Sepsis ( mis ) management : The hazards of a faith-based approach *

Not long ago, a respected colleague at my hospital asked if our intensive care unit (ICU) had a weaning protocol. I was shocked because we had one for 5 yrs, developed by an enthusiastic team, following published guidelines (1). Although we routinely measure performance, we do not monitor adherence to our weaning protocol. If asked, I would have assumed naively that our practice was excellent and the protocol was followed more closely than it really was. Lesson learned: if you do not track performance, you do not really know what is happening in your unit. The frustrating gap between recommended and actual practice is particularly poignant for sepsis management. When used appropriately, the life-saving potential of individual therapies is staggering: a 16% absolute risk reduction for early goal directed therapy (2), 9% for low tidal volume ventilation (3), 17% for bacteremic patients managed with tight glucose control (4), 10% for low-dose corticosteroids (5), and at least 6% for recombinant activated protein C (6). The impressive math once prompted Dr. Gordon Bernard to suggest at a national meeting that we would soon have more patients leaving the ICU than going in. Although sepsis case fatality rates are decreasing (7), morbidity and mortality remain too high and recommended lifesaving therapies are used too inconsistently (8, 9). In this issue of Critical Care Medicine, Brunkhorst et al. (10) add to a growing list of studies describing the failure to employ evidence-based practice. On a single day in 2003, the investigators studied a random sample of 214 German ICUs, representing a wide range of hospitals, from small community institutions to large ones affiliated with universities. ICU directors were asked how often several evidence-based interventions were used, including low tidal volume ventilation for acute respiratory distress syndrome/acute lung injury, tight glycemic control, activated protein C, and low-dose hydrocortisone. Charts were audited to compare survey responses to actual practice. The authors studied 366 randomly selected patients with severe sepsis or septic shock. A total of 79.9% of ICU directors reported adherence to low tidal volume strategies. However, among patients with acute respiratory distress syndrome/acute lung injury, 80.3% audited were managed with volumes above 8 mL/kg predicted body weight. Similarly, 65.9% of ICU directors reported adherence to strict glucose control whereas 66.2% of patients audited were frankly hyperglycemic. Similar gaps between perceived and actual practice were shown for all strategies studied. Findings were the same for hospitals of all sizes and affiliations, although perceived adherence was higher in larger, academic institutions. This important study has many strengths. It was executed by well-respected investigators from the German Sepsis Competence Network (SepNet) and the quality of data collection was exemplary. The investigators studied a rich array of ICUs, and it is reasonable to consider the findings generalizable beyond Germany. The article does have limitations. Because the investigators focused on maximum tidal volumes and glucose measurements, adherence may seem worse than it really was: a single recording outside the recommended range constituted nonadherence, even if other measurements were acceptable. Use of average or median measurements might have been more convincing. In addition, the study was not designed to identify reasonable decisions to override guidelines, which must have occurred in some patients. Certainly 100% adherence to guidelines would be neither achievable nor desirable. Despite these concerns, it seems appropriate to conclude that practice shortcomings are widespread. Why do our colleagues fail to routinely employ evidence-based practice? Reasons include knowledge deficits, institutional barriers, and thoughtful disagreement (11–15). Strategies to promote adherence seem particularly suited to knowledge deficits and institutional barriers (15). For example, obstacles to using low tidal volumes include the failure to diagnose acute respiratory distress syndrome/acute lung injury and unwarranted concerns about sedation, both of which should be amenable to education (16, 17). Concerns over loss of autonomy (14) could be addressed by including all stakeholders when developing protocols. Potentially useful practices include standardized order sets, bundles, and easily followed algorithms (18–20). Reasoned disputes over guideline content raise a bigger challenge. Legitimate arguments can be made over the science supporting some recommendations (21, 22). The quality of guidelines and consensus statements has been criticized (12) and their content may fail to satisfy some experts (11). New findings can quickly undermine the rationale for certain recommendations such as aggressive glucose management (23). Little debate should remain over the value of low tidal volumes for acute respiratory distress syndrome/acute lung injury. Even allowing for subtle disagreements about study interpretation, consistent evidence supporting low tidal volumes (or against high ones) has essentially created a standard of care (3, 8, 24). Nevertheless, it is not difficult to imagine situations in which rigid adherence to a protocol would be scientifically unsound if not dangerous. For example, to avoid overdistention, the ARDSNet ventilation protocol recommends reducing volumes to as low as 4 mL/kg predicted body weight when plateau pressures exceed 30 cm H2O (3). However, external compression of the lungs, for instance due to abdominal compartment syndrome, could easily push plateau pres*See also p. 2719.