Anda di halaman 1dari 8

Intensive Care Med (2018) 44:925–928


The Surviving Sepsis Campaign Bundle:

2018 update
Mitchell M. Levy1*, Laura E. Evans2 and Andrew Rhodes3

© 2018 SCCM and ESICM

Introduction improves outcomes [7–11, 14, 16–21]. The guidelines

The “sepsis bundle” has been central to the implemen- state that these patients need urgent assessment and
tation of the Surviving Sepsis Campaign (SSC) from the treatment, including initial fluid resuscitation while pur-
first publication of its evidence-based guidelines in 2004 suing source control, obtaining further laboratory results,
through subsequent editions [1–6]. Developed separately and attaining more precise measurements of hemody-
from the guidelines publication by the SSC, the bundles namic status. A guiding principle is that these complex
have been the cornerstone of sepsis quality improve- patients need a detailed initial assessment and then ongo-
ment since 2005 [7–11]. As noted when they were intro- ing re-evaluation of their response to treatment. The ele-
duced, the bundle elements were designed to be updated ments of the 2018 bundle, intended to be initiated within
as indicated by new evidence and have evolved accord- the first hour, are listed in Table 1 and presented in the
ingly. In response to the publication of “Surviving Sepsis following. Consistent with previous iterations of the SSC
Campaign: International Guidelines for Management of sepsis bundles, “time zero” or “time of presentation” is
Sepsis and Septic Shock: 2016” [12, 13], a revised “hour-1 defined as the time of triage in the emergency depart-
bundle” has been developed and is presented below ment or, if referred from another care location, from the
(Fig. 1). earliest chart annotation consistent with all elements
The compelling nature of the evidence in the literature, of sepsis (formerly severe sepsis) or septic shock ascer-
which has demonstrated an association between com- tained through chart review. Because this new bundle is
pliance with bundles and improved survival in patients based on the 2016 Guidelines publication, the guidelines
with sepsis and septic shock, led to the adoption of the themselves should be referred to for further discussion
SSC measures by the National Quality Forum (NQF) and and evidence related to each element and to sepsis man-
subsequently both by the New York State (NYS) Depart- agement as a whole.
ment of Health [14] and the Centers for Medicare and
Hour-1 bundle
Medicaid Services (CMS) [15] in the USA for mandated
The most important change in the revision of the SSC
public reporting. The important relationship between the
bundles is that the 3-h and 6-h bundles have been com-
bundles and survival was confirmed in a publication from
bined into a single “hour-1 bundle” with the explicit
this NYS initiative [16].
intention of beginning resuscitation and management
Paramount in the management of patients with sep-
immediately. We believe this reflects the clinical reality
sis is the concept that sepsis is a medical emergency. As
at the bedside of these seriously ill patients with sepsis
with polytrauma, acute myocardial infarction, and stroke,
and septic shock—that clinicians begin treatment imme-
early identification and appropriate immediate manage-
diately, especially in patients with hypotension, rather
ment in the initial hours after development of sepsis
than waiting or extending resuscitation measures over a
longer period. More than 1 h may be required for resusci-
Department of Medicine, Division of Pulmonary/Critical Care Medicine,
tation to be completed, but initiation of resuscitation and
Alpert Medical School at Brown University, Providence, RI, USA treatment, such as obtaining blood for measuring lactate
Full author information is available at the end of the and blood cultures, administration of fluids and antibiot-
This article is being simultaneously published in Critical Care
ics, and in the case of life-threatening hypotension, ini-
Medicine ( and tiation of vasopressor therapy, are all begun immediately.
Intensive Care Medicine.

