CHICAGO – A move toward crystalloids for initial fluid therapy and away from dopamine as a first-line vasopressor are among the new recommendations in the Surviving Sepsis Campaign consensus guidelines for severe sepsis and septic shock due out later this year.
Efforts were extraordinarily vigorous to ensure the independence of the guideline revision, following controversy that unrestricted industry grant funding of previous guidelines may have influenced which treatments were included and how they were rated, Dr. Alan E. Jones said at the annual meeting of the Society for Academic Emergency Medicine (SAEM). No direct or indirect industry support was used for the 2012 revision, and committee members judged to have financial – or even academic – competing interests on a topic were recused from the closed discussion sessions and from voting on the topic.
The revised guidelines will also take into account the often-litigious issue of standard of care, said Dr. Jones, who represented the SAEM on the guideline-writing committee and is an emergency physician at Carolinas Medical Center in Charlotte, N.C. The authors note that resource limitations in some institutions and countries may prevent physicians from accomplishing particular recommendations, and clearly state that the recommendations are intended to be best practices and were not created with standard of care in mind.
"I can tell you that the use of the Surviving Sepsis Campaign guidelines in medical malpractice cases is unbelievable," he said. "Having this statement in there will really help [stress] the fact that these are guidelines and clinicians should not be held to these as a standard, but rather as best practice.
"I think that’s a huge step forward that the committee did truly recognize the power of the guidelines and how [they are] used by nonmedical personnel."
Dr. Stephen W. Trzeciak, who also served as a SAEM representative during the revision process, said the guidelines are important tools that decrease unnecessary heterogeneity in clinical practice, but they also represent a one-size-fits-all approach.
Dr. Stephen Trzeciak
"We take in a lot of very important information at the bedside, and there are plenty of times that we need to deviate from guidelines because ... in taking care of an individual patient, our clinical judgment will be to do something else," he said. "That’s reasonable. In fact, it’s the right thing to do."
Diagnosis
The diagnostic tests that will allow clinicians to make a diagnosis in real time, including identification of the causative organism, are not yet ready for prime time, although this area of sepsis research is going to accelerate over the next 10 years, said Dr. Trzeciak, a critical care and emergency physician at Cooper University Hospital in Camden, N.J.
The guidance on diagnosis remains relatively unchanged, with at least two blood cultures to be obtained before antimicrobial therapy is administered, as long as doing so does not cause a significant delay. The revised guidelines, however, now define this delay as more than 45 minutes and specify that one of the cultures should be drawn percutaneously and the other drawn through a vascular access device.
Vasopressors
One of the big changes in the guidelines for emergency physicians is that norepinephrine is recommended as the first-choice vasopressor, rather than dopamine. This reflects accumulating evidence that dopamine use in patients with septic shock is associated with an increased risk of death and arrhythmias, compared with norepinephrine (Crit. Care Med. 2012;40:725-30), Dr. Trzeciak said. Phenylephrine was also removed from the guidelines and replaced with epinephrine as the treatment of choice when an additional agent is needed to maintain adequate blood pressure.
Initial Fluid Therapy
The new guidelines recommend that crystalloids be used in the initial fluid resuscitation of severe sepsis, and caution against the use of hydroxyethyl starches with a molecular weight greater than 200 kDa or a degree of substitution exceeding .04 because data show they may not be effective and may actually be detrimental, Dr. Jones said. The committee also suggests albumin in the initial fluid resuscitation, based in large part on a recent meta-analysis of 17 studies showing that use of albumin as a resuscitation fluid was associated with lower mortality (odds ratio 0.82; P = .047) in sepsis patients (Crit. Care Med. 2011;39:386-91).
Fluid Responsiveness
The 2012 guidelines also emphasize using dynamic measures such as delta pulse pressure or stroke volume variation to determine the adequacy of fluid resuscitation, rather than such static measures as central venous pressure. The newer dynamic measures of fluid responsiveness have really taken hold in the critical care community, particularly in Europe, and focus on what the left ventricle does in response to fluids rather than what the central venous pressure is, Dr. Jones said.