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New clinical practice guidelines of the surviving sepsis campaign: A critical appraisal
Nuevas guías de práctica clínica de la «Campaña sobrevivir a la sepsis»: lectura crítica
E. Palencia Herrejón
, B. Bueno García
Corresponding author
Servicio de Medicina Intensiva, Hospital Universitario Infanta Leonor, Madrid, Spain
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Palencia Herrejón, B. Bueno García" "autores" => array:2 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Palencia Herrejón" "email" => array:1 [ 0 => "epalenciah@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Bueno García" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Infanta Leonor, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nuevas guías de práctica clínica de la «Campaña sobrevivir a la sepsis»: lectura crítica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1426 "Ancho" => 2173 "Tamanyo" => 148325 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Level of evidence of the recommendations.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Clinical practice guides (CPGs) are “documents that include recommendations designed to optimize patient care, based on a systematic review of the evidence and assessment of the benefits and risks of the different options”.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The first edition of the CPG “Surviving sepsis campaign” (SSC) for the treatment of severe sepsis and septic shock was published in the year 2004.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This was the first time in decades in which effective treatments for sepsis seemed to have been established at last: goal-directed resuscitation,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> activated protein C,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and hydrocortisone.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> At the same time, the importance of early antibiotic treatment in patients with septic shock became apparent.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Above all, however, the guide offered a firm and global approach to the management of this syndrome, which up until then had only been addressed in a fragmented manner.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In 2007, a consensus document of the SEMES-SEMICYUC was published on the diagnosis and initial treatment of severe sepsis, placing emphasis on the need for multidisciplinary collaboration,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> while the second edition of the CSS guide appeared in 2008,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> for the first time basing its recommendations on the GRADE system.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> While positive and in some cases spectacular results were reported with application of the guide in individual hospitals,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> together with positive but not so brilliant results in large multicenter studies with a lesser degree of compliance,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> some doubts started to appear regarding the efficacy of the therapeutic measures on which the recommendations of the guide were based.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14–17</span></a> The third edition of the SSC guide for the treatment of severe sepsis and septic shock has now been published,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> providing an update to the previous editions in the light of new knowledge.</p><p id="par0015" class="elsevierStylePara elsevierViewall">During the last decade, the paradox has been that good results have been obtained using measures which to a considerable degree have been shown to be ineffective when evaluated individually (activated protein C, strict blood glucose control, liberal indications of hydrocortisone), or which lack a plausible physiological basis—such as the use of central venous pressure to guide fluid therapy during the resuscitation phase.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> While the recommendations dependent upon time and which require an organized approach (quantitative resuscitation, early antibiotic treatment) are maintained (albeit with an insufficient level of evidence), the more specific measures now disappear from the recommendations (activated protein C), or their indications have been amended and reduced (hydrocortisone). The key consideration in a syndrome as complex and heterogeneous as sepsis is probably the importance of the organization of medical care, rather than the particular effectiveness of the individual measures, which are inserted in a complex management plan that must be applied within a narrow time window.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Some years ago, Pronovost wrote a very appropriate sentence that is fully applicable to the treatment of sepsis: “the greatest opportunity for improving the patient prognosis in the next 25 years will come not from the discovery of new treatments but from learning how to make more effective use of the already existing therapies”.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It is recognized that although the recommendations are made based on the best available evidence, they cannot be regarded as a standard of treatment, because the degree of compliance (and of acceptance) of many of them by the health professionals has been<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> and remains<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> poor. Why the CPGs are not followed is a complex problem that will not be discussed here, though in the case of the SSC guidelines the main reason is probably the fact that the quality of the evidence on which they are based is insufficient; as a result, many professionals do not take them to be reliable. Another reason is that the application of these guides requires profound organizational modifications, a radical cultural change and important institutional support, which to date have not received the necessary impulse.