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The Surviving Sepsis Campaign
A Critical Analysis
Andrew A. Quartin, M.D., M.P.H.
Professor of Clinical Medicine
Division of Pulmonary and Critical Care
University of Miami Miller School of Medicine
Miami, Florida
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7/30/2019 The Surviving Sepsis Campaign: A Critical Analysis
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First released in 2004, updated in 2008
2nd revision published in February 2013
Simultaneous release in Critical Care Medicine and Intensive Care
Medicine
68 experts, 58 pages, 88 recommendations
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Surviving Sepsis CampaignImproving Survival
0.00
0.05
0.10
0.15
0.20
0.25
0.30
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
SepsisMor
talityRate
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Surviving Sepsis CampaignOops Wrong Time Period!
0.00
0.05
0.10
0.15
0.20
0.25
0.30
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992
SepsisMor
talityRate
Martin, NEJM 2003
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Surviving Sepsis CampaignStart With Appropriate Skepticism
When you see this . . .
Mortali ty by quarter at 165 sitesafter implementing SSC protocols
Levy, Crit Care Med 2010
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7/30/2019 The Surviving Sepsis Campaign: A Critical Analysis
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Surviving Sepsis CampaignStart With Appropriate Skepticism
Martin, NEJM 20
When you see this . . . Remember this . . .
Mortali ty by quarter at 165 sitesafter implementing SSC protocols
Levy, Crit Care Med 2010
Trends in sepsis mortality in theU.S. over 20 years before SSC
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Surviving Sepsis CampaignApplying a Little Skepticism
Mortali ty by quarter at 165 sitesafter implementing SSC protocols
Levy, Crit Care Med 201
Only the most enthusiastic si teswould have 7-8 quarters of data
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Surviving Sepsis Campaign (2004)Strength of Recommendations
Grade A Supported by at least 2 large randomized tr ials with clearcut results
Grade B Supported by 1 large randomized tr ial with clearcut results
Grade C Supported by small randomized trials with uncertain results
Grade D Supported by at least one non-randomized study using
contemporaneous controls
Grade E Even less case series, use of historical controls, expert opinion
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Surviving Sepsis Campaign (2004)
Recommendations and Evidence Grades
No High DoseSteroids
DVTDrug Prophylaxis
Vent WeaningSBT Protocol
Grade A
Ant ithrombinNot Recommended
EPONot Recommended
Transfuse at Hgb 7 g/dLIf Not Hypoperfusing
rhAPC for Patients At High Risk of Death
Do Not Use Renal Dose Dopamine
EGDT SCVO270% Goal
(Hct to 30%, dobutamine)
EGDT Basic GoalsMAP65, CVP 8-12
Grade B
SemirecumbentBody Position
Low-Dose SteroidIf On Pressors
Grade C
Cultures Before
Grade D
26 Really Weakly
Supported
Recommendations
Grade E
No SupranormalO2 Delivery Goal
PUD ProphylaxisFor All Patients
ALI Venti lat ionLow Vt/Pplat Strategy
SedationProtocol With Goal
SedationIntermittent or Daily Wake
Renal ReplacmentIHD or CRRT Okay
Crystalloids orColloids Okay
High PCO2 Okay ifNeeded for Low Vt
No BicarbonateFor pH>7.15
Ant ib io tics to Cover
Norepi or Dopamine
Glucose
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Surviving Sepsis Campaign (2004)
Recommendations and Evidence Grades
Grade A
EGDT SCVO270% Goal
(Hct to 30%, dobutamine)
Grade B Grade C Grade D Grade E
No SupranormalO2 Delivery Goal
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7/30/2019 The Surviving Sepsis Campaign: A Critical Analysis
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Surviving Sepsis Campaign (2004)
Recommendations and Evidence Grades
Grade A
EGDT SCVO270% Goal
(Hct to 30%, dobutamine)
Grade B Grade C Grade D Grade E
No SupranormalO2 Delivery Goal
How does one achieve
Supranormal O2 Delivery?
