The International Sepsis Forum Round Table: Mission Accomplished in Sepsis? (Plenary)

The International Sepsis Forum Round Table: Mission Accomplished in Sepsis?

Blog by Jack Wong Edited by Adrian Wong

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The International Sepsis Forum Round Table: Mission Accomplished in Sepsis?

Chair: Mervyn Singer

From left to right: Derek Angus, Claudia Dos Santos, Peter Pickkers , Ron Daniels, Tim Walsh, Rinaldo Bellomo

 

Disclaimer: The following summary is the author’s understanding of the round table discussion and it is not verbatim transcription of expert’s statement during the discussion.

In response to the 3 major sepsis trials (ARISE, PROCESS and PROMISE) with negative results (ie. protocolized sepsis management does not change outcome) in contrast to the findings of Rivers et al in the concept of EGDT, Mervyn Singer raise the question about the plausibility of spending millions of dollars in studies for sepsis to the panel.

  • Angus: Albeit the result, trial of protocolized approach as a mean of knowledge dissemination (of sepsis management) is worth probing
  • Dos Santos: Where should we go from here with the findings? Is the problem due to inability to define patient cohort and the future will be scrutinizing our work
  • Pickkers: “Whatever we do in ICU doesn’t work with mortality rates does decrease”
  • Daniels: There is a need to engage non-intensivist, including public and GP etc with the help of protocol and guidelines in sepsis recognition and management. We should stick to using sepsis bundle.
  • Walsh: Doing something is better than doing nothing. Management has changed over time
  • Bellomo: These comment are “rationale” (Reference to previous talk about medicine is all about rational astrology). We might just not understand what we are doing. If study design is appaling then we have to question the credibility of “evidence” (Referring to Rivers) – At the end of the day, we do what we think is right.

 

Where should we go from here in management of sepsis?

  • Walsh: Proper clinical examination, direct patient assessment is the way to do it.
  • Daniels: Step by step as per bundle
  • Pickkers: Give fluid!
  • Dos Santos: Examine the patient and base it on clinical assessment rather than advance monitor like ECHO etc
  • Angus: More accurate monitoring perhaps (Referring to increasing use of PA catheter in the USA)

 

Antibiotic resistance problem: Whats your take?

  • Daniels: Give it! in case they don’t get it
  • Pickkers: Watch and give it when indicated.
  • Angus: When it is clear – give it! If it is doubtful then use clinical judgement.
  • Bellomo: If patients is in hospital, give antibiotics! Antibitoics rersistance issue contributed by ICM is minute.
  • Angus: *Reminds Bellomo about risk of CDT diarrhoea*
  • Walsh: Increased awareness nowadays hence more doctors are able to make clinical judgement earlier (regarding when to administer antibiotics)
  • Singer: NCEPOD stated lots of patients with sepsis were not given antibiotics (prompting there is still a gap in appropriate management)

If RCT doesn’t tell us what we do, then what should we do?

  • Angus: Causal inference – we still need to randomized rather than doing things randomly.
  • Dos Santos: Randomization is still the right way to go. What is sepsis as defined by Science? We need to understand process of sepsis more with phenotypes / genetic level / biotyping.
  • Bellomo: Suggests cluster randomization by hospital.
  • Walsh: Careful selection / randomization of patient with better design eg. don’t compare 80 years old with 20 years old.
  • Daniels: All patients are not equal so treat individually.
  • Angus: Commenting re:failure in oncology research when wrong things are measured. With research advancement which might lead to better understand of a disease (eg malignant melanoma) dose not mean it will lead to a better patient outcome (ie mortality)

 

Could we use more rapid POC test / biomarkers to improve outcome?

  • Walsh: Need more evidence and need more collaboration across the globe.
  • Daniels: It is important to put biomarker result into context.
  • Pickkers: Biomarkers are overrated. Does number means truth?
  • Angus: We have always had biomarkers (Temp, WCC)

 

De-escalation – When and how to do it?

  • Bellomo: We tend to overload our patients, why are we doing it? We don’t have the answer.
  • Dos Santos: De-escalation is important during recovery phase in high risk patient group but identification of high risk patient is a challenge.
  • Bellomo: Maybe it doesn’t matter at all

 

New sepsis definition (Sepsis 3.0 to be published in Feb 2016 in SCCM) – Do we need a new definition?

  • Daniels: It is helpful to have more pragmatic guidance to help assessor recognise and treat sepsis.
  • Walsh: We need them to help with trial
  • Pickkers: (Referring to the title of the discussion: Mission Accomplished?) Mission is not at all accomplished. We have no public awareness and we need to put more effort into it.
  • Bellomo: It is a work in progress. A new definition is part of the big process.