Surviving Sepsis Campaign - Using Bundles in Health Care

Using Bundles in Health Care

Using bundles in health care simplifies the complex processes of the care of patients with severe sepsis. A bundle is a selected set of elements of care distilled from evidence-based practice guidelines that, when implemented as a group, have an effect on outcomes beyond implementing the individual elements alone. Each hospital's sepsis protocol may be customized, but it must meet the standards created by the bundle.

The first 6 hour SSC Resuscitation Bundle includes:

• Blood cultures obtained prior to antibiotic administration.
• serum lactate measured
• Broad-spectrum antibiotics administered within two hours of admission/diagnosis. For every hour a patient is denied AB therapy after the onset of septic shock, the patients chance of survival is reduced by 7.9% (Survivesepsis.org 2005)

Further management is centered around Early Goal Directed Therapy (EGDT).

• In the event of hypotension and/or lactate > 4 mmol/L, delivering an initial minimum of 20 ml/kg of crystalloid or 5mls/kg of colloid. Recent updates to Surviving Sepsis Campaign recommend 30ml/kg bolus.
• Apply vasopressors, usually noradrenaline for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg, in the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L (36 mg/dl):

Resuscitation Goals are:

• To achieve central venous pressure (CVP) of > 8 mm Hg
• To achieve central venous oxygen saturation (ScvO2) of > 70%
• To achieve MAP > 65mmHg and a urine output of >0.5mls/kg/hr

The 24 hour SSC Management Bundle includes:

• Low-dose steroids administered for septic shock in accordance with a standardized ICU policy
• activated protein C administered in certain conditions, this however is controversial with concerns regarding the guidelines being funded by the manufacturer Eli Lilly and Company and a 2011 Cochrane review finding that its use cannot be recommended as it does not improve survival but does increase bleeding risk. On October 25, 2011 Eli Lilly & Co. withdrew Xigris from the market after a major study showed no efficacy for the treatment of sepsis.
• Glucose control maintained below upper limit of normal (8.3 mmol/L) with an insulin sliding scale regime (usually short-acting insulin such as Human Actrapid)
• Lung Protective Ventilator Strategy utilising 5-8 mls/kg tidal volumes for mechanically ventilated patients to avoid volutrauma and barotrauma.