CICM SAQ 2015.2 Q12

Question

Outline the strengths and limitations of the current Surviving Sepsis Campaign Guidelines, using examples to illustrate your points.

Answer

Answer and interpretation

Strengths:

  • The guidelines are formulated by an international panel of experts reviewing and grading the
    evidence.
  • Use of the Grading of Recommendations Assessment Development and Evaluation (GRADE) for
    guideline development.
  • GRADE separates the assessment of the quality of the evidence from the ultimate strength
    of the recommendations (allows for strong recommendations when the quality of evidence is weak or weak recommendations when the quality of evidence is strong, particularly when patient values and preferences may strongly factor into the equation).
  • Intensivists may use as a decision-making tool in their practice as:
    • Information to aid practice
    • An established source of references
    • Reduce variations in clinical practice
    • The current recommendations may generate areas for future research and consensus statements for this high-risk and high-cost patient group.

Limitations

  • The GRADE system, although transparent, is still subjective. Recommendations depend greatly on
    the values and preferences of the committee members.
  • Guidelines attempt to include nearly every aspect of critical care potentially related to sepsis,
    thereby losing focus in the process and becoming a general ICU guideline.
  • A narrower guideline dedicated to sepsis-specific management might be more useful.
  • Complexity and diversity of sepsis may defy a single guideline for all cases.
  • Guidelines may rapidly become out-dated
    • E.g. the 2012 guidelines on prone positioning for patients with PaO2/FiO2 ratios < 100 despite such manoeuvres (Grade 2C). This would now potentially be (1B)
    • Recommends use of proton pump inhibitors over histamine-2 receptor antagonist for stress ulcer prophylaxis (grade 2C), although the emerging consensus suggests that this approach may not be beneficial and indeed may even be harmful.
  • There are recommendations that may be considered controversial
    • E.g. Conservative fluid strategy in patients with sepsis-induced adult respiratory distress syndrome in the absence of evidence of tissue hypo perfusion (grade 1C)
  • The guidelines emphasize ‘bundles’ of care for sepsis resuscitation, although the evidence behind some of the bundled recommendations is not strong, for example using central venous pressure readings to guide volume resuscitation.
  • Significant risk that bundles will be utilised as quality measures with which Intensivist (who may validly disagree with some of the recommendations) treating sepsis will be assessed/benchmarked.
  • Pass rate: 52%
  • Highest mark: 8.1
Exams LITFL ACEM 700

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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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