Initial resuscitation from severe sepsis: one size does not fit all

Abstract

Over recent decades many recommendations for the management of patients with sepsis and septic shock have been published, mainly as the Surviving Sepsis Campaign (SSC) guidelines. In order to use these recommendations at the bedside one must fully understand their limitations, especially with regard to preload assessment, fluid responsiveness and cardiac output. In this review we will discuss the evidence behind the bundles presented by the Surviving Sepsis Campaign and will try to explain why some recommendations may need to be updated. Barometric preload indicators, such as central venous pressure (CVP) or pulmonary artery occlusion pressure, can be persistently low or erroneously increased, as is the case in situations of increased intrathoracic pressure, as seen with the application of high positive end-expiratory pressure, or in situations with increased intra-abdominal pressure. Chasing a CVP of 8 to 12 mm Hg may lead to under-resuscitation in these situations. On the other hand, a low CVP does not always correspond to fluid responsiveness and may lead to over-resuscitation and all the deleterious effects on end-organ function associated with fluid overload. We will suggest the introduction of new variables and more dynamic measurements. During the initial resuscitation phase, it is equally important to assess fluid responsiveness, either with a passive leg raising manoeuvre or an end-expiratory occlusion test. The use of functional hemodynamics with stroke volume variation or pulse pressure variation may further help to identify patients who will respond to fluid administration or not. Furthermore, ongoing fluid resuscitation beyond the first 24 hours guided by CVP may lead to futile fluid loading. In patients that do not transgress spontaneously from the Ebb to Flow phase of shock, one should consider (active) de-resuscitation guided by extravascular lung water index measurements.

The SEP-1 quality mandate may be harmful: How to drown a patient with 30 mL per kg fluid!

“…Recent evidence suggests that patients with sepsis may have improved outcomes when treated with a conservative, physiologically guided fluid strategy and state-of-the-art supportive care together with a novel pharmacologic intervention [3,4,36,37]. Following this strategy patients with sepsis and septic shock may not develop progressive organ failure, with a reported mortality of less than 10%, this being despite poor compliance with the SEP-1 mandate (only 11%) [37].…”

“…In summary, there is now scientific evidence, supported by legal precedent that not only are the EGDT, SSC and SEP-1 protocols of limited benefit to patients if blindly followed, they are potentially harmful [3,[38][39][40]. These protocols violate the American Medical Association (AMA) and American College of Physicians (ACP) code of ethics [41,42], and the basic Hippocratic Principle of Medicine, "Primum Non Nocere".…”

“…Moreover, recent clinical trials suggest that protocolized resuscitation strategies, which are also mandated by Rory's Regulations, may paradoxically lead to increased lengths of stay in the ICU and in the hospital and higher costs [3,[28][29][30][31]. The regulations may also lead to antibiotic overuse, if hospitals, in an attempt to increase their adherence to guidelines, give antibiotics to patients who are not infected [32].…”

“…Both the Federal Government in the United States of America (USA) and the authors of the SSC decree there are no exceptions to this rule; surprisingly, they mandate that patients with pneumonia or acute lung injury be intubated so that they can receive the potentially harmful 30 mL kg -1 fluid bolus [2]. This can only be described as reckless, and clearly one size may not fit all [3]. It is critical to stress that the SSC recommendation and the SEP-1 mandate are devoid of any supporting scientific evidence, indeed, a strong body of scientific evidence suggests that such an approach may be harmful [4].…”

A Retrospective Study on the Compliance with Surviving Sepsis Campaign Guideline in Patients with Sepsis Admitted to Intensive Care Unit in Hong Kong

“…Therefore, dopamine was usually initiated in the general wards and then switched to noradrenaline after transfer to ICU when a central line had been inserted for CVP monitoring as well as for noradrenaline infusion. The dosage of vasopressor used was titrated individually, as the optimal mean arterial pressure would be higher in those with underlying hypertension than in the young without cardiovascular risk factors or comorbidities [23].…”