Fig. 1 Hour-1 Surviving Sepsis Campaign Bundle of Care

Table 1 Bundle elements with strength of recommendations and under-pinning quality of evidence [12, 13]
Bundle element Grade of recommendation and level of evidence
Measure lactate level. Re-measure if initial lactate is > 2 mmol/L Weak recommendation, low quality of evidence
Obtain blood cultures prior to administration of antibiotics Best practice statement
Administer broad-spectrum antibiotics Strong recommendation, moderate quality of evidence
Rapidly administer 30 ml/kg crystalloid for hypotension or lactate ≥ 4 mmol/L Strong recommendation, low quality of evidence
Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain Strong recommendation, moderate quality of evidence
MAP ≥ 65 mm Hg

It is also important to note that there are no published Obtain blood cultures prior to antibiotics
studies that have evaluated the efficacy in important Sterilization of cultures can occur within minutes of the
subgroups, including burns and immunocompromised first dose of an appropriate antimicrobial [29, 30], so cul-
patients. This knowledge gap needs to be addressed in tures must be obtained before antibiotic administration
future studies specifically targeting these subgroups. The to optimize the identification of pathogens and improve
elements included in the revised bundle are taken from outcomes [31, 32]. Appropriate blood cultures include at
the Surviving Sepsis Campaign Guidelines, and the level least two sets (aerobic and anaerobic). Administration of
of evidence in support of each element can be seen in appropriate antibiotic therapy should not be delayed in
Table 1 [12, 13]. We believe the new bundle is an accurate order to obtain blood cultures.
reflection of actual clinical care.
Administer broad-spectrum antibiotics
Measure lactate Empiric broad-spectrum therapy with one or more intra-
level venous antimicrobials to cover all likely pathogens should
While serum lactate is not a direct measure of tissue be started immediately [21] for patients presenting with
perfusion [22], it can serve as a surrogate, as increases sepsis or septic shock. Empiric antimicrobial therapy
may represent tissue hypoxia, accelerated aerobic gly- should be narrowed once pathogen identification and
colysis driven by excess beta-adrenergic stimulation, or sensitivities are established, or discontinued if a decision
other causes associated with worse outcomes [23]. Ran- is made that the patient does not have infection. The link
domized controlled trials have demonstrated a significant between early administration of antibiotics for suspected
reduction in mortality with lactate-guided resuscitation infection and antibiotic stewardship remains an essential
[24–28]. aspect of high-quality sepsis management. If infection
If initial lactate is elevated (> 2 mmol/L), it should be is subsequently proven not to exist, then antimicrobials
remeasured within 2–4 h to guide resuscitation to nor- should be discontinued.
malize lactate in patients with elevated lactate levels as a
marker of tissue hypoperfusion [24].
A absence of any clear combined Acknowledgements
benefit following the inotrope/vasopressor The authors gratefully acknowledge
d Deb McBride and Lori Harmon for
administration of colloid selection in septic shock their
m invaluable assistance with
compared with crystalloid are outlined in a large
i solutions in the combined number of literature
manuscript preparation and
editing (DM) and overall
n subgroups of sepsis, in reviews [38–47]. support for this work (DM and
i con- junction with the LH).
expense of albumin, S Compliance with ethical
supports a strong u standards
recommendation for the m Conflicts of interest
use of crystalloid
r m Dr. Levy is a Member of the Surviving
Sepsis Campaign Executive
solutions in the initial
resuscitation of patients a Committee
