Treatment of patients with severe sepsis and septic shock: real-life lessons

Letters

CJEM 2006;8(4):244-245

To the Editors: Evidence-based therapies for severe sepsis and septic shock include broad spectrum antibiotics, early goal-directed resuscitation, corticosteroids, glycemic control and recombinant human activated protein C (rhAPC).1 Prior to dissemination of the Surviving Sepsis Guidelines in 2004,1 we found that 94% (32/34) of our septic patients received greater than 20 mL/kg intravenous fluid within 6 hours, that 85% (29/34) received low-dose corticosteroids, that 68% (23/34) received antibiotics within 3 hours, and that 82% (29/33) received rhAPC within 24 hours of admission to the intensive care unit. At the same time, only 38% (13/34) received central venous pressure monitoring, and only 6% (2/34) had central venous oximetry performed within 6 hours. This "care-gap" offers a provocative area for research and improvement.

Pharmaceutical companies have provided a great deal of education focused on products such as rhAPC. Unfortunately, educational funding to promote the use of equally efficacious but inexpensive therapies, such as steroids, fluids or pressure monitoring, is lacking. Early goal-directed therapy saves lives, and mortality increases for each hour that appropriate antibiotics and fluid resuscitation are delayed.2,3 With any time-dependant therapy, it is necessary to expedite a continuum of care. The concepts of "chain-of-survival," "door-to-drug time" and "taking treatment to the patient" are as relevant to sepsis as they are to acute coronary syndromes (ACS) — perhaps more so, given the high incidence, mortality and cost of severe sepsis and septic shock — yet sepsis has not received the same level of attention or funding as ACS.4,5

Just as with ACS, the first step is deciding that delays are unacceptable. Comprehensive therapy can only begin once a disease is brought to medical attention. Yet few hospitals triage septic patients in the same aggressive fashion they do for ACS. Pre-hospital sepsis care is unusual; pre-hospital cardiac care is the norm. Early and aggressive treatment of severe sepsis and septic shock will save many lives. Our challenge is to convert guidelines into meaningful clinical practice and change.6 We have work to do.

Jonathan S. Davidow, MD

Departments of Emergency Medicine

and Critical Care Medicine

Peter G. Brindley, MD

Department of Critical Care Medicine

Michael J. Jacka, MD, MSc

Departments of Critical Care Medicine

and Anesthesiology & Pain Medicine

R.T. Noel Gibney, MB

Department Critical Care Medicine

University of Alberta

Edmonton, Alta.

References

1. Dellinger RP, Carlet JM, Masur H, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-72.
2. Ronald J, Suppes R, Gulati H, et al. The effect of timing of antimicrobial administration on mortality in septic shock patients. Can J Anaesth 2005;54:A4.
3. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77.
4. American Heart Association. Part 1: Introduction to the International Guidelines 2000 for CPR and ECC: a consensus on science. Circulation 2000; 102: 1-11.
5. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29: 1303-10.
6. Levy M, Pronovost J, Dellinger RP, et al. Sepsis change bundles: converting guidelines into meaningful change in behavior and clinical outcome. Crit Care Med 2004;32(suppl):S595-7.