Sepsis is a deadly condition. Among patients presenting to emergency rooms with septic shock, reported in-hospital mortality ranges from about 20% to 50%. The greatest opportunity to reduce mortality from severe sepsis and septic shock occurs within the first few hours of diagnosis. The last 15 years have seen a remarkable evolution of treatment concepts, which have refined medical interventions and reduced mortality.
Recently one of our clients asked us to review the evidence surrounding care bundles for sepsis. Care bundles are a small set of clear evidence-based practices that, when reliably performed together, result in better patient outcomes than when they are implemented individually. The most widely known sepsis care bundles are those published by the Surviving Sepsis Campaign (SSC). The SCC guidelines stress the importance of early recognition of sepsis with vigorous fluid resuscitation, early antibiotics, various vasopressors as indicated, and blood transfusions if needed to achieve explicit predefined physiologic endpoints using measurements obtained from central venous catheters.
Unfortunately, compliance with the SSC guidelines has not been as robust as desired. Although resource limitations in some hospitals may prevent implementation of the SCC care bundles, one of the main reasons for a lack of more unquestioned acceptance appears to be concern that the core recommendations are based on the results of 1 small, single-center study.
Interesting developments in sepsis management have been coming out of the United Kingdom and Ireland that reinforce the long-standing importance of early diagnosis of sepsis and the rapid initiation of treatment. Our colleagues in Great Britain and Ireland are adopting the Sepsis Six 1-hour bundle that involves the performance of 6 interventions within 1 hour of the diagnosis of severe sepsis:
- Deliver high-flow oxygen
- Take blood cultures and other cultures, consider source control
- Administer empirical IV antibiotics
- Measure serum lactate or an alternative test
- Start IV fluid resuscitation
- Commence accurate urine output measurement
In thinking about this, I am struck by a phrase that comes from the world of fighter pilots and aerial combat. When you talk to fighter pilots about dog fighting, a phrase repeatedly rises to the top as the most important thing. That phrase is Speed is Life. Sepsis is similar; the sooner you realize what is going on and start doing something about it, the better chance the patient will have of surviving. The British and the Irish have latched onto this concept and are pushing their clinicians to utilize the Sepsis Six 1-hour bundle. Hayes encourages clinicians in the United States to use evidence to inform their decisions and take advantage of opportunities to improve outcomes by implementing care bundles.