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Hallie Prescott, pulm/crit physician and co-chair of the recent Surviving Sepsis guideline writing committee, gives some insight into the new document, including a few interesting additions and some points of controversy.
For more thoughts, especially from an EM perspective, Scott Weingart also interviewed Hallie over at EMcrit.
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Takeaway pearls
- The new guidelines suggest/recommend:
- Prehospital sepsis screening, and in systems with >60 minutes to hospital evaluation and the appropriate systems in place, prehospital antibiotic administration. (This is a fairly narrow recommendation that won’t apply to many in the US, mostly rural systems with long transport times.)
- Don’t give anaerobic antibiotic coverage if not suspicious of anaerobic infection
- Target a MAP >65 in most, but in patients >65 years old, target only >60.
- Don’t use qSOFA exclusively for screening; use other more sensitive tools like NEWS.
- Consider SDD (selective decontamination of the digestive tract), the use of targeted local and systemic antibiotics in intubated patients to reduce the bacterial load in the upper GI tract and reduce the risk of VAP. This has a long presence in the literature and is more practiced in Europe than the US, but the data is fairly good.
- Suggest measuring serum lactate, and perhaps trending it, but not necessarily trying to normalize it.
- Prolonged infusions of beta-lactam antibiotics are supported (for subsequent doses; the first dose should still be a bolus) due to reasonably positive data.
- If final cultures are negative, consider deescalating/stopping antimicrobials. (Obviously, this means most patients have already received a few days of therapy by then.)
- Other old standards like 30 cc/kg fluid boluses and early antibiotic administration remain. Some are upset about this, as they have been translated into US quality measures (the SEP-1 CMS standard) that invoke monetary penalties when not adhered to—a standard that has caused much headache for EM particularly. But Hallie says: this is a global standard with >25 nations involved, and is oriented around medical realities. Translating it into national quality standards, rightly/wrongly, appropriately or bluntly, is not the business of the guideline group, and is purely an American issue.