Surviving Sepsis Campaign, early goal-directed therapy and 'bundles'

The Surviving Sepsis Campaign (SSC) was established to raise awareness of severe sepsis and to improve its management. It is a collaboration between the Society of Critical Care Medicine (SCCM), the European Society of Intensive Care Medicine (ESICM) and the International Sepsis Forum (ISF). The campaign has devised guidelines which are divided into 'bundles'. Bundles represent groups of evidence-based recommendations within a single protocol. The idea is that following these bundles improves patient survival. The guidelines highlight that early aggressive management of sepsis, ie before the patient ends up in an intensive care setting, is crucial for improving patient outcomes]

Some of the recommendations include the following]

Aggressive rehydration titrated to a central venous pressure (CVP) of 8-12 mm Hg - using high volumes of crystalloids. Earlier use of blood transfusion, eg haemoglobin level <10 g/dL provided the patient resuscitated to CVP 8-12 mm Hg. Using SvO2 to determine oxygenation of tissues. SvO2 is an estimate of oxygen saturation of blood returning to the right side of the heart. SvO2 <65% is associated with a worse prognosis and, provided CVP, haemoglobin and mean arterial pressure are satisfactory, patients should be started on a dobutamine. Early and appropriate empirical antibiotic therapy.

The SSC divides therapy into two bundles]

Resuscitation bundle - complete within 6 hours of hospital attendance. This includes measuring serum lactate, obtaining blood cultures, broad-spectrum antibiotics, fluid resuscitation (for hypotension or high lactate levels) - using CVP and SvO2 as guidance, vasopressor therapy when adequate fluid resuscitation fails. Management bundle - complete within the first 24 hours. This includes low-dose corticosteroids, glucose control, ventilatory support .

Initially, when these guidelines were published there were concerns that the evidence on which they were founded was limited and some suspected there was too much involvement of the pharmaceutical industry.However, despite these concerns, outcomes of the sepsis programmes are very good and, on average, a 10-20% reduction in overall mortality has been reported.[ In addition to this, length of hospital stay is reduced, resulting in this method being cost-effective.

Prognosis
Sepsis, especially when there is a delay in institution of therapy, is associated with 40% mortality (which increases to over 60% in the presence of septic shock.] These figures can be improved with early goaldirected