and is a Surviving Sepsis
i with sepsis and septic r Campaign Guidelines Author. Dr.
Evans is a Member of the
n shock. Because some y Surviving Sepsis Campaign
evidence indicates that a Previous iterations of the Steering Committee and is a
sustained positive fluid sepsis bundle were Surviving
r balance during ICU stay is introduced Sepsis Campaign Guidelines Co-
Chair. Dr. Rhodes is a Member of the
a harmful [33–37], fluid as a means of providing Surviving Sepsis Campaign
v administration beyond education and Executive Committee and is a
improvement related to Surviving Sepsis Campaign
e initial resuscitation
Guidelines Co-Chair.
requires careful sepsis management. The
n literature supports the use
assessment of the
o likelihood that the of sepsis bundles for Received: 5 January 2018
Accepted: 1 February 2018
u patient remains fluid improving outcomes in Published online: 19 April 2018
s responsive. patients with sepsis and
septic shock. This new
A sepsis “hour-1 bundle,”
p based on the 2016 References
l p guidelines, should be 1. Dellinger RP, Carlet JM, Masur H
et al (2004) Surviving Sepsis
u l intro- duced to emergency Campaign
Management Guidelines
i y department, floor, and
Committee. Surviving Sepsis
d ICU staff as the next Campaign guide- lines for
Early effective fluid iteration of ever- management of severe
v improving tools in the sepsis and septic shock. Crit
resuscitation is crucial for Care Med
the stabi- a care of patients with 32:858–873
lization of sepsis-induced s sepsis and septic shock as 2. Dellinger RP, Carlet JM, Masur
H et al (2004) Surviving Sepsis
tissue hypoperfusion or o we all work to lessen the
Campaign Management
septic shock. Given the p global burden of sepsis. Guidelines Committee.
urgent nature of this Surviving Sepsis Campaign
r A guide- lines for management
medical emer- gency, e of severe sepsis and septic
initial fluid resuscitation shock. Intensive Care Med
s t 30:536–555
should begin imme-
diately upon recognizing s h
3. Dellinger RP, Levy MM, Carlet
JM et al (2008) Surviving
a patient with sepsis o o Sepsis Campaign:
and/or hypotension and r r
international guidelines for
management of severe
elevated lactate, and s sepsis and septic shock: 2008.
completed within Urgent restoration of an Crit Care Med 36:296–327
3 h of recognition. The adequate perfusion 4. Dellinger RP, Levy MM, Carlet
pressure to e JM et al (2008) Surviving
guidelines recommend Sepsis Campaign:
this should comprise a the vital organs is a key t international guidelines for
minimum of 30 ml/kg of part of resuscitation. This a management of severe
should not be delayed. If sepsis and septic shock:
intravenous crystalloid i 2008. Intensive Care Med
fluid. Although little blood pressure is not 34:17–60
literature includes con- restored after ini- tial fluid 5. Dellinger RP, Levy MM,
resuscitation, then s Rhodes A et al (2013)
trolled data to support 1
Department of Medicine, Surviving Sepsis Campaign:
this volume, recent vasopressors should be Division of Pulmonary/Critical international guidelines for
interventional studies com- menced within the Care Medicine, Alp- management of severe
ert Medical School at Brown sepsis and septic shock, 2012.
have described this as first hour to achieve
University, Providence, RI, USA. 2 Intensive Care Med 39:165–
usual practice in the early mean arterial pressure New York Univer- sity School of 228
(MAP) of ≥ 65 mm Hg. Medicine, New York, NY, USA. 3 St. 6. Dellinger RP, Levy MM,
stages of resuscitation, and
The physiologic effects of George’s University Hospitals NHS Rhodes A et al (2013)
observational evidence is Foundation Trust and St George’s Surviving sepsis campaign:
sup- portive [7, 8]. The vasopressors and University of London, London, UK. international guidelines for
management of severe
sepsis and septic shock:
2012. Crit Care Med 41:580–
