Debates focus on controversies in Surviving Sepsis Campaign Guidelines

Angel O. Coz Yataco, MD, FCCP
Angel O. Coz Yataco, MD, FCCP

The latest iteration of the Surviving Sepsis Campaign (SSC) Guidelines, published in 2021, continues to generate controversy.

The 2021 SSC Guidelines maintained an intravenous fluid recommendation of 30 mL/kg for resuscitation in patients with tissue hypoperfusion/septic shock and the addition of vasopressin instead of escalating the dose of norepinephrine. The SSC also suggested balanced crystalloids over normal saline and made no recommendation on restrictive vs liberal approaches to fluid administration in sepsis.

“There is always a lot of controversy when recommendations come out in comparison to what clinicians feel they should do in the best interests of their patients,” said Angel O. Coz Yataco, MD, FCCP, staff pulmonologist and critical care specialist at the Cleveland Clinic Respiratory Institute. “There have been some changes in the SSC recommendations, and this will be the first live CHEST meeting since the guidelines came out. It is an excellent venue to discuss the pros and cons of those recommendations.”

Two sessions will be devoted to the SSC 2021 Guidelines at CHEST 2022. The first, Surviving Sepsis: Standardized vs Individualized Volume Resuscitation and Choice of Vasopressors, will feature two debates on Monday, October 17, from 11:00 AM – 12:00 PM CT, in Room 101DE. Laura Evans, MD, MSc, FCCP, professor of pulmonary, critical care and sleep medicine and medical director of critical care at University of Washington Medical Center, will argue that 30 mL/kg is a good start for most patients with sepsis.

Bennett deBoisblanc, MD, FCCP, professor of medicine and physiology at Louisiana State University and director of critical care services at Medical Center of Louisiana, will argue that one size does not fit all when it comes to fluids. Some in the sepsis community see more convincing evidence for an individualized approach to fluids, especially in patients with heart failure and/or chronic kidney disease.

There are similarly divergent approaches to the choice of vasopressors in profound shock.

There is broad consensus for the use of norepinephrine as the first-line vasopressor, Dr. Coz Yataco noted, and significant variability in practice over when, or if, to add vasopressin. The SSC Guidelines recommend the addition of vasopressin rather than increasing norepinephrine. While this can be a more costly intervention, the evidence is conflicting when it comes to patient outcomes.

Namita Jayaprakash, MBBCh, critical care and emergency medicine specialist and physician lead for the sepsis program at the Henry Ford Health System, will argue in favor of high-dose norepinephrine. Seth Bauer, PharmD, medical intensive care unit clinical specialist at the Cleveland Clinic, will argue the advantages of adding vasopressin early on patient outcomes.

Dr. Coz Yataco will chair the second session, Surviving Sepsis: Controversies in Choice of Fluid Type and Liberal vs Restrictive Approach, with two debates on Tuesday, October 18, from 9:15 AM – 10:15 AM CT, in Room 101DE.

Matthew Semler, MD, assistant professor of medicine and biomedical informatics at Vanderbilt University Medical Center, will argue for balanced solutions in sepsis. Jayshil Patel, MD, associate professor of critical care medicine at the Medical College of Wisconsin, will take a second look at evidence that purports to support balanced solutions.

Liberal vs restrictive approaches in fluid administration is one of the hottest topics in sepsis.

“For a number of years, we were aggressive with fluid resuscitation,” Dr. Coz Yataco explained. “But then we learned that too liberal fluid administration could be harmful. There is movement to not giving so much fluid and focus on vasopressors to manage blood pressure. The SSC Guidelines did not make a recommendation due to heterogeneous evidence.”

Catherine Chen, MD, associate professor of pulmonary and critical care medicine at the University of Texas Southwestern Medical Center, will argue that a restrictive fluid approach is better for patients with sepsis. Dr. Coz Yataco will argue for a closer look at the outcomes of restrictive approaches.

“We know that being too liberal in giving fluids is bad, but I don’t know that we have enough evidence to make blanket statements about liberal or restrictive,” Dr. Coz Yataco said. “What was a restrictive approach in one study was comparable to the liberal approach of another study. Until we settle on what restrictive actually means, I don’t know that we can translate that into clinical practice.”

CHEST 2023 Call for Topics

Help shape the curriculum for CHEST 2023, October 8–11 in Hawaiʻi! Submit topic ideas from areas you’re passionate about, issues affecting your practice, or new technologies you’d like to learn more about. But don’t delay. Submissions are due Monday, December 5, 2022, at 12:00 PM CT.