Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

Abstract

shock (27). The specific components of performance improvement did not appear to be as important as the presence of a program that included sepsis screening and metrics.Sepsis screening tools are designed to promote early identification of sepsis and consist of manual methods or automated use of the electronic health record (EHR). There is wide variation in diagnostic accuracy of these tools with most having poor predictive values, although the use of some was associated with improvements in care processes (28)(29)(30)(31). A variety of clinical variables and tools are used for sepsis screening, such as systemic inflammatory response syndrome (SIRS) criteria, vital signs, signs of infection, quick Sequential Organ Failure Score (qSOFA) or Sequential Organ Failure Assessment (SOFA) criteria, National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS) (26,32). Machine learning may improve performance of screening tools, and in a meta-analysis of 42,623 patients from seven studies for predicting hospital acquired sepsis the pooled area under the receiving operating curve (SAUROC) (0.89; 95% CI, 0.86−0.92); sensitivity (81%; 95% CI, 80−81), and specificity (72%; 95% CI, 72−72) was higher for machine learning than the SAUROC for traditional screening tools such as SIRS (0.70), MEWS (0.50), and SOFA (0.78) (32).Screening tools may target patients in various locations, such as in-patient wards, emergency departments, or ICUs (28)(29)(30)32). A pooled analysis of three RCTs did not demonstrate a mortality benefit of active screening (RR, 0.90; 95% CI, 0.51−1.58) (33-35). However, while there is wide variation in sensitivity and specificity of sepsis screening tools, they are an important component of identifying sepsis early for timely intervention.Standard operating procedures are a set of practices that specify a preferred response to specific clinical circumstances (36). Sepsis standard operating procedures, initially specified as Early Goal Directed Therapy have evolved to "usual care" which includes a standard approach with components of the sepsis bundle, early identification, lactate, cultures, antibiotics, and fluids (37). A large study examined the association between implementation of state-mandated sepsis protocols, compliance, and mortality. A retrospective cohort study of 1,012,410 sepsis admissions to 509 hospitals in the United States in a retrospective cohort examined mortality before (27 months) and after (30 months) implementation of New York state sepsis regulations, with a concurrent control population from four other states (38). In this comparative interrupted time series, mortality was lower in hospitals with higher compliance with achieving the sepsis bundles successfully.Lower resource countries may experience a different effect. A meta-analysis of two RCTs in Sub-Saharan Africa found higher mortality (RR, 1.26; 95% CI, 1.00−1.58) with standard operating procedures compared with usual care, while it was decreased in one observational study (adjusted hazard ratio [HR]; 95% CI, 0.55...

Prognostic accuracy of using lactate in addition to the quick Sequential Organ Failure Assessment score and the National Early Warning Score for emergency department patients with suspected infection

“…Therefore, minimising the number of missed cases is a priority, and several authors have argued that a clinical prediction tool for sepsis should favour‘sensitivity, even at the expense of specificity’ 5 23. Our results concur with the growing literature suggesting that qSOFA≥2 alone (sensitivity 50% in this study) is insufficient to predict unfavourable outcomes in ED patients with suspected sepsis,8–10 and acts more as a severity assessment score 11 24. NEWS≥7 alone, with a sensitivity of 69% in our study, suffers from the same predicament.…”

“…However, although qSOFA is predictive of mortality in ED patients with suspected infection,4–7 its sensitivity in several meta-analyses8–10 ranges from 42% to 54%, insufficient for an early screening tool. Thus, the 2021 Surviving Sepsis Campaign guidelines stated that although qSOFA was designed as a predictor of poor outcome, it should not be used as a screening tool for sepsis or septic shock in these patient populations 11…”

Aberrant blood MALT1 and its relevance with multiple organic dysfunctions, T helper cells, inflammation, and mortality risk of sepsis patients

“…Sepsis continues to be a global health problem with in-hospital mortality ranging from 15.6% to 30%. [1][2][3][4][5] Generally, sepsis is featured by severe, potentially fatal, multiple organic dysfunctions caused by dysregulated host response to infection; meanwhile, it is usually accompanied by inflammatory storm. 6 Over the decades, though progressions have been made in the prevention and treatment of sepsis, its incidence still increases unexpectedly; meanwhile, its mortality rate remains unsatisfying.…”

The Evolution of Toolkits and Bundles to Improve the Care of Sepsis Patients

“…While guidelines apply the robust GRADE methods to appraise published evidence and develop key recommendations, bundles are designed to facilitate implementation of the optimal care outlined in the guidelines (1). The latest update to the SSC guidelines published in Critical Care Medicine and Intensive Care Medicine (2, 3) represents the state-of-the-art in knowledge and care processes for patients with sepsis. Some readers may be surprised that SSC care bundles, such as the Hour-1 Bundle, are not addressed in the latest SSC guidelines.…”

“…Some readers may be surprised that SSC care bundles, such as the Hour-1 Bundle, are not addressed in the latest SSC guidelines. Because bundles are developed through a separate process from the guidelines (2), the Hour-1 Bundle remains in place as the foremost tool to deliver the right care at the right time (Right Care, Right Now™) for patients with sepsis and septic shock.…”