Surviving Sepsis campaign – outcome of severe sepsis can be improved by revising procedural standards

APPROXIMATELY 10 years ago an international diagnostic and classifications standard for sepsis was adopted. It has since provided reliable information on the frequency and prognosis of sepsis. Rather surprisingly, in the earliest studies from the US, it was found that sepsis is a very common cause of death; responsible for more deaths than breast cancer and on par with heart attacks (1). Although there have been no similar studies in Scandinavia, it is not unreasonable to assume that the results of the US study also hold true in Scandinavia. In the US it was found that the frequency of sepsis can be as high as three cases per thousand annually; when applied to Scandinavia, this means that approximately 75,000 cases of sepsis occur every year. As sepsis has a mortality of 30—50%, it is clear that sepsis is a significant issue. Recent studies have shown that it is possible to improve the predicted outcome of sepsis. As cutting-edge research slowly translates to clinical practice, European and US intensive care associations launched the Surviving Sepsis campaign to raise awareness of sepsis and, eventually, develop a global standard for treatment of sepsis (www.survivingsepsis.org). How does one go about improving the outcome of sepsis? A study by Rivers showed that the most effective way to combat sepsis is early diagnosis and treatment [Early Goal Directed Therapy (EGDT)] (2). Treatment aiming to secure adequate tissue oxygenation (fluids, red cells, inotropes) begun at an early stage significantly reduced mortality; while in standard treatment the rate was 45%, the EGDT group had a mortality of 30.5%. The number of patients needed to treat in order to save one (NNT) was six. Intensive care aims not only to support organ function but also to eliminate the cause of infection and contain the immune response to the infection. Surgical treatment of the source of sepsis, when possible, is still the cornerstone of treatment. Also, targeted antimicrobial medication has been proven to reduce mortality. Anti-inflammatory, antitrombotic and fibrinolytic-activated protein C treatment improves the prognosis of sepsis cases (3). A study sample of approximately 1600 patients has shown that this treatment reduces mortality by at least 6.1%; in this study, NNT was 16. Long-term improved prognosis in patients with APACHE II score 25, while there is obviously a benefit for patients with lower scores (4). By developing supporting treatments undertaken during intensive care it should be possible to further improve the prognosis of a patient with sepsis. Sepsis is associated with impaired pulmonary function; if mechanical ventilation is restricted to delivering small volumes during treatment, damage to the lungs can be avoided and mortality due to respiratory dysfunction decreases (5). A US-based study has shown that mortality decreased by 8.8% (31% vs. 39.8%, NNT 11) when volumes delivered via mechanical ventilation were reduced to approximately half of those previously used. Another finding that questions the basics of old sepsis treatment standards is van der Berghe’s finding on the significance of blood glucose in normal ICU patients (6). It was found that among the 1548 patients studied, those subjected to tight control of blood sugar levels during treatment had lower mortality. Patients whose blood sugar was kept at a normal level (4.4—5.6 mmol l ) had a mortality of 4.6%, while a lax control of blood sugar (aim 10.0—11.1 mmol l ) resulted in a mortality of 8.0% (NNT 29). Although the patient sample in this study was chiefly made up of surgical ICU patients, there is no reason to Acta Anaesthesiol Scand 2005; 49: 597—598 Copyright # Acta Anaesthesiol Scand 2005 Printed in UK. All rights reserved ACTA ANAESTHESIOLOGICA SCANDINAVICA