associated with many other conditions. Unfortunately, this has meant that late diagnosis is a common occurrence and, as a consequence, approximately 10% of sepsis patients do not receive prompt, appropriate antibiotic therapy, which could significantly improve their chances of survival. Early intervention is critical as once a patient reaches the stage of severe sepsis the mortality rate can be 30% to 50%, or 50% to 60% for septic shock. Furthermore, mortality associated with sepsis is increasing – mainly due to the growing use of invasive procedures and increasing numbers of elderly and high-risk individuals, such as cancer and HIV patients. In a bid to reduce unacceptably high mortality rates, the Surviving Sepsis Campaign (SSC) was developed by the European Society of Critical Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine, with the aim of improving diagnosis and treatment of sepsis. Sepsis guidelines were developed and a target established of achieving a 25% reduction in mortality over five years, by 2009. The results are now due to be published. However, in the interim period, Mitchell Levy, who headed the third phase of the campaign, commented that although achieving compliance has proven to be a challenge and there has been some academic debate over the bundles of care, the initiative has saved lives.1 Key to the campaign has been the implementation of the sepsis resuscitation bundle, which outlines evidence-based goals that must be completed within six hours for patients with severe sepsis, septic shock and/or lactate >4 mmol/L (36 mg/dL). The protocol includes the following bundle elements:

Sepsis resuscitation bundle
 • Bundle Element 1: Measure serum lactate.• Bundle Element 2: Obtain blood cultures prior to antibiotic administration. • Bundle Element 3: Administer broadspectrum antibiotic within three hours of ED admission and within one hour of non-ED admission. • Bundle Element 4: In the event of hypotension and/or serum lactate >4 mmol/L: i) Deliver an initial minimum of 20 mL/kg of crystalloid or an equivalent. ii) Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) >65 mm Hg. • Bundle Element 5: In the event of persistent hyptension despite fluid resuscitation (septic shock) and/or lactate >4 mmol/L: i) Achieve a central venous pressure (CVP) of ³8 mm Hg. ii) Achieve a central venous oxygen saturation (ScvO2) ³70% or mixed venous oxygen saturation (SvO2) ³65%.

Sepsis management bundle
The management bundle may be completed within 24 hours of presentation for patients with severe sepsis or septic shock and comprises the following protocols: • Administer low-dose steroids for septic shock in accordance with a standardised ICU policy. If not administered, document why the patient did not qualify for low-dose steroids based on the standardised protocol. • Administer drotrecogin alfa (activated) in accordance with a standardised ICU policy. If not administered, document why the patient did not qualify for drotrecogin alfa (activated). • Maintain glucose control ³70, but <150 mg/dl. • Maintain a median inspiratory plateau pressure (IPP) <30 cm H2O for mechanically ventilated patients. (A copy of the full protocol can be obtained at: www.survivingsepsis.org).