Reducing Mortality in Severe Sepsis and Septic Shock

Andrew T. Levinson, M.D., M.P.H.; Brian P. Casserly, M.D.; Mitchell M. Levy, M.D.

Disclosures

Semin Respir Crit Care Med. 2011;32(2):195-205. 

In This Article

The Surviving Sepsis Campaign

An analysis of the mortality data from control arms of sepsis trials conducted between 1990 and 2000 showed a decline in mortality from 44 to 35%.[11,12] The study concluded that the basic care of the septic patient has improved with modernization of ICU care. Others have noted that the history of sepsis research has seen more failures than successes and that there is a lack of interventions that have been shown to be efficacious in randomized, controlled trials (RCTs).[13] Hopeful that mortality might be reduced by standardizing care and informed by data from an increasing number of clinical trials, the European Society of Intensive Care Medicine, the International Sepsis Forum, and the Society of Critical Care Medicine launched the Surviving Sepsis Campaign (SSC) in 2004. The initial evidence-based guidelines were endorsed by 11 professional societies. An updated version of the guidelines was published in 2008.[14,15] The next revision of the current SSC guidelines is planned for 2011. The development and publication of guidelines often do not lead to changes in clinical behavior, and guidelines are rarely, if ever, integrated into bedside practice in a timely fashion. The failure to translate evidence into practice has been identified as one of the great challenges of modern medicine.[16,17]

The most effective means for achieving knowledge transfer remains an unanswered question across all medical disciplines.[18,19] After the development of the evidence-based guidelines, the SSC steering committee partnered with the Institute for Healthcare Improvement to develop a quality improvement program to extend the Campaign guidelines to the bedside management of severely septic and septic shock patients.[20] In partnership with the Institute for Healthcare Improvement, key elements of the guidelines were identified and organized into "bundles" of care (Fig. 1).[15] A two-phase approach was established, which included the generation of two sets of performance measures: the first set to be accomplished within 6 hours of presentation with severe sepsis (the resuscitation bundle); and a second set to be accomplished within 24 hours (the management bundle).[21] Bundles are considered important drivers of change in clinical practice based on the quality of available published data. It should be acknowledged, however, that a significant challenge to the guidelines process is the inherent limitations of the available literature. The conflicting evidence from the two large RCTs regarding the administration of steroids in septic shock is one such example.[22,23] Fortunately, the dynamic nature of the Surviving Sepsis guidelines will allow further modifications with the emergence of new clinical evidence from ongoing trials. As with all guidelines, they represent the best available synthesis of contemporary knowledge in reducing mortality in severe sepsis and should therefore have clinical applicability. This article critically reviews the current evidence for the mortality benefit of current specific treatments and therapies during initial resuscitation as well as in the postresuscitation period.

Figure 1.

Surviving Sepsis Campaign severe sepsis bundles. (From Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Critical Care Medicine 2010;38(2):368. Reproduced with permission from the Surviving Sepsis Campaign and the Institute for Healthcare Improvement. With kind permission of Wolters Kluwer Health.)

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