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Validity</span><p id="par0025" class="elsevierStylePara elsevierViewall">Excluding those targeted to the pediatric population, the current guide contains 97 recommendations divided into 23 sections, and cover very diverse aspects related to the general management of critical patients, such as mechanical ventilation, the prevention of infections, thromboprophylaxis, the prevention of digestive bleeding, or artificial nutrition. Only a third of the recommendations are directly related to the management of infection and sepsis. Each recommendation is followed by an explanatory text (rationale), and a total of 636 literature references are cited.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It had already been pointed out after the first edition of the guide that the level of evidence on which the recommendations of the SSC are based is often insufficient.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> This shortcoming has not been improved by the new guide: only 7 of the 97 recommendations are based on a high level of evidence (A), and over one-half are based on low (C), very low (D) or non-classified levels of evidence (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Only 17% of the recommendations regarded as “strong” (grade 1) are based on a high level of evidence. None of the 7 recommendations based on high quality evidence are specifically referred to sepsis but rather to general supportive measures, and none of the 7 recommendations of the new bundles of measures are based on high quality evidence (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Precisely one of the reasons for the insufficient level of evidence is that many of the studies on which the general recommendations are based do not involve critical patients; as a result, their assigned level of evidence has been lowered. The lack of clinical trials exclusively involving septic patients generates noise and lessens the statistical power of the studies and their applicability to patients with sepsis.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24–26</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Inconsistencies</span><p id="par0040" class="elsevierStylePara elsevierViewall">Although it falls beyond the scope of this review to discuss the validity of the recommendations (the degree to which they fit the evidence, and the level of evidence on which they are based), it does seem questionable that the quality of the underlying evidence has not been assessed in 10 years. Moreover, the final drafting of the guide shows some inconsistencies. Several recommendations, even some considered to be “strong”, are not accompanied by any supporting literature references. Some of the recommendations are simply stated, without any explanation, and some “explanations” address issues unrelated to the recommendations they are supposed to refer to.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Some unexplained changes have been made regarding the previous recommendations: the current guide recommends a hydrocortisone dose of 200<span class="elsevierStyleHsp" style=""></span>mg/day (weak recommendation) in refractory septic shock, in contrast to the previous recommendation of “up to 300<span class="elsevierStyleHsp" style=""></span>mg/day”, though no reasons for this change are given. On the other hand, and with respect to the previous guidelines, the option of using fludrocortisone with hydrocortisone has been eliminated, without any explanation, and no recommendations are made on the use of etomidate for the intubation of patients with sepsis. A maximum dobutamine dose of 20<span class="elsevierStyleHsp" style=""></span>μg/kg/min (strong recommendation) is advised, though without justification of this amount or references. For the initial phase of resuscitation the guide recommends (strong recommendation) a “minimum of 30<span class="elsevierStyleHsp" style=""></span>ml/kg of crystalloids”, though the previous guides made no reference to this. Here again, no justification or references are given.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In our opinion, the text has some imbalances in relation to both the selected topics (e.g., the section on the prevention of infections only addresses digestive decontamination, with oral chlorhexidine—but nothing else is mentioned) and the extent to which they are discussed and referenced (some sections describe the results of clinical trials, while others do not even provide references to such studies). Only 7 tables of evidence are presented: one in the main text and 6 in the supplementary electronic material, with no clarification of the selection criteria used.</p><p id="par0055" class="elsevierStylePara elsevierViewall">An important inconsistency of the guide, and which can lead to confusion, is the lack of concordance between the recommendation (grade 1) to administer antibiotics in the first hour following the identification of severe sepsis and septic shock, and the bundles of measures, which include the start of antibiotic treatment in the first 3<span class="elsevierStyleHsp" style=""></span>h.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">AGREE II assessment</span><p id="par0060" class="elsevierStylePara elsevierViewall">Recently, use of the AGREE II instrument has been proposed for assessing CPGs.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the results of the assessment independently made by the authors of this review in the 6 evaluated domains. We feel that the guidelines clearly have room for improvement in two of the domains: the methodological rigor used in developing and drafting them, and participation in elaboration of the guidelines. The literature search made and the study selection criteria used remain to be explained, in the same way as assessment of the quality of the recommendations (lacking in 10 of them). Likewise, it would have been better to secure a broader participation of relevant scientific societies and other elements that should be implicated in development of the guide. Future editions should make a greater effort to ensure multidisciplinary collaboration (internists, surgeons, in- and out-hospital emergency care physicians, general practitioners, nurses, health management and administrative personnel, and professional organizations)—this being an aspect that has already been addressed in this country.