Transfuse PRBCs
Dobutamine
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Surviving Sepsis Campaign (2004)
Recommendations and Evidence Grades
Grade A
EGDT SCVO270% Goal
(Hct to 30%, dobutamine)
Grade B Grade C Grade D Grade E
No SupranormalO2 Delivery Goal
How does one achieve
Supranormal O2 Delivery?
Transfuse PRBCs
Dobutamine
Conflict!
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Surviving Sepsis Campaign (2004)
Recommendations and Evidence Grades
No High DoseSteroids
DVTDrug Prophylaxis
Vent WeaningSBT Protocol
Grade A
Ant ithrombinNot Recommended
EPONot Recommended
Transfuse at Hgb 7 g/dLIf Not Hypoperfusing
rhAPC for Patients At High Risk of Death
Do Not Use Renal Dose Dopamine
EGDT SCVO270% Goal
(Hct to 30%, dobutamine)
EGDT Basic GoalsMAP65, CVP 8-12
Grade B
SemirecumbentBody Position
Low-Dose SteroidIf On Pressors
Grade C
Cultures Before
Grade D
26 Really Weakly
Supported
Recommendations
Grade E
No SupranormalO2 Delivery Goal
PUD ProphylaxisFor All Patients
ALI Venti lat ionLow Vt/Pplat Strategy
SedationProtocol With Goal
SedationIntermittent or Daily Wake
Renal ReplacmentIHD or CRRT Okay
Crystalloids orColloids Okay
High PCO2 Okay ifNeeded for Low Vt
No BicarbonateFor pH>7.15
Ant ib io tics to Cover
Norepi or Dopamine
Glucose
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Surviving Sepsis Campaign (2004)Positive Recommendations To Do Something
Recommendations and Evidence Grades
DVTDrug Prophylaxis
Vent WeaningSBT Protocol
Grade A
rhAPC for Patients At High Risk of Death
EGDT SCVO270% Goal
(Hct to 30%, dobutamine)
EGDT Basic GoalsMAP65, CVP 8-12
Grade B
SemirecumbentBody Position
Low-Dose SteroidIf On Pressors
Grade C
Cultures Before
Grade D
20 Really Weakly
Supported
Recommendations
Grade E
PUD ProphylaxisFor All Patients
ALI Venti lat ionLow Vt/Pplat Strategy
SedationProtocol With Goal
SedationIntermittent or Daily Wake
Ant ib io tics to Cover
Norepi or Dopamine
Glucose
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Surviving Sepsis Campaign (2004)Sepsis Specific Positive Recommendations
Recommendations and Evidence Grades
Grade A
rhAPC for Patients At High Risk of Death
EGDT SCVO270% Goal
(Hct to 30%, dobutamine)
EGDT Basic GoalsMAP65, CVP 8-12
Grade B
Low-Dose SteroidIf On Pressors
Grade C
Cultures Before
Grade D
11 Really Weakly
Supported
Recommendations
Grade E
Ant ib io tics to Cover
Norepi or Dopamine
Ant ib io tics
Suspect Bugs
As 1st Line Pressor
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Surviving Sepsis CampaignRevised Grading for 2008 and 2012
A numeric score for strength of recommendation 1: Strongly recommended, thought very likely to improve outcome
We recommend . . .
2: Weakly recommended, less confident that benefits exceed risks
We suggest . . .
A letter score for quality of evidence A: High B: Moderate C: Low D: Very Low
Some play in this
Randomized trials usually graded A, but may be downgraded for
concerns over reporting bias, limitations in implementation, etc.
