Severe sepsis: international and specialty variations in initial management

Introduction

Four years after release of the Surviving Sepsis Campaign (SSC) guidelines, doctors' approaches to early sepsis resuscitation are unknown. We sought to understand the strategies used in Australasia (ANZ), the United Kingdom and the USA.

Methods

In 2007 we invited members of the UK, US and ANZ intensive care, emergency medicine (EM) and, in the UK, acute internal medicine (AM) societies to answer an anonymous online questionnaire. Respondents described their management of a severe sepsis patient, with multiple choice questions based around eight decision nodes in the SSC 6-hour resuscitation bundle.

Results

The response rate was 21% (2,461/11,795). Guideline compliance was low (Figure 1): 0.1% (n = 2) complied with all recommendations; 2% (n = 32) implemented all but intubation for a persistently low central venous oxygen saturation (ScvO₂); 21% (n = 356) complied with all but intubation plus any one of the other elements. The most marked interspecialty and intercountry differences were as follows. In ANZ, 57% of intensivists and 31% of EM doctors checked lactate at presentation, and 15% and 65% respectively transfused blood for a haematocrit <30% and ScvO₂ < 70%. In the UK, 89% of intensivists and 44% of AM doctors placed an arterial catheter. In the USA, 76% of intensivists inserted a central line; 44% in EM did so. Among EM doctors, in the USA 30% checked lactate compared with 79% in the UK. Among intensivists, only 15% in ANZ targeted central venous pressure (CVP) 8–12 mmHg, compared with 55% in the USA; 15% versus 52% respectively transfused blood when indicated; and 20% and 49% started an inotrope for SvcO₂ < 70%. Time concerns prevented 40% of EM doctors implementing the 6-hour bundle, and 40% of intensivists expressed concern at the transfusion threshold. More than 20% of all respondents felt evidence supporting SSC lacking and preferred tailored care.

Figure 1

(abstract P415)

Conclusion

Despite 4 years of guideline dissemination, the SSC 6-hour resuscitation bundle is not well supported. Management varies between specialties and countries. Concerns relate to knowledge, attitudes and resources, and differ markedly between groups.