Critical care professionals are forever problem solving and adapting to a patient’s dynamic individual needs. Healthy skepticism of new and old approaches drives progress toward better patient care.
Sepsis has plagued critical care problem solving for many years. At every conference I attend, it is prominent if not dominant. There is scholarly debate on concept, methods, analysis, and outcomes. The Surviving Sepsis Campaign (SSC), a joint initiative of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM), is the global consortium on early identification and treatment of sepsis. The SSC guidelines represent the current state of the science, but these are not the first guidelines, and no one believes that they will be the last. In fact, the next guidelines update task force has already been created to start working on the next installment. New questions of generalizability to the wards and under-resourced environments have been added. Extensive bench and clinical research continues. How will nanosponges and nanoparticles (1) and other future technologies be used in sepsis management? We devour each new study, but always with skepticism. At a recent conference, when asked about the use of a particular cardiac medication for sepsis management, I said, “I am not convinced.” That does not mean I would not consider using it in a particular situation – but at this point, the evidence relative to my population raises some validity, reliability and generalizability questions. A conference attendee reported that his group had just completed a study in which this cardiac class of beta blockers had significantly reduced mortality, so we were encouraged to watch for it after peer reviews are concluded. We were excited at the possibility, hopeful about the outcome (2) and, of course, skeptical.
Periodically diseases and syndromes must be redefined, as with the new Berlin definition of acute respiratory distress syndrome. (3) Clarity and uniformity of definitions are necessary so that research addresses a single entity rather than being hampered by wide error variance. The time has come for a redefinition of sepsis, and this work has been undertaken by a newly formed task force from the SCCM and ESICM.
Healthy skepticism is important, yes – but we must remember to celebrate our efforts and achievements. The World Sepsis Alliance has selected the Surviving Sepsis Campaign as a Sepsis Hero. On the second World Sepsis Day, September 13, 2013, the Surviving Sepsis Campaign will announce a point prevalence study, a 24-hour assessment of the global burden of sepsis. Additional celebratory achievements include the National Quality Forum’s recent ratification of sepsis metrics, the action taken by New York State about adopting the sepsis bundles, and the Gordon and Betty Moore Foundation’s continued grant support.
Perfect or one-size-fits-all solutions are rare in our field. Algorithms, protocols, guidelines, and team huddles all help improve patient outcomes, but our healthy skepticism is a major asset. When you hear yourself say, “I am not convinced,” smile and know you are an active participant in the great search for providing the best care for the critically ill.
2. Achor S. The Happiness Advantage. New York, NY: Crown Business; 2010.
3. Ferguson ND, Fan E, Camporota L, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012;38(10):1573-1582.