June 12, 2018 by Agnes Usoro
By now, we’ve all heard about Sepsis and understand the significant public health burden sepsis plays in our society . But since the landmark Rivers paper in 2001, much has changed in the management of sepsis.
- In 2014, the ProCESS Trial revealed that there was no difference between early-goal directed therapy and standard therapy (adequate fluid resuscitation and antibiotics) for sepsis. This dramatically reduced the number of central line catheters inserted for CVP and ScvO2 monitoring.
- In 2016, the 3rd International Consensus for Sepsis guidelines were produced which redefined sepsis and septic shock (and eliminated the term severe sepsis) and recommended use of the quick Sequential Organ Failure Assessment (qSOFA), over the traditional SIRS criteria, as a bedside clinical tool for early identification of septic patients.
- In 2017, qSOFA was validated and recommended as a more accurate assessment tool than SIRS criteria in the Emergency Department.
- In 2017, it was revealed that absolute mortality increased 0.3% for each hour delay in antibiotic administration from time of initial Emergency Department registration. This is why Core Sepsis Guidelines recommend antibiotic administration within 1 hour of sepsis recognition.
- In 2017, a systematic review and meta-analysis revealed that prolonged infusions of antibiotics (infusions lasting at least 3 hours long) compared to traditional short hour-long infusions, reduced mortality by 30%.
- Also in late 2017, the FDA approved a new drug – Angiotensin II (Giapreza) for the management of septic shock. This would serve as an alternative vasopressor infusion to maintain blood pressure.
We have come a long way in sepsis management, but despite our advancements, sepsis remains the leading cause of mortality and critical illness worldwide. Thus, it is imperative that as clinicians, we remain up-to-date on the recommendations for management of sepsis. This includes: being aware of the qSOFA decision tool (given that it has replaced SIRS criteria), understanding that timely antibiotic administration is key (goal: within 1 hour of sepsis identification), and recognizing that new antibioitic administration guidelines may be on the horizon for sepsis management. In some years from now, we may instead be ordering continuous antibiotic infusions instead of scheduled interval doses; who knows? Regardless, we all must be aware of our role in sepsis management if we are going to stay ahead of the game.
Rivers, 2011. https://www.nejm.org/doi/full/10.1056/NEJMoa010307
Process Trial, 2014.https://www.emrap.org/episode/august2014/paperchase2
Sepsis-3, 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968574/
Early Timing of Antibiotics, 2017. https://www.ncbi.nlm.nih.gov/pubmed/?term=28345952
qSODA Validation, 2017. https://www.ncbi.nlm.nih.gov/pubmed/28114554
Prolonged Antibiotic Infusion, 2017: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30615-1/fulltext
Image #1: New Sepsis-3 Guidelines Summary. http://blog.clinicalmonster.com/2016/03/mo/
Image #2: qSOFA. http://rebelem.com/sepsis-3-0/qsofa/