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> As strong points of the guide, mention must be made of the relevance of the topic dealt with, and the efforts to orientate the recommendations toward practical application—though precisely the lack of a broader participation may make this difficult. It can be concluded that in some aspects the guidelines are closer to being a “consensus conference” among experts than a CPG as defined at the start of this review.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0065" class="elsevierStylePara elsevierViewall">The future revisions of the CPG for the management of severe sepsis and septic shock should include greater participation on the part of the implicated professionals, adopting a multidisciplinary and multinational approach, with space for participation in the development of the guide for health management and administrative personnel on one hand and patients on the other. The guidelines should be developed with the maximum methodological rigor, seeking explicit and exhaustive evidence and likewise explicit study screening and assessment criteria. Greater care also should be placed on the drafting of the recommendations, the references and explanations provided, and the presentation of the tables of evidence—ensuring complete and homogeneous consideration of all the relevant issues dealt with.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding the future of the “Surviving sepsis campaign”, further quality research is needed in search of effective treatments, with increased effort focused on exploring and introducing organizational changes in the healthcare process—placing priority on the early detection of sepsis in both the out-hospital setting and in the emergency services and conventional hospital wards. To this effect we will need the firm support of the authorities and healthcare management, with promotion of the development of modern tools—especially software based systems—for the early and (where possible) automated detection of the alarm signs.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">There have been no sources of funding.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres299269" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec282331" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres299270" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec282330" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Validity" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Inconsistencies" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "AGREE II assessment" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Financial support" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec282331" "palabras" => array:3 [ 0 => "Sepsis" 1 => "Surviving sepsis campaign" 2 => "Clinical practice guidelines" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec282330" "palabras" => array:3 [ 0 => "Sepsis" 1 => "Campaña sobrevivir a la sepsis" 2 => "Guías de práctica clínica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In 2004 the first edition of the “Surviving sepsis campaign” guidelines for the management of severe sepsis and septic shock was published, opening a new era in the treatment of this syndrome. The paradox is that the application of these guidelines has produced positive results despite including in some cases the treatments proved ineffective. Eight years later has been published the third edition of the guides, which updates the prior in the light of new knowledge, but the quality of evidence remains weak. In this paper the authors express their critical view on the current edition of the guides, pointing out their weaknesses and suggesting how the development of future editions should be.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El año 2004 se publicó la primera edición de las guías de práctica clínica para el tratamiento de la sepsis grave y el shock séptico de la «Campaña sobrevivir a la sepsis», abriendo una nueva etapa en el tratamiento de este síndrome. Se da la paradoja de que en estos años se han producido resultados positivos aplicando medidas que en algunos casos se han demostrado ineficaces. Ocho años después se publica la tercera edición, que actualiza las previas a la luz de los nuevos conocimientos, pero la calidad de la evidencia en que se basan las recomendaciones sigue siendo insuficiente. En este documento, los autores expresan su punto de vista crítico sobre la edición actual de las guías, señalan sus puntos débiles y apuntan cómo debe ser en su opinión el desarrollo de futuras ediciones.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Palencia Herrejón E, Bueno García B. Nuevas guías de práctica clínica de la «Campaña sobrevivir a la sepsis»: lectura crítica. Med Intensiva. 2013;37:600–604.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1426 "Ancho" => 2173 "Tamanyo" => 148325 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Level of evidence of the recommendations.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">To be done in the first 3</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Measurement of lactic acid (non-classified) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obtainment of blood cultures before the administration of antibiotics (C) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Administration of broad spectrum antibiotics (B) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Administration of 30<span class="elsevierStyleHsp" style=""></span>ml/kg of crystalloids in the case of hypotension or lactic acid ≥4<span class="elsevierStyleHsp" style=""></span>mmol/l (C) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">To be done in the first 6</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Administration of vasopressors to maintain mean blood pressure ≥65<span class="elsevierStyleHsp" style=""></span>mmHg (C) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>In case of septic shock or lactic acid ≥4<span class="elsevierStyleHsp" style=""></span>mmol/l, measure central venous pressure and SvcO<span class="elsevierStyleInf">2</span> (C) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Repeat lactic acid measurement if initial value was high (C) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab438429.