For patients with sepsis, a serious infection causing widespread inflammation, immediate treatment is essential to improve the chances of survival. An updated “Hour-1 Bundle” of the international, evidence-based guidelines for treatment of sepsis has been released.
The 2018 update of the Surviving Sepsis Campaign (SSC) focuses on five treatment steps that healthcare professionals should initiate within the first hour after recognising sepsis. “Like multiple trauma, heart attack, or stroke, sepsis is a medical emergency,” comments Dr Mitchell M Levy, of Brown University School of Medicine, lead author of the latest SSC update. “Our revised Hour-1 Bundle reflects the clinical reality at the bedside of seriously ill patients with sepsis or septic shock – with the explicit intention of beginning resuscitation and management immediately.”
Sepsis is a common and potentially life-threatening condition, occurring when the immune system mounts an overwhelming inflammatory response to infection in the blood or elsewhere in the body. Septic shock occurs when sepsis leads to a sharp drop in blood pressure and other metabolic abnormalities, with a risk of progression to organ failure.
The SSC is a global cooperative effort to improve treatment of sepsis and reduce its associated high mortality rate. The first SSC treatment bundle was introduced in 2004, followed by frequent updates in response to new evidence. Studies have shown significant reductions in the risk of sepsis-related death after implementation of the SSC guidelines.
Reflecting the latest evidence, the Hour-1 Bundle highlights five steps that healthcare professionals should begin as soon as sepsis is recognized: measure the blood lactate level. A high lactate level may indicate that the tissues are not getting enough oxygen from the blood and may identify a patient at higher risk of further deterioration; perform blood cultures to identify the cause of the infection. Blood samples should be taken before antibiotics are administered, if possible; administer broad-spectrum antibiotics that are active against the causative organism; start intravenous fluids. Fluid resuscitation is an essential step to stabilise the patient’s condition; and administer vasopressors to raise blood pressure. This is a critical resuscitation step in patients with septic shock.
“There is no reason to delay treatment for patients with sepsis and septic shock,” Levy comments. “Recognising the urgent need to treatment, clinicians must (and many already do) begin treatment immediately, rather than waiting for 3 or 6 hours in these critically ill patients.”
The authors point out that the new revision is based on the 2016 SSC guidelines update, which provides further discussion and evidence related to each step and to comprehensive management of sepsis. They also note some important gaps in current knowledge, including the need for further studies in important subgroups such as patients with burns and compromised immune function.
Levy and co-authors emphasise that the Hour-1 Bundle should be implemented in emergency departments, intensive care units, and throughout the hospital “as the next iteration of ever-improving tools in the care of patients with sepsis and septic shock as we all work to lessen the global burden of sepsis.”
The SSC is a joint collaboration between SSCM and the European Society of Intensive Care Medicine (ESICM), committed to reducing mortality and morbidity from sepsis and septic shock worldwide.
The “sepsis bundle” has been central to the implementation of the Surviving Sepsis Campaign (SSC) from the first publication of its evidence-based guidelines in 2004 through subsequent editions (1–6). Developed separately from the guidelines publication by the SSC, the bundles have been the cornerstone of sepsis quality improvement since 2005 (7–11). As noted when they were introduced, the bundle elements were designed to be updated as indicated by new evidence and have evolved accordingly. In response to the publication of “Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” (12, 13), a revised “hour-1 bundle” has been developed and is presented below (Fig. 1).