?Updated Bundles in Response to New Evidence
The leadership of the Surviving Sepsis Campaign (SSC) has believed since its inception that both the SSC Guidelines and the SSC performance improvement indicators will evolve as new evidence that improves our understanding of how best to care for patients with severe sepsis and septic shock becomes available.

With publication of 3 trials that do not demonstrate superiority of required use of a central venous catheter (CVC) to monitor central venous pressure (CVP) and central venous oxygen saturation (ScvO2) in all patients with septic shock who have received timely antibiotics and fluid resuscitation compared with controls or in all patients with lactate >4 mmol/L, the SSC Executive Committee has revised the improvement bundles as follows:

TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION*:
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate ?4mmol/L

* “Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.

TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ?65mmHg
6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ?4 mmol/L, re-assess volume status and tissue perfusion and document findings . 7. Re-measure lactate if initial lactate elevated. DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH: EITHER • Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings. OR TWO OF THE FOLLOWING: • Measure CVP • Measure ScvO2 • Bedside cardiovascular ultrasound • Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge Ref: INTERNATIONAL GUIDELINES ON SURVIVING SEPSIS. The following allied topics also available from author on request. Initial Resuscitation and Infection Issues . Hemodynamic Support and Adjunctive Therap?y. Other Supportive Therapy of Severe Sepsis. Special Considerations in Pediatrics???????. G Mohan.