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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
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Potential Conflicts of Interest
• No potential financial conflict of interest as to any material
presented in this presentation
• Leadership position in Surviving Sepsis Campaign
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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
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Phil and the Lion’s Den
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Dellinger’s Last Stand
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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
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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: International guidelines for
management of severe sepsis and septic shock: 2012
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Currently Funded with a Gordon and Betty
Moore Foundation Grant
(Intel family).
Surviving Sepsis Campaign
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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
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Guidelines Are Not Enough
• Protocols
• Performance Improvement Programs
• Audit and Feedback
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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
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Primary Advantage of Bundle Care
• Structuring of care to promote consistency in
the management of clinical conditions
(standardization of care)
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Critics of Bundled Care
• Cookbook medicine
• Supplanting clinical judgment
• Complacency
• Effect on medical education
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Bundles should not negate deviations when
particular patient scenario warrants
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Converting Goals to
Measurable Indicators
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Bundled Care
• Indicators of care retrievable from chart review
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Early Screening and a Performance
Improvement Program (1C)
Surviving Sepsis Campaign 2013
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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
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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
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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
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Blood Cultures
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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
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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
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Antibiotic Therapy
Cover broad initially
Reassess antibiotic regimen daily for de-
escalation
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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
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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
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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
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Resuscitation of Sepsis Induced Tissue
Hypoperfusion
• Recommend MAP 65 mm HgGrade 1C
Surviving Sepsis Campaign 2013
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Potential Conflicts of Interest
• No potential financial conflict of interest as to any material
presented in this presentation
• Leadership position in Surviving Sepsis Campaign
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Sepsis Induced Tissue Hypoperfusion
Requirement for vasopressors after
fluid challenge
Lactate ≥ 4 mg/dL
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Protocolized
Care
Protocolized Quantitative Resuscitation
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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
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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
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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)
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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*
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Jones, A. E. et al. JAMA 2010;303:739-746.
Hospital Mortality and Length of Stay
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Am J Respir Crit Care Med. 2010 Sep 15;182(6):752-61.
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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
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www.survivingsepsis.org
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Thank You