Sepsis News Tops Critical Care Meeting Agenda

Marcia Frellick

January 29, 2019

SAN DIEGO — The effect of an alternative to lactate-guided resuscitation strategies on 28-day mortality rates for sepsis will be in the spotlight at the upcoming Society of Critical Care Medicine (SCCM) 2019 Congress.

Detailed findings from the ANDROMEDA-SHOCK randomized controlled trial (NCT03078712) will be presented by Glenn Hernandez, MD, PhD, from Pontificia Universidad Católica de Chile in Santiago, during a plenary that will also highlight results from two other major trials.

"It's the first time the congress has had late-breaking trials in the plenary sessions," said Steven Greenberg, MD, from the NorthShore University Health System in Evanston, Illinois, who is cochair of the conference planning committee.

Experts from around the world will debate strategies to lower the rate of sepsis-related mortality. The condition affects nearly 270,000 Americans each year and has a mortality risk of 30% to 60%. Nearly one in three patients who die in the hospital have sepsis, according to the Centers for Disease Control and Prevention.

Among the sepsis controversies that will be highlighted at the meeting are whether children's hospital guidelines should be based on Centers for Medicare and Medicaid Services (CMS) recommendations for adult care and the way adherence to the protocols should be measured.

Do Adult Guidelines Apply in Pediatrics?

"Even in the adult population, less than 50% of hospitals today are fully complying with the CMS standards," Greenberg told Medscape Medical News.

Talks will center on the best fluids to give for resuscitation and whether invasive or noninvasive measurements should be used to decide when the patient has had enough fluid. And speakers will tackle ways to manage fluids once septic shock has resolved.

The debate over steroids returns this year, with discussions on whether there is still a role for them and which patients should and should not get them.

An examination of whether a protocol-based approach to sepsis management is better than an approach based on a patient's physiology and other comorbidities will be delivered by Mitchell Levy, MD, from Warren Alpert Medical School of Brown University in Providence, Rhode Island.

He and several other speakers will debate whether federal mandates that require a protocol to be followed in cases of suspected sepsis can have unintended consequences.

Do Mandates Have Unintended Consequences?

"We've demonstrated that compliance with these measures is associated with improved survival," Levy told Medscape Medical News, explaining that his research has shown that strict compliance results in a steep decline in mortality.

In New York hospitals, which have used the sepsis protocol since 2013, risk-adjusted mortality decreased from 28.8% to 24.4% (P <  .001) when patients were treated in accordance with the protocol, he and his colleagues demonstrated (Am J Respir Crit Care Med. 2018;198:1406-1412).

In addition, "greater hospital compliance with 3-hour and 6-hour bundles was associated with shorter length of stay and lower risk and reliability-adjusted mortality," the team writes.

"The better you do it, the more the mortality rate goes down in your hospital," Levy reported.

The mandated protocol is simple, he explained: measure lactate; get blood cultures before antibiotics; give antibiotics within 1 hour of recognizing sepsis. If a patient has low blood pressure, give fluids and then remeasure lactate.

Some argue that giving antibiotics so quickly could feed antibiotic resistance because, often, suspected sepsis is later found to be something else. But most physicians agree with the approach of giving the first dose of the antibiotic quickly, Levy said, and then immediately investigating whether the patient is truly infected.

"You marry early, aggressive antibiotic administration with antibiotic stewardship," he said.

Most of the field would say that a single dose of an antibiotic is not going to be harmful, Levy said. However, the problem is that in many hospitals, once you get started on an antibiotic regimen, it continues for a week or 10 days without critical evaluation.

"Academics love to argue about this kind of thing," he said. "We just do."

Greenberg and Levy have disclosed no relevant financial relationships.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick

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