Relative Impact of the 2012 SSC Guideline Recommendations under the Scope of Numbers Needed to Treat (NNTs).

The surviving sepsis campaign (SSC) guidelines aimed to reduce mortality in severe sepsis and septic shock. The present study was performed to find out which and how many recommendations of the 2012 SSC update were based on significant effects from clinical studies in adult patients with severe sepsis and septic shock, leading to numbers needed to treat (NNTs). Every reference of the SSC 2012 guideline regarding clinical trials in adult patients was screened for absolute risk reduction regarding mortality to calculate NNTs. 17 relevant clinical trials out of 338 were identified. The NNTs ranged between 3.55 to 23.24. Significant reductions of mortality were detected, and items recommended in the SSC guidelines regarding early goal directed therapy (EGDT)/standard operating procedures (SOP)/sepsis bundles, early therapy with antibiotics, combined antibiotic therapy, and use of norepinephrine. Therapy with norepinephrine and the 6h bundles revealed the lowest NNTs. Significant reductions in mortality with restricted or no recommendations regarded therapy with hydrocortisone, therapy with highdose antithrombin III, and enteral feeding with eicosapentaenoic acid, gamma-linolenic acid and antioxidants. In conclusion, only a few recommendations of the 2012 SSC guidelines are based on significant beneficial effects coming from clinical trials in patients with severe sepsis and septic shock. When transferring study results and NNTs, physicians should take into account the own setting and own subgroup of patients. If feasible, costs of additional treatment success may be quantified underlying NNTs.

Surviving Sepsis Campaign Bundles Adherence and Their Limits in Surgical Patients with Septic Shock in an ICU.

Aims: The Surviving Sepsis Campaign (SSC) guidelines aimed to reduce heterogeneity of conventional therapy and mortality. The present study was performed in septic shock to describe the adherence to the 2008 SSC guidelines, confounding factors, and limitations. Study Design: Prospective observational study. Place and Duration of Study: Clinic of Anaesthesiology, University Hospital Medical School, and Clinical Economics at the Institute of History, Philosophy and Ethics in Medicine, University of Ulm, between January 2008 and June 2009. Methodology: The adherence to 36 items of the 6-hour and 24-hour bundles of the 2008 SSC guidelines was investigated in 98 surgical patients with septic shock. Results: The adherence to the 36 items varied between 0% and 95%. Besides the categories “adherent“ and “nonadherent“, additional categories “partially adherent“, “notapplicable“ and “unknown“ were used. None of the single items alone was essential for survival. Patients with septic shock on admission (n=68) had significantly higher SOFA scores (degree of organ dysfunctions) compared to patients developing septic shock in the ICU (n = 30). Conclusion: As many confounders are limiting the adherence to complex guidelines, the complete adherence will hardly be possible in severe diseases such as septic shock. Our results suggest that efforts associated with early diagnosis and active encouragement outside the ICU are necessary to improve applicability and adherence to the SSC guidelines in patients with septic shock in order to reduce the time lag of diagnosis and treatment, which may be reached by focusing on few essential points.