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Quality of the evidence of the 7 recommendations included in the new bundle of measures.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Conclusion: Are these guides recommendable for use? Yes, with modifications.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Raw and standardized score (0–100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Standard deviation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Level of discrepancy between evaluators \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Scope and objective<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (83%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Participation of all implicated parts<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (44%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Rigor of preparation<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (35%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Clarity presentation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (78%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Applicability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (54%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6. Editorial independence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (79%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Global quality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8/14 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab438428.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Strong point (score above 80%).</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Weak points (score below 50%).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">AGREE II assessment of the “Surviving sepsis campaign” clinical practice guides.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical practice guidelines we can trust" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R. Graham" 1 => "M. Mancher" 2 => "D.M. Wolman" 3 => "S. Greenfield" 4 => "E. Steinberg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "fecha" => "2011" "paginaInicial" => "1" "paginaFinal" => "300" "editorial" => "National Academy of Sciences, Institute of Medicine" "editorialLocalizacion" => "Washington, DC" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surviving sepsis campaign guidelines for management of severe sepsis and septic shock" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.P. Dellinger" 1 => "J.M. Carlet" 2 => "H. Masur" 3 => "H. Gerlach" 4 => "T. Calandra" 5 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 35 | 27 | 62 |
| 2024 October | 254 | 126 | 380 |
| 2024 September | 241 | 114 | 355 |
| 2024 August | 249 | 145 | 394 |
| 2024 July | 243 | 104 | 347 |
| 2024 June | 254 | 122 | 376 |
| 2024 May | 250 | 108 | 358 |
| 2024 April | 372 | 183 | 555 |
| 2024 March | 439 | 185 | 624 |
| 2024 February | 592 | 242 | 834 |
| 2024 January | 537 | 258 | 795 |
| 2023 December | 451 | 281 | 732 |
| 2023 November | 657 | 281 | 938 |
| 2023 October | 671 | 292 | 963 |
| 2023 September | 442 | 192 | 634 |
| 2023 August | 299 | 112 | 411 |
| 2023 July | 246 | 87 | 333 |
| 2023 June | 243 | 88 | 331 |
| 2023 May | 293 | 87 | 380 |
| 2023 April | 257 | 87 | 344 |
| 2023 March | 259 | 111 | 370 |
| 2023 February | 170 | 88 | 258 |
| 2023 January | 106 | 56 | 162 |
| 2022 December | 127 | 84 | 211 |
| 2022 November | 155 | 103 | 258 |
| 2022 October | 112 | 77 | 189 |
| 2022 September | 121 | 74 | 195 |
| 2022 August | 116 | 66 | 182 |
| 2022 July | 68 | 44 | 112 |
| 2022 June | 82 | 43 | 125 |
| 2022 May | 119 | 64 | 183 |
| 2022 April | 79 | 56 | 135 |
| 2022 March | 116 | 67 | 183 |
| 2022 February | 70 | 47 | 117 |
| 2022 January | 88 | 38 | 126 |
| 2021 December | 65 | 55 | 120 |
| 2021 November | 93 | 54 | 147 |
| 2021 October | 362 | 80 | 442 |
| 2021 September | 79 | 48 | 127 |
| 2021 August | 71 | 40 | 111 |
| 2021 July | 71 | 39 | 110 |
| 2021 June | 74 | 59 | 133 |
| 2021 May | 137 | 58 | 195 |
| 2021 April | 388 | 197 | 585 |
| 2021 March | 197 | 46 | 243 |
| 2021 February | 145 | 41 | 186 |
| 2021 January | 130 | 54 | 184 |
| 2020 December | 128 | 32 | 160 |
| 2020 November | 106 | 30 | 136 |
| 2020 October | 98 | 48 | 146 |
| 2020 September | 64 | 29 | 93 |
| 2020 August | 64 | 26 | 90 |
| 2020 July | 69 | 20 | 89 |
| 2020 June | 80 | 30 | 110 |
| 2020 May | 79 | 15 | 94 |
| 2020 April | 94 | 28 | 122 |
| 2020 March | 44 | 19 | 63 |
| 2020 February | 197 | 36 | 233 |
| 2020 January | 64 | 31 | 95 |
| 2019 December | 71 | 27 | 98 |
| 2019 November | 80 | 37 | 117 |
| 2019 October | 164 | 29 | 193 |
| 2019 September | 98 | 46 | 144 |
| 2019 August | 61 | 18 | 79 |
| 2019 July | 95 | 35 | 130 |
| 2019 June | 73 | 30 | 103 |
| 2019 May | 83 | 25 | 108 |
| 2019 April | 86 | 42 | 128 |
| 2019 March | 79 | 37 | 116 |
| 2019 February | 66 | 36 | 102 |
| 2019 January | 49 | 26 | 75 |
| 2018 December | 65 | 40 | 105 |
| 2018 November | 153 | 79 | 232 |
| 2018 October | 53 | 35 | 88 |
| 2018 September | 37 | 15 | 52 |
| 2018 August | 30 | 14 | 44 |
| 2018 July | 43 | 17 | 60 |
| 2018 June | 32 | 18 | 50 |
| 2018 May | 17 | 12 | 29 |
| 2018 April | 31 | 14 | 45 |
| 2018 March | 32 | 11 | 43 |
| 2018 February | 25 | 18 | 43 |
| 2018 January | 42 | 18 | 60 |
| 2017 December | 35 | 13 | 48 |
| 2017 November | 34 | 23 | 57 |
| 2017 October | 43 | 14 | 57 |
| 2017 September | 41 | 17 | 58 |
| 2017 August | 30 | 22 | 52 |
| 2017 July | 26 | 11 | 37 |
| 2017 June | 51 | 36 | 87 |
| 2017 May | 38 | 22 | 60 |
| 2017 April | 46 | 21 | 67 |
| 2017 March | 29 | 18 | 47 |
| 2017 February | 21 | 19 | 40 |
| 2017 January | 15 | 20 | 35 |
| 2016 December | 40 | 26 | 66 |
| 2016 November | 49 | 46 | 95 |
| 2016 October | 62 | 37 | 99 |
| 2016 September | 65 | 31 | 96 |
| 2016 August | 62 | 26 | 88 |
| 2016 July | 29 | 20 | 49 |
| 2016 June | 6 | 0 | 6 |
| 2016 May | 3 | 0 | 3 |
| 2016 April | 4 | 0 | 4 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 4 | 0 | 4 |
| 2015 December | 2 | 0 | 2 |
| 2014 October | 1 | 0 | 1 |
| 2014 June | 1 | 0 | 1 |
Show all
