ACEP endorsed the latest iteration of the Surviving Sepsis Campaign (SSC) guidelines, totaling 67 pages with 93 statements on early management and 655 references.1,2 An important note: Guidelines should be a counselor, not a jailer. Guidelines provide a framework for direction and standardization where possible but require clinical context for individual patients. This summary includes items specifically pertinent to emergency medicine and is not intended to be all-inclusive.
Explore This IssueACEP Now: Vol 36 – No 03 – March 2017
All the data informing guideline development were based on the established definitions, not Sepsis-3. The Sepsis-3 and established definitions were modified for the purpose of guideline application.3 In the 2016 SSC guidelines, sepsis equates to the established definitions of severe sepsis (infection + organ dysfunction, including hyperlactemia) and septic shock (hypotension ± lactate). The Quick Sepsis Related Organ Failure Assessment (qSOFA) did not inform any part of the guidelines. ACEP and other organizations did not support or endorse the Sepsis-3 definitions due to patient safety concerns.4,5 The SSC guidelines acknowledged that:
- There is insufficient data to apply the Sepsis-3 definitions to the guidelines.
- Lactate is important and part of the established definition of severe sepsis (or sepsis in the guidelines). Additionally, the guidelines highlight the importance of lactate normalization. Both early monitoring and early management of hyperlactemia are key components of emergent resuscitation and patient care principles important in ACEP’s decision to support the guidelines when it did not support the Sepsis-3 definitions.
Consistent with the law of unintended consequences, even when compatible care is provided, clinicians implementing Sepsis-3 definitions may appear to provide worse care than those using established definitions on national quality metrics (see Table 1). So now there are three definitions: the established definitions, the SSC definitions that are based on the established definitions, and the Sepsis-3 definitions (see Table 1). What a mess. Which ones do we use? I suggest that we use the established definitions for care.
Perhaps future prospective evaluation will support the use of Sepsis-3 and qSOFA. However, that should be played out in further academic work and not via national payment metrics.