Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021

Abstract

The Surviving Sepsis Campaign (SSC) International Guidelines for the Management of Sepsis and Septic Shock provide guidance on the care of hospitalized adult patients with (or at risk for) sepsis, based on systematic summary and assessment of relevant literature. This executive summary reviews the history, scope, methodology, and major recommendations of the guidelines, focusing on aspects that are new or different compared with the 2016 guidelines that were published in 2017. Full description of the guidelines process and recommendations are provided in the complete guidelines document. HISTORY AND SCOPE OF THE GUIDELINES The SSC first published guidelines for the management of severe sepsis and septic shock in 2004. Updates were published in 2008, 2012, and 2017. The guidelines are sponsored by the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM), with methodological support by the Guidelines in Intensive Care Development and Evaluation (GUIDE) group, and endorsement by 24 additional societies. There is no funding from any industry partner. Panel membership, patient involvement, and conflict of interest management are discussed in the complete guidelines document. The guidelines provide recommendations on the management of sepsis, focusing on aspects of care specific to sepsis and limiting duplication with other guidelines wherever possible. It is not intended to replace clinical judgement, which must account for the unique circumstances of an individual patient. Following the recommendation of SCCM and ESICM, there are now separate guidelines for sepsis in children (1). The SSC also published separate guidelines specific to the management of COVID (2,3). The 2021 guidelines largely apply to high-resource settings but discuss applicability of the recommendations to lower-resource settings as data allow. The SSC also creates sepsis bundles (4) (a selected set of interventions or processes of care distilled from evidence-based practice guidelines) to facilitate quality improvement and implementation of guidelines recommendations. However, the bundles are developed via a separate process and published separately from the guidelines. Definitions The guidelines recognize sepsis as life-threatening organ dysfunction secondary to a dysregulated host response to infection consistent with the Sepsis-3 consensus definition (5). However, studies were not required to use a particular sepsis definition to be considered as relevant evidence for the guidelines. Question Development and Outcome Prioritization Guidelines questions were selected based on panel rating, clinical practice variability, and inclusion in prior SSC guidelines, and then assigned to one of six SSC adult guidelines working groups: screening and initial resuscitation; infection; hemodynamics; ventilation; additional therapies; and goals of care and long-term outcomes. Clinical practice variation was identified through a global survey of SCCM and ESICM members regarding their current practice and how it related to previous recommendations. All questions were structured in the Population, Intervention, Control, and Outcomes (PICO) format. For each question, relevant outcomes were enumerated and ranked prior to the literature search. Search Strategy and Evidence Summation Professional librarians drafted and executed the search strategy for each PICO question (or group of similar questions), with input from subgroup members. Only English language studies published before May 2019 were included (the lag was the result of the guideline review and approval process coupled with the COVID-19 pandemic). For PICO questions addressed in the 2016 guidelines, the search strategy was revised and updated. Reviewers in the systematic review team, with input from methodologists and experts, screened article titles and abstracts to identify the highest quality evidence, particularly recent randomized controlled trials and high-quality systematic reviews. When new or updated meta-analyses were required, relevant data were abstracted with emphasis on intention-to-treat data where possible and conventional meta-analytic techniques were used to produce pooled estimates. Quality of Evidence and Formulation of Recommendations Using the GRADE approach, methodologists and panelists assessed the quality of evidence for each PICO question as high, moderate, low, or very low. Using the Evidence-to-Decision (EtD) framework (6), each subgroup drafted preliminary recommendations for their assigned PICO questions. The EtD framework took into account not only the magnitude of effect and quality of evidence, but also patient values, resources and cost, equity, acceptability, and feasibility (6). The strength of each recommendation was informed by the quality of the evidence and other components of the EtD framework. Strong recommendations (signified by “we recommend”) reflect high confidence that the desirable effects of adhering to a