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Wednesday 12 June 2019
Sepsis Guidelines

This week we suggest to read "Sepsis Guidelines", published on "The New England Journal of Medicine" in April 2019.


The authors reported a case vignette, which is followed by specific options, neither of which can be considered either correct or incorrect. In short essays, experts in the field argue for each of the options, and readers are invited to choose one of the options, providing their reasons.

The readers have been discussing sepsis management with colleagues. The guidelines recommend that for all patients presenting with sepsis, the condition should be managed with a set of interventions (“bundle”), within 1 hour after presentation (defined as the “time of triage in the emergency department or, if referred from another care location, from the earliest chart annotation consistent with all elements of sepsis [formerly severe sepsis] or septic shock ascertained through chart review”). The bundle consists of measuring lactate level, obtaining blood cultures before administering antibiotics, administering broad-spectrum antibiotics, administering 30 ml of crystalloid per kilogram of body weight if the patient has hypotension or a lactate level higher than 4 mmol per liter, and administering vasopressors if the patient remains hypotensive despite fluid resuscitation. However, emergency department staff have expressed concerns that tightening the 3-hour bundle to 1 hour would draw resources away from other time-sensitive emergencies and might adversely affect emergency department performance measures. The hospital administrator is asking to discuss the appropriateness of adopting a 1-hour goal for the sepsis bundle.

Adopt a 1-Hour Goal for the Sepsis Bundle:

Sepsis and septic shock are medical emergencies, and treatment and resuscitation should begin immediately. Earlier sepsis treatment results in a greater chance of survival, and no studies suggest that slower treatment is better. The authors in favor of this option reported some hospital experiences (New York, California, Minnesota), which underlined the success applying of the 1-hour strategy. They criticized the main arguments against a 1-hour bundle: 1) a disbelief that sepsis actually is an emergency, 2) a belief that a single dose of broad-spectrum antibiotics represents a greater risk of harm

to a noninfected patient than it does a potential benefit to a patient with infection-induced lifethreatening organ dysfunction, and 3) a belief that a bolus of 30 ml per kilogram is too much for some patients.

Maintain the 3-Hour Goal for the Sepsis Bundle:

The authors in favor of this approach reported the statement of The American College of Emergency Physicians and the Society of Critical Care Medicine which “recommend that hospitals do not implement the Hour-1 bundle in its present form.” They underlined that there are fundamental problems with construct validity in the term “sepsis”, whose definition has been in flux for decades.

They reported that the 1-hour bundle could hurt some patients with sepsis considering: 1) aggressive fluid resuscitation could lead to aggressive hydration; 2) it could divert attention away from emergencies, that are amenable to interventions for which time-sensitivity has been proved by high-quality or from emergencies that clearly require urgent action; 3) broad-spectrum antibiotics could be administered to uninfected patients, wasting nurses’ time, and consuming blood culture bottles and other supplies.

AUTHORS: Angela X. Chen, M.B., B.S., M.P.H., Steven Q. Simpson, M.D., and Daniel J. Pallin, M.D., M.P.H.

Read more here.