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Intensive Care Med (2018) 44:925–928

https://doi.org/10.1007/s00134-018-5085-0

SPECIAL EDITORIAL

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-
*Correspondence: mitchell_levy@brown.edu
1
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-
article
This article is being simultaneously published in Critical Care
ics, and in the case of life-threatening hypotension, ini-
Medicine (https://doi.org/10.1097/CCM.0000000000003119) and tiation of vasopressor therapy, are all begun immediately.
Intensive Care Medicine.
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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].
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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
s
supports a strong u standards
t
recommendation for the m Conflicts of interest
e
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
t
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,”
f
p based on the 2016 References
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Department of Medicine, Surviving Sepsis Campaign:
this volume, recent vasopressors should be Division of Pulmonary/Critical international guidelines for
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have described this as first hour to achieve
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