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Hot in Journal CHEST® January 2019

By: Dr. Deep Ramachandran

Deep Ramachandran 2017Each month, we ask our Social Media Co-Editors of CHEST, to weigh in on the hot topics in CHEST. It's January, so let's hear from Dr. Ramachandran as he outlines his highlights. After reviewing the issue, be sure to share your hot list on our Facebook wall, tweet with the hashtag #journalCHEST, or discuss in the CHEST LinkedIn group.




It’s Time to Retire the Surviving Sepsis Guidelines: Or Is It?

Sepsis is a controversial topic. From the initial Rivers and colleagues study to today, the diagnosis and management of this condition has been fraught with controversy. This debate has culminated most recently in 2018, when the Surviving Sepsis Campaign (SSC) revised its 3- and 6-hour bundle recommendations into a “Hour-1 bundle.” That prompted a strong response from the SSC’s detractors, including an online petition to retire and replace the SSC’s guidelines altogether. The January 2019 issue of CHEST® features perhaps the most fascinating pro-con debate we’ve ever published. The debate is led by two prominent critical care physicians: Paul Marik, MD, FCCP, on one side, and Mitchell Levy, MD, FCCP, who serves as an SSC guidelines author, on the opposing side. The most relevant points from this point-counterpoint have been amalgamated below. The full article is a fascinating read and is highly recommended.

Point: Should the Surviving Sepsis Guidelines Be Retired? Yes.

  • The development of the Surviving Sepsis Guidelines was sponsored by industry.
  • The guidelines have a “track record of making strong recommendations based on weak evidence and being poorly responsive to new evidence.”
  • Aside from antibiotics, other elements of sepsis bundles have been found to be devoid of scientific evidence of positive patient outcomes.
  • The Infectious Disease Society of America did not endorse the 2016 guidelines due to concerns of excessive antibiotic use and excessively rigid timelines.
  • Pressuring EDs to comply with bundles has caused patient harm.
  • The 2018 recommendations effectively “double down” on the previous recommendations, despite a lack of evidence.

Reference
Marik PE, Farkas JD, Speigal R, et al. POINT: Should the surviving sepsis campaign guidelines be retired? Yes. Chest. 2019;155(1):12-14.

Counterpoint: Should the Surviving Sepsis Guidelines Be Retired? No.

  • Surviving Sepsis Campaign received industry funding until 2006 and has been free of it since that time.
  • “Most recent SSC guidelines (2016) were sponsored by 35 international professional medical societies and have emerged as the global standard for sepsis management.”
  • Hospitals with better compliance with bundles have better survival compared with those that do not.
  • A significant 4.4% reduction in absolute mortality was seen in New York State, associated with timely completion of the 3-h bundle. Conversely, mortality increased for each hour delay in completion of the 3-h bundle.
  • The Hour-1 bundle stresses that septic shock should be recognized as a medical emergency with intervention initiated within the first hour. It recognizes that all elements will not be completed, only initiated within an hour.
  • It has been subsequently recommended that the Hour-1 bundle not be implemented in the United States and not be adopted as a quality indicator by regulatory agencies.

Reference
Levy MM, Rhodes A, Evans LE, et al. COUNTERPOINT: Should the surviving sepsis campaign guidelines be retired? No. Chest. 2019;155(1):14-17.

Point: Rebuttal

  • Studies that claim to support improved outcomes due to 3-hour and 6-hour sepsis bundles have a number of flaws, which include methodological flaws and bias.
  • Combination of these bundles into a 1-hour bundle is “arbitrary” for which “no evidence seems to exist.”
  • Countries that have not implemented SSC bundles have shown reduction in sepsis mortality. This suggests global improvements in care, not sepsis bundles, have resulted in improved mortality.

Reference
Marik PE, Farkas JD, Speigal R, et al. Rebuttal from Drs Marik, Farkas, Spiegel et al. Chest. 2019;155(1):17-18.

Counterpoint: Rebuttal

  • Despite claims otherwise, new SSC guidelines have responded to new evidence, such as removal of recommendations for tight glucose control, drotrecogin alfa, and central line placement.
  • Evidence to support the benefits of bundle implementation is robust, and there is no evidence of demonstrated harm from implementation of these bundles.
  • The Hour-1 bundle recognizes that earlier initiation of elements of the bundle can improve patient outcomes.

Reference
Levy MM, Rhodes A, Evans LE, et al. Rebuttal from Drs Levy, Rhodes, and Evans. Chest. 2019;155(1):19-20.