Australian study casts doubt on sepsis guidelines

World Health Matters – Australia- by Gary Finnegan: New research suggests treatment in Australia and New Zealand for patients with sepsis is the best in the world but the study has raised questions about practices elsewhere and may prompt a review of global guidelines.

The large-scale six-year study, led by the Australian and New Zealand Intensive Care Research Centre at Monash University in Melbourne, divided 1,600 patients into two groups, who were admitted to emergency care with early stage sepsis from across more than 40 hospitals.

The first group of 796 patients received Early Goal Directed Therapy (EGDT), an aggressive treatment not currently used in Australia and New Zealand, which inserts a catheter into the jugular vein to monitor oxygen levels in the blood returning from the body to the heart.

The second group of 804 patients received the usual course of standard care given in Australia and New Zealand – a combination of rapid specialist-led care, powerful and immediate antibiotics and rapid resuscitation in either Emergency Departments or Intensive Care Units.

Previous studies found mortality rates for sepsis were as high as 46%, but were lowered to 30% if EGDT was also used. Subsequently the therapy has been recommended globally and is endorsed by the Surviving Sepsis Campaign.

In contrast, the new study found that, in Australia and New Zealand, hospital mortality rates for both groups were close to 15% – the lowest ever reported for this life threatening condition.

The Monash-led research, published in the New England Journal of Medicine, sheds doubt on the reported effectiveness of EGDT because researchers found it did not make any noticeable different to survival rates.

One of the lead researchers, Professor Rinaldo Bellomo of the Monash University’s School of Public Health and Preventive Medicine, said one of the reasons for the high survival rates could be down to Australia and New Zealand’s healthcare systems.

“Australia and New Zealand have one of the longest and most scrutinised joint training programmes in the world for doctors and nurses working in emergency and intensive care. Intensive care units routinely have one highly trained specialist nurse for each patient to maximise level of care and minimise cross infection and healthcare professionals have a reputation for collaboration and team work,” he said.

“We don’t know if these factors are responsible for the high survival rates, our next step is to carry out further work to determine this,” Professor Bellomo said.

Sepsis, a fast-moving bloodstream infection that kills millions of people globally every year, is caused by the immune system’s response to serious infection. In extreme cases, the body begins to shut down resulting in heart, lung, kidney and other organ failure. To combat the infection early diagnosis and intensive care are critical.

Introduced in 2001, EGDT is reported to have cut sepsis death rates by as much as a third. Used in many countries as a key strategy for septic shock admitted to emergency departments, a catheter is inserted into the jugular vein and slid near to the heart to monitor the level of oxygen in the blood. If oxygen levels are too low, transfusions are used to elevate it and drugs administered to make the heart beat faster

Professor Bellomo said the new findings suggest it is time to review global sepsis treatment guidelines.

“Sepsis survival rates are one of the highest in Australia and New Zealand. We believe this is because of the standard of care, rather than the use of EDGT, an expensive and invasive procedure, which has never been widely used in either country,” he said.

“In our study, mortality rates for both groups were the same, it was very clear that EDGT does not increase your chances of survival. Our study proves it is neither needed nor beneficial,” Professor Bellomo said.