7. Levy MM, Dellinger RP,
Townsend SR et al (2010)
Surviving Sepsis Campaign.
The Surviving Sepsis
Campaign: results of an
international guideline-
based performance
improvement program
targeting severe sepsis. Crit
Care Med 38:367–374
8. Levy MM, Rhodes A, Phillips
GS et al (2015) Surviving
Sepsis Campaign:
association between
performance metrics and
outcomes in a 7.5-year
study. Crit Care Med 43:3–
9. Levy MM, Pronovost PJ,
Dellinger RP et al (2004)
Sepsis change bundles:
converting guidelines into
meaningful change in
behavior and clinical
outcome. Crit Care Med
10. Damiani E, Donati A, Serafini
G et al (2015) Effect of
performance improvement
programs on compliance
with sepsis bundles and
mortal- ity: a systematic
review and meta-analysis of
observational studies. PLoS
One 10:e0125827
11. Rhodes A, Phillips G, Beale R
et al (2015) The Surviving
Sepsis Cam- paign bundles
and outcome: results from
the International
Multicentre Prevalence
Study on Sepsis (the
IMPreSS study). Intensive
Care Med
12. Rhodes A, Evans L, Alhazzani W
et al (2017) Surviving sepsis
international guidelines for
management of sepsis and
septic shock:
2016. Crit Care Med 45:486–552
13. Rhodes A, Evans L,
Alhazzani W et al (2017)
Surviving sepsis campaign:
International guidelines for
management of sepsis and
septic shock:
2016. Intensive Care Med
death-moves- state-to-action-
Accessed on 27 December
15. Lactate clearance vs central 31. Cardoso T, Carneiro AH, 42. Bollaert PE, Bauer P, venous oxygen saturation Ribeiro O et al (2010) Audibert G et al (1990)
Newsroom/MediaRelea as goals of early sepsis Reducing mortality in severe Effects of epinephrine on
seDatabase/Fact- therapy: a randomized sepsis with the hemodynamics and
sheets/2014-Fact- clinical trial. JAMA 303:739– implementation of a core 6- oxygen metabolism in
sheets-items/2014-08- 746 hour bundle: results from the dopamine-resistant septic
04-2.html. Accessed on 26. Lyu X, Xu Q, Cai G et al (2015) Portuguese community- shock. Chest 98:949–953
28 Efficacies of fluid resuscitation acquired sepsis study 43. Levy B, Bollaert PE,
December 2017) as guided by lactate clearance (SACiUCI study). Crit Care Charpentier C et al (1997)
16. Seymour CW, Gesten F, rate and central venous 14:R83 Comparison of norepi-
Prescott H et al (2017) oxygen saturation in patients 32. De Sousa AG, Fernandes nephrine and dobutamine to
Time to treatment and with septic shock. Zhonghua Junior CJ, Santos GPD et al epinephrine for
mortality during Yi Xue Za Zhi 95:496–500 (2008) The impact of each hemodynamics, lactate
mandated emergency 27. Tian HH, Han SS, Lv CJ et al action in the Surviving Sepsis metabolism, and gastric
care for sepsis. N Engl J (2012) The effect of early Campaign measures on tonometric variables in septic
Med goal lactate clear- ance rate hospital mor- tality of patients shock: a prospec- tive,
376:2235–2244 on the outcome of septic with severe sepsis/septic randomized study. Intensive
17. Liu VX, Morehouse JW, shock patients with severe shock. Einstein 6(3):323–327 Care Med 23:282–287
Marelich GP et al (2016) pneumo- nia. Zhongguo Wei 33. Acheampong A, Vincent 44. Zhou SX, Qiu HB, Huang YZ
Multicenter implementa- tion Zhong Bing Ji Jiu Yi Xue JL (2015) A positive fluid et al (2002) Effects of
of a treatment bundle for 24:42–45 balance is an inde- norepinephrine,
patients with sepsis and 28. Yu B, Tian HY, Hu ZJ et al pendent prognostic epinephrine, and
intermediate lactate values. (2013) Comparison of the factor in patients with norepinephrine-
Am J Respir Crit Care Med effect of fluid resus- citation sepsis. Crit Care 19:251 dobutamine on systemic
193(11):1264–1270 as guided either by lactate 34. Brotfain E, Koyfman L, and gastric mucosal
18. Leisman DE, Doerfler ME, clearance rate or by central Toledano R et al (2016) oxygenation in septic shock.
