Sepsis is a major cause of death in the ICU. It is a complex disease, and treatment is typically guided by evidence-based guidelines. However, it is important to remember that guidelines provide a systematic approach to patient evaluation and treatment decisions, but they are not a compilation of truth.
The Surviving Sepsis Campaign (SSC) Guidelines are the most reliable guidelines used by the intensive care community for the treatment of sepsis. Experts have invested significant time and effort to formulate these guidelines even though there is very little new evidence. The majority of clinical trials performed over the last few decades have shown no significant beneficial effect of interventions on patient outcomes. While this may suggest that the tested interventions are ineffective, that is not completely the case. It is more likely that certain patients benefit from treatments that are yet to be identified. The broad inclusion criteria used by most clinical trials often dilutes study findings.
Management of patients with sepsis may not always be most effective when adhering to guidelines. What could be more effective is personalised management where clinicians consider the clinical implications of the underlying disease and other factors such as the chronic health status, physiology and physiological reserves. Whenever any intervention is used, it is important to monitor the patient response and based on this response, to alter/preset the intervention accordingly.
Adopting a generalised approach to patient management is indeed less labour intensive, but the importance of individualised management must be recognised. Sepsis is a condition where few interventions improve patient outcomes, especially mortality. It is a disease with a huge spectrum of clinical situations, clinical presentation and response. With so much variability and complexity, treating a condition like sepsis requires a personalised approach to care. This can be done while adhering to guidelines.
In this review, the authors propose how the Surviving Sepsis Campaign guidelines can be adapted to individualise care. These recommendations include:
- Individualising the timing of ICU admission.
- Individualising the decision to admit a patient to the ICU.
- Individualising the timing of antibiotic therapy.
- Individualising the need for and timing of tracheal intubation.
- Individualising respiratory settings in mechanically ventilated patients.
- Individualising oxygenation targets.
- Individualsing sedation therapies.
- Individualising initial fluid resuscitation.
- Individualising fluid therapy.
- Individualising the type of intravenous fluid administered.
- Monitoring chloride levels.
- Individualising the invitation of vasopressor therapy.
- Individualising arterial blood pressure levels.
- Optimising oxygen delivery.
- Using a multimodal approach to assessing tissue perfusion.
- Individualising blood transfusion.
- Individualising administration of inotropic agents.
- Individualising the decision to administer corticosteroids.
- Involving senior colleagues and consultants.
- Measuring and monitoring the effects of any therapeutic measures undertaken.
The goal should always be to do better. And this can only be achieved if clinicians move from a mass approach to more pragmatic approaches tailored to specific patients. For a condition like sepsis, the one size fits all approach does not work, and it is time to acknowledge this reality and adopt a more individualised approach to care.
Source: Critical Care
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