7 Sep - Sepsis Guidelines

Discussion today focused primarily on the early management of sepsis.  This is a condition for which the mortality has not really decreased much since the advent of antibiotic therapy.  A few interventions have been shown to decrease mortality, and there are a core set of interventions that should be considered in all septic patients.

The Surviving Sepsis Campaign has papers and pocket cards that review the current interventions shown to improve mortality in septic shock.  They focus their measures on two phases of care - the first 6 hours (primarily ED interventions) and the following 24 hours (primarily ICU interventions).

This Nov 2001 trial on early goal directed therapy for sepsis formed the basis for much of the recommendations in this guideline.  The only part that gives me pause is the recommendation to transfuse above a HCT of 30 if patients have low SVO2 despite volume resuscitation.  This somewhat conflicts with other studies that show trends for worse outcomes with higher transfusion targets.

As for steroid therapy in sepsis, the clinical trial data follows a roughly 11 year cycle that I think correlates with sunspot activity cycles.  The most recent data from recent JAMA and NEJM trials is pessimistic, and argues that any benefit from steroids, if truly present, is likely small.  This benefit comes with the clearly documened risks of steroid therapy, to include worsening immunosuppression and hyperglycemia.  If you so choose to use them, current dogma is to not base the decision on a ACTH stim test and only use low doses of hydrocortisone.

One side discussion revolved around the impact of severe sepsis on cognitive decline in elderly survivors of sepsis.  A recent trial published in Mayo Clinic Proceedings demonstrated significant persistent cognitive decline in elderly patients post-surgery.  This corresponds with previous studies that have shown similar persistent declines in elderly patients after severe sepsis.  The rate of significant permanent cognitive impairment in elderly sepsis survivors is high, and fundamentally alters independent living for many patients.  These studies should help you set realistic expectations for families when dealing with elderly family members facing major surgeries or critical illness.