Ward MF et al (2017) venous oxygen saturation Positive fluid balance as a Acta Pharmacol Sin 23:654–
Survival benefit and cost in patients with sepsis. major predictor of clinical 658
savings from compliance Zhonghua Wei Zhong Bing outcome of patients with 45. Mackenzie SJ, Kapadia F,
with a simplified 3-hour Ji Jiu Yi Xue 25:578–583 sepsis/septic shock after ICU Nimmo GR et al (1991)
sepsis bundle in a series of 29. Zadroga R, Williams DN, discharge. Am J Emerg Med Adrenaline in treatment of
prospective, multisite. Gottschall R et al (2013) 34:2122–2126 septic shock: effects on
Observational cohorts. Crit Comparison of 2 blood 35. Mitchell KH, Carlbom D, haemodynamics and oxygen
Care Med culture media shows Caldwell E et al (2015) transport. Inten- sive Care
45:395–406 significant differences in Volume overload: preva- Med 17:36–39
19. Ferrer R, Martin-Loeches I, bacterial recovery for lence, risk factors, and 46. Moran JL, O’Fathartaigh
Phillips G et al (2014) patients on antimicrobial functional outcome in MS, Peisach AR et al (1993)
Empiric antibiotic treatment therapy. Clin Infect Dis survivors of septic shock. Epinephrine as an
reduces mortality in severe 56:790–797 Ann Am Thorac Soc inotropic agent in septic
sepsis and septic shock 30. Kanegaye JT, 12:1837–1844 shock: a dose-profile
from the first hour: results Soliemanzadeh P, Bradley JS 36. de Oliveira FS, Freitas FG, analysis. Crit Care Med
from a guideline-based (2001) Lumbar puncture in Ferreira EM et al (2015) 21:70–77
performance improvement pediatric bacterial Positive fluid balance as a 47. Yamazaki T, Shimada Y,
program. Crit Care Med meningitis: defining the prognostic factor for mortality Taenaka N et al (1982)
42:1749–1755 time interval for recovery of and acute kidney injury in Circulatory responses to
20. Kumar A, Roberts D, Wood KE cerebrospinal fluid severe sepsis and septic afterloading with
et al (2006) Duration of pathogens after parenteral shock. J Crit Care 30:97–101 phenylephrine in
hypotension before initiation antibiotic pretreatment. 37. Malbrain ML, Marik PE, hyperdynamic sepsis. Crit
of effective antimicrobial Pediatrics 108:1169–1174 Witters I et al (2014) Fluid Care Med
therapy is the critical overload, de-resus- citation, 10:432–435
determinant of survival in and outcomes in critically ill
human septic shock. Crit Care or injured patients: a
Med 34:1589–1596 systematic review with
21. Kumar A (2016) Systematic suggestions for clinical
bias in meta-analyses of time practice. Anaesthesiol
to antimicrobial in sepsis Intensive Ther
studies. Crit Care Med 46:361–380
44:e234–e235 38. Day NP, Phu NH, Bethell DP et
22. Levy B (2006) Lactate and al (1996) The effects of
shock state: the metabolic view. dopamine and adrenaline
Curr Opin Crit infusions on acid-base balance
Care 12:315–321 and systemic haemodynamics
23. Casserly B, Phillips GS, in severe infection. Lancet
Schorr C et al (2015) 348:219–223
Lactate measurements in 39. De Backer D, Creteur J, Silva E
sepsis-induced tissue et al (2003) Effects of
hypoperfusion: results dopamine, norepi- nephrine,
from the Surviving Sepsis and epinephrine on the
Campaign database. Crit splanchnic circulation in
Care Med 43:567–573 septic shock: which is best?
24. Jansen TC, van Bommel J, Crit Care Med 31:1659–1667
Schoonderbeek FJ et al (2010) 40. Martin C, Papazian L, Perrin
LACTATE study group. Early G et al (1993)
lactate-guided therapy in Norepinephrine or
intensive care unit patients: a dopamine for the treatment
multicenter, open-label, of hyperdynamic septic
randomized controlled trial. shock? Chest 103:1826–
Am J Respir Crit Care Med 1831
182:752–761 41. Martin C, Viviand X, Leone M
25. Jones AE, Shapiro NI, et al (2000) Effect of
Trzeciak S et al (2010) norepinephrine on the
Emergency Medicine Shock outcome of septic shock. Crit
Research Network Care Med 28:2758–2765
(EMShockNet) Investigators.