An Opinion Too Far—The Campaign Against the Surviving Sepsis Campaign

Evidence should not be viewed in isolation

After decades of negative multicenter, randomized, placebo-controlled, double-blind clinical trials in patients with critical illness, the last decade witnessed the publication of a series of studies demonstrating an improved outcome for a variety of interventions. These positive studies and interventions have subsequently been brought together into "bundles" of care. This rush to change clinicians' practice has often been with little regard for the context in which the evidence was generated and the problems created by the difference between efficacy and effectiveness. This methodology created a bypass mechanism through which implementation of a package of interventions could be fast-tracked to a much larger group of critically ill patients that differ significantly from those in whom the evidence was generated, without being validated as a bundle. The risk of this process is that the bundle tools will be used for issues such as quality control, performance evaluation, and legal and regulatory purposes without the necessary background of robust validation studies. This has resulted in a "two-weight, two-measures" situation that needs to be resolved to avoid the risk of taking interventions completely out of the context in which the positive results were generated and putting patients and professionals at risk of being harmed by the package of interventions.

The Surviving Sepsis Campaign: a history and a perspective

BACKGROUND

The Surviving Sepsis Campaign (SSC) was launched in 2002 as a collaborative initiative of the European Society of Intensive Care Medicine (ESICM), the International Sepsis Forum (ISF), and the Society of Critical Care Medicine (SCCM). Its objective was, through the development and promulgation of evidence-based guidelines that facilitated the application of knowledge derived from clinical trials to bedside practice, to effect a 25% reduction in the relative risk of death from severe sepsis and septic shock.

METHODS

The evolution and content of the SSC is summarized and the scientific basis of the conclusions is reviewed from the literature.

RESULTS

The SSC developed evidence-based management guidelines and undertook a broad educational program to implement them by integrating their recommendations into resuscitation and management bundles. The process engaged practitioners in North America, Europe, and South America and was supported by professional societies around the world. It also engendered controversy based on accusations of undue industry influence and some dissatisfaction among individuals who were antagonistic toward protocolization of care. By its conclusion, more than 22,000 patients with sepsis had been entered in the SSC database, and analysis of the results showed that participation in the SSC was associated with a 5.4% absolute survival benefit.

CONCLUSIONS

The SSC has impacted the care of septic patients and catalyzed changes that are likely to persist and evolve.