Equilibrating SSC guidelines with individualized care

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Sepsis is a major cause of death worldwide, not least because complex interventions need to be provided within a short window of opportunity. Evidence-based guidelines for the treatment of sepsis are therefore welcome, providing a common ground for all clinicians involved in decision-making regardless of their expertise. Such guidelines should therefore serve as an overarching reference document. As previously stated, ‘Guidelines are the product of an explicit, systematic approach to the evaluation and synthesis of available information on a particular clinical topic. They are not a compilation of truths, but are a summary of what is accepted by the authors as the best available evidence at that time’ 1. As the evidence base evolves over time, the new Surviving Sepsis Campaign (SSC) guidelines 2 are timely and important. We appreciate the tremendous amount of time invested by the experts who formulated the new guidelines to provide the intensive care community with a clear and comprehensive manuscript. We also recognize the challenge of providing evidence-based guidelines when the strength of evidence available to direct recommendations is limited. Indeed, the large majority of randomized, controlled trials (RCTs) performed over the last three decades in intensive care medicine, including those in sepsis, have shown no significant beneficial effect of the tested intervention on outcomes 3. At face value, this may simply suggest that the myriad of interventions that have been tested are all ineffective. However, it is more likely that subsets of patients who benefit from specific treatments have yet to be identified. The often broad patient inclusion criteria could easily lead to dilution of positive findings by non-responders, or to positive effects in some patients being offset by harm in others 4. This treatment effect heterogeneity has been clearly indicated in many trials (for example 5–8). The most severely ill patients usually suffer less from a single condition than from a complex physiological imbalance that defies specific disease definitions. Management that strictly adheres to guidelines may not necessarily be the best option. However, personalizing management of these patients mandates that the treating clinician appreciates the clinical implications of the underlying disease(s) and individual host factors (chronic health status, physiology, and physiological reserves). Additionally, the individual response to interventions must be closely monitored and, depending on that response and whether or not the pre-set goal of that intervention has been achieved, the clinician can then decide to maintain or alter the intervention accordingly. We fully acknowledge this is demanding in resources, time, personnel, and bedside expertise. It is more convenient and less labor-intensive to adopt a generalized approach, yet customization is surely the underlying foundation of intensive care. When we forget the fundamental importance of individualized management, the ultimate result is that few interventions improve meaningful patient outcomes, especially mortality 3. We Open Access