Evolution and Current Status of Sepsis Bundles
The Surviving Sepsis Campaign (SSC) has been a joint collaboration of international critical care and infectious disease experts since 2002 with the goal of building awareness and reducing mortality of sepsis. Recommendations on the acute management of sepsis and septic shock were originally published in 2004. Subsequent revisions have been published in 2008, 2013, and 2017. Each revision is an update to the previous version as new evidence becomes available.
Although published separately from the SSC guidelines, the sepsis bundle elements have played a major role in the implementation of the guidelines. A bundle is a set of individual, evidence-based care elements which provide a greater proven benefit when applied together than individually.
REVIEW of Sepsis Bundles
2005 Bundle Definition
The original set of sepsis bundles consisted of a resuscitation (5 elements) and management (4 elements) bundle elements, to be completed within 6 and 24 hours respectively. From the beginning, several of these recommendations were questioned and not always accepted regarding their proven value.
While the 6 and 24-hour bundles were never tested prospectively, they remained part of the revised 2009 SSC guidelines.
The 2013 SSC revisions included revisions to the bundle elements after review of 32,000 patient charts from 239 hospitals in 17 countries. The management bundle was dropped. The resuscitation bundle was segmented into 2 parts: A 3-hour bundle (4 elements) and a 6-hour bundle (3 elements). The measurement of central venous pressure (CVP) and central venous oxygen saturation (ScvO2), without specific targets were recommended if the patient did not respond to fluid resuscitation. However, compliance with CVP and ScvO2 was highly variable and typically low, with their contribution to mortality reduction remaining questionable. Soon after these recommendations, additional data demonstrated the measurement of CVP and ScvO2 was not necessary for successful resuscitation and these elements were removed. However, in the presence of persistent hypotension or initial serum lactate concentrations above 4 mmol/L, some documented reassessment of intravascular volume status is required.
Following the 2018 SSC revisions, the 3-hour and 6-hour bundles have been combined into a single 1-hour bundle (5 elements). The goal is to begin both resuscitation and management immediately as longer delays may lead to higher mortality.