Observational studies are usually graded C, but may be
upgraded if the magnitude of effect is particularly large
A score of UG (ungraded) added for 2012
S i i S i C i E l ti
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Surviving Sepsis Campaign EvolutionEGDT and Resuscitation
2004 2008 2012
A B C D E
SCVO270% Goal(Hct to 30%, dobutamine)
Basic GoalsMAP65, CVP 8-12 1C
Start resusci tation before
ICU if BP low or lactate high
1C
Goals: MAP65, CVP 8-10*,
and UO0.5 mL/kg/hr
*12-15 recommended on vent
2C
If SCVO2
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Surviving Sepsis Campaign EvolutionEGDT and Resuscitation
2004 2008 2012
A B C D E
SCVO270% Goal(Hct to 30%, dobutamine)
Basic GoalsMAP65, CVP 8-12 1C
Start resusci tation before
ICU if BP low or lactate high
1C
Goals: MAP65, CVP 8-10*,
and UO0.5 mL/kg/hr
*12-15 recommended on vent
2C
If SCVO2
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Surviving Sepsis Campaign EvolutionActivated Protein C (Xigris)
2004 2008 2012
A B C D E
2B
rhAPC for Patients
At High Risk of Death
APACHE 25
Or
Multiple Organ Failures
rhAPC for Patients
At High Risk of Death
1A
Do Not Use rhAPC for
Patients
At Low Risk of Death
APACHE < 20
And
0-1 Organ Failures
Drug Off Market
S i i S i C i E l ti
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Surviving Sepsis Campaign EvolutionActivated Protein C (Xigris)
2004 2008 2012
A B C D E
2B
rhAPC for Patients
At High Risk of Death
APACHE 25
Or
Multiple Organ Failures
rhAPC for Patients
At High Risk of Death
1A
rhAPC NOT for Patients
At Low Risk of Death
APACHE < 20
And
0-1 Organ Failures
Drug Off Market
What evidence came out between the 2004 and 2008 guidelines to downgrade
the quality of the orig inal PROWESS trial of rhAPC?
Surviving Sepsis Campaign Evolution
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Surviving Sepsis Campaign EvolutionCorticosteroids
2004 2008 2012
A B C D E
1A No High Dose Steroids
Low-Dose SteroidIf Pressor Dependent
No High DoseSteroids
Do Not Treat Sepsis With
Steroids if Not Shock
Stop Steroid i f ACTH
Response Intact
Wean Steroid Dose as
Pressor Dose Declines
Add Fludrocorti sone
To Hydrocort isone
2CConsider Low-Dose Steroid If
Vasopressor Dependent
2B
If Steroid Used,
Hydrocortisone Preferred
1DDo Not Treat Sepsis With
Steroids if Not Shock
2B Do Not Use ACTH Response
2D
Wean Steroids Only When
Off Pressors
2CAdd Fludrocortisone to
Hydrocortisone
2COnly Use Steroid If Fluid
and Pressors Ineffectiv
2D
Use Continuous Infusio
Hydrocortisone (200 mg/d
1DDo Not Treat Sepsis Wi
Steroids if Not Shock
2B Do Not Use ACTH Respo
2D
Wean Steroids Only Wh
Off Pressors
Surviving Sepsis Campaign Evolution
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Surviving Sepsis Campaign EvolutionCorticosteroids
2004 2008 2012
A B C D E
1A No High Dose Steroids
Low-Dose SteroidIf Pressor Dependent
No High DoseSteroids
Do Not Treat Sepsis With
Steroids if Not Shock
Stop Steroid i f ACTH
Response Intact
Wean Steroid Dose as
Pressor Dose Declines
Add Fludrocorti sone
To Hydrocort isone
2CConsider Low-Dose Steroid If
Vasopressor Dependent
2B
If Steroid Used,
Hydrocortisone Preferred
1DDo Not Treat Sepsis With
Steroids if Not Shock
2B Do Not Use ACTH Response
2D
Wean Steroids Only When
Off Pressors
2CAdd Fludrocortisone to
Hydrocortisone
2COnly Use Steroid If Fluid
and Pressors Ineffectiv
2D
Use Continuous Infusio
Hydrocortisone (200 mg/d
1DDo Not Treat Sepsis Wi
Steroids if Not Shock
2B Do Not Use ACTH Respo
2D
Wean Steroids Only Wh
Off Pressors
Corticosteroids Reduced to Salvage Therapy