Millions of people die each year from sepsis and septic shock. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection (JAMA 2016;315:801-10).
The Surviving Sepsis Campaign (SSC) formed in 2002 as a joint collaboration of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). The campaign's mission is the reduction of morbidity and mortality from sepsis and septic shock worldwide. In October 2021, the SSC released their 5th edition of International Guidelines for Management of Sepsis and Septic Shock (Crit Care Med 2021;49:e1063-1143).Previous versions were released in 2004, 2008, 2012, and 2016 (Crit Care Med 2021;49:1974-82). Overall, there are 93 statements in the updated guidelines. Fifteen of the statements are strong recommendations, 54 are weak recommendations, 15 are best practice statements, and nine statements make no recommendation regarding a specific intervention (Crit Care Med 2021;49:1974-82). Separate guidelines exist for sepsis in children and for the management of COIVD-19 patients (Pediatr Crit Care Med 2020;21:e52-106; Crit Care Med 2021;49:e219-34). Recommended care bundles are published separately. The updated recommendations are intended to guide clinical care of adult patients with sepsis and septic shock, not replace clinicians' decision-making.
Why it matters
These guidelines are important to anesthesiologists, who must often weigh the risks of managing unstable or critically ill patients in the perioperative period or in the ICU. It is imperative that appropriate time-critical in sepsis and septic shock management be understood and continued as needed throughout a patient's hospital course. The SSC has not updated their guidelines since 2016, and new evidence has emerged. The 2021 guidelines demonstrate greater consideration for patients' post-ICU course.
Six recommendations are new or have changed since 2016. The guidelines now suggest balanced crystalloids over normal saline for resuscitation based on realized adverse effects such as hyperchloremic acidosis and evidence of improved mortality with balanced fluids. When needed, peripherally infused vasopressors were deemed safer than delaying initiation of vasopressor medications while awaiting central venous access. Despite increasing interest in the use of vitamin C in sepsis patients, no mortality benefit has been found. Using corticosteroids in patients with ongoing shock who are receiving vasopressor medications is a weak recommendation in these guidelines. Reduction in shock and the number of days on vasopressor medications was felt to outweigh the risks of neuromuscular weakness and lack of demonstrated mortality benefit with corticosteroid use. The SCC continues to recommend the Hour-1 bundle addressing initial resuscitation, obtaining blood cultures, early antibiotics, measurement of serum lactate, and using vasopressor medications for shock.
Although evidence is still greater for high-resourced settings, there is greater consideration for patients and practitioners in resource-limited settings. Readers should be aware of the risks of liberal fluid strategies in both children and adults with septic shock in Sub-Saharan Africa, as there is evidence that liberal fluid administration can increase mortality in both groups (N Engl J Med 2011;364:2483-95; JAMA 2017;318:1233; Crit Care 2020;24:286). Patients travel, as do providers, thus increasing the relevance of this context-specific evidence and the importance of vigilance in perioperative and ICU clinicians.