Thread by @iceman_ex

Now @Manu_Malbrain arguing for the retirement of the surviving Sepsis guidelines #lives2018

The fall in Sepsis mortality hasn’t coincided with the introduction of the guidelines #lives2018 🤔

Is the pro-con debate of the surviving Sepsis guidelines nothing more than a liberal vs restrictive fluid argument? #Lives2018

The guidelines support lactate guided therapy...

However that’s full of holes intensivecarenetwork.com/understanding-… #lives2018

This is my bugbear with the guidelines.

30ml/kg is a lot of fluid.

The effect of a bolus is short lived and may be harmful... #lives2018

Fluid overload has multi-organ effects.

Tailored care, carefully titrate to response, may be better than a “one size fits all” bundle... @Manu_Malbrain #lives2018

A MAP target of 65 may not be the right one- we haven’t done trials to confirm this

(SEPSISPAM had a bunch of interesting secondary outcomes mind. thebottomline.org.uk/summaries/icm/…) #lives2018

The guidelines And bundles are based on a lot of correlative studies (Kumar and antibiotics, Seymour and bundles)

But correlation is not causation.

So you end up with recommendations based on low quality evidence #lives2018

Only 7% of current guideline recommendations are based on strong evidence

And if the bundles are so great, why was there a reversal on the implementation of the 1 hour bundle? #lives2018

Now in the opposing corner, Mitchell Levy #lives2018

He asks the question:

If your relative got sick, would you want them to go to a guideline positive hospital, or a free for all hospital?

Majority chose hospital 1

(Isn’t this a straw man argument @emcrit @avkwong @EMNerd_?) #lives2018

CLASS MOMENT.

Mitchell’s screen suddenly goes blank

Michell: “Manu, is that you?” #lives2018

This is a superb argument.

Our perceived adherence to guidelines isn’t as good as our actual adherence (ping @docpgb) #lives2018

Here is great data (soon to be published in @ATSBlueEditor ) showing an association with bundle compliance and improved Sepsis mortality

And a suggestion of a dose effect too (more compliance= better mortality) #lives2018

Hey @PulmCrit and @emcrit getting a pasting from Mitchell #lives2018

He didn’t appreciate the Darth Vader/Death Star/secret police comparisons 😉 emcrit.org/pulmcrit/ssc-p…

Shots fired at Mervin Singer!!!!

“He doesn’t let antibiotics be started by a resident without them calling him directly”

“WTF?”

-Mitchell Levy #lives2018

🤣

Mitchell accepts that identifying infection can be challenging in some patients jamanetwork.com/journals/jama/… #lives2018

That doesn’t mean we shouldn’t try to help the ones who turn out to be septic...

And giving a single dose of antibiotics doesn’t mean we need to continue it...

Mitchell Kevy clearing up some myths:

You don’t need to COMPLETE the one hour bundle in the first hour

Time zero for the most part now is accepted as time of presentation

#lives2018

Summary from Mitchell #lives2018

Rebuttal from @Manu_Malbrain:

Guidelines should remain guidelines.

They should never replace the mind of an attentive clinician.

Rebuttal from Mitchell Levy:

Local clinicians are the very people engaging with the guidelines.

#lives2018

“If clinicians are not reminded, they will fail to do the right thing” #lives2018

This is amazing- Mervin Singer is in the audience and is shooting down Mitchell Levy!!

U.K. data- NO CHANGE in Sepsis mortality despite the SSC guidelines

-Mervyn Singer #lives2018