This may sound crazy, but there are several lines of evidence that support a restrictive fluid approach, including a randomized controlled trial of children with severe malaria, a severity-adjusted analysis of 23,513 septic adults that found each liter beyond five associated with a mortality increase, and a recent randomized controlled trial of adults with septic shock showing significantly improved survival among those getting 2 versus 3.5 L in the first six hours.8-10 A randomized trial of a liberal versus restrictive fluid approach for septic ED patients is currently being planned by the Prevention and Early Treatment of Acute Lung Injury network.
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ACEP Now: Vol 37 – No 03 – March 2018I asked Peter DeBlieux, MD, an emergency medicine and critical care specialist at Louisiana State University in New Orleans, for his perspective. He said, “Despite some missteps, the best aspect of SSC is promoting recognition; early recognition of sepsis means sooner antibiotics, source control, and care coordination with consultants. Continued recognition of the need for research to improve outcomes for this major killer is critically important.”
One of my mentors once told me it’s best to be neither the first nor the last to embrace an innovation. Unfortunately, in many ways, we’re back to where we started with sepsis.
References
- Dellinger RP1, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med. 2004;30(4):536-555.
- Eichacker PQ, Natanson C, Danner RL. Surviving sepsis—practice guidelines, marketing campaigns, and Eli Lilly. N Engl J Med. 2006;355(16):1640-1642)
- Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008;34(1):17-60.
- Rivers E, Nguyen B, Havstad S, et al.Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377.
- Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant activate proten C for severe sepsis. N Engl J Med. 2001;344(10):699-709.
- Lindenauer PK, Lagu T, Shieh MS, et al. Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003-2009. 2012;307(13):1405-1413.
- Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486-552.
- Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364(26):2483-2495.
- Marik PE, Linde-Zwirble WT, Bittner EA, et al. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive Care Med 2017;43(5):625-632.
- Andrews B, Semler MW, Muchemwa L, et al. Effect of an early resuscitation protocol on in-hospital mortality among adults with sepsis and hypotension: a randomized clinical trial. JAMA. 2017;318(13):1233-1240.
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5 Responses to “Opinion: How the Surviving Sepsis Campaign Got Almost Everything Wrong”
March 29, 2018
Mike WardI do not see any listed references?
April 6, 2018
KevinWhere are the references cited?
April 7, 2018
Alex LimkakengDon’t entirely disagree with Dr. Talan on certain examples of overzealousness (or worse) of the SSC (in the case of Xigris, for example), however, 2 caveats: the PROCESS trial used the exact same enrollment criteria as the Rivers Trial, yet had a much lower rate of mortality in the control arm. Therefore the general trend for more liberal coding of sepsis cannot entirely explain the difference.
Second, I think it’s unfair to critique a guideline for being wrong in light of the subsequent new knowledge that accrues over 10 years. Like all guidelines, SSC represented the best available evidence and expert opinion at the time. That is the nature of all science, and the SSC should be credited with raising awareness about sepsis as an emergency condition and focusing researchers on where the gaps in evidence existed such that it was possible to make new recommendations. They should also be lauded for their inclusion of emergency physician researchers.
April 8, 2018
David CassidyReferences?
April 9, 2018
Dawn Antoline-WangSorry, the missing references have been added.