More on the Surviving Sepsis Guidelines 2004-2008

Last Tuesday I began a review of the changes in the Surviving Sepsis Guidelines (SSG) as reflected in the 2008 revisions, recently made available in full text via Medscape. In that post I focused on the controversial recommendations concerning activated protein C, noting that the guideline authors had taken into account the best and most current evidence. Their decision to downgrade the recommendation for activated protein C should put to rest concerns about commercial influence corrupting the guidelines.

What else is new and of interest? I’ll present a summary here of other significant changes from 2004, along with points of special interest.

Early goal directed therapy (EGDT)

The recommendation for EGDT remains strong and has not significantly changed from the 2004 guidelines. The authors again emphasize that the protocol should begin immediately upon recognition of hypoperfusion and not be delayed until ICU admission. The assessment of a patient’s candidacy for EGDT, which can be rapidly and simply done in the ER, includes establishing that SIRS is present, infection is clinically suspected, hypotension or lactate elevation is present and that the patient does not have an advanced decision documented which would preclude hemodynamic resuscitation.

Antibiotic selection

The guidelines contain stronger language than in 2004 concerning the importance of a broad spectrum of initial antibiotic therapy and add a discussion of the importance of anti-MRSA coverage. Noteworthy is this new statement:

Patients with severe sepsis or septic shock warrant broad-spectrum therapy until the causative organism and its antibiotic susceptibilities are defined. Restriction of antibiotics as a strategy to reduce the development of antimicrobial resistance or to reduce cost is not an appropriate initial strategy in this patient population.

They go on to stress that antibiotics can be narrowed later after microbiologic date are available.

Choice of vasopressor

Data in recent years from observational studies, including the SOAP study which came out since the 2004 guidelines, have suggested inferior outcomes with dopamine. Nevertheless, the guideline authors recommend norepinephrine and dopamine as equal alternatives for initial pressor therapy, noting that high level direct comparison studies have not been done.

Corticosteroids

The corticosteroid recommendation, as I predicted late last year, was made more restrictive in keeping with evidence from the CORTICUS study. The 2004 recommendations called for “stress doses” of hydrocortisone in patients requiring pressors after fluid resuscitation. The 2008 guidelines restrict the use of steroids to patients who demonstrate refractoriness to pressor therapy. The guidelines do not recommend cortrosyn stimulation testing to diagnose critical illness related corticosteroid insufficiency (CIRCI). CIRCI, however, is to be distinguished from classical adrenal insufficiency, which may warrant testing in critically ill patients.

Glycemic control

The 2008 SSGs provide a strong recommendation for glycemic control utilizing an insulin drip protocol. However, the recommendation for a specific target (150 mg/dl) is a weak one, reflecting controversy and uncertainty that has prevailed about the appropriate target since publication of the 2004 guidelines.

This summary of the 2008 SSG recommendations is not comprehensive. The document should be read in the original and maintained for reference.