The Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) collaborate on other projects in addition to the Surviving Sepsis Campaign.
SCCM/ESICM Joint Project on Definition of Refractory Septic Shock: Global Expert Consensus Using Delphi Methodology
Project Cochairs:
Project Protocol:
Delphi Process
The Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) convened an international, multidisciplinary Steering Committee (ML, AKK, SNM, SD, LR, PMW, LD, SS, and BR) with professional expertise in sepsis management to develop a definition for refractory septic shock. LD, SS, and BR served as the methodology experts. The Delphi method was employed to reach expert consensus and formulate a standardized definition of refractory septic shock. Survey rounds were conducted based on a previously published Delphi study and were reported in accordance with the Accurate Consensus Reporting Document (ACCORD) guidelines.
An international, multidisciplinary, diverse panel of experts from multiple professions and disciplines (intensive care, anesthesia, cardiology, physicians, pharmacists, nurses) were convened based on predefined selection criteria: clinical expertise in adult sepsis management, demonstrated involvement in sepsis-related research, policy or protocol development, education, or other professional activities. Due to the specific focus of the project and the complexity of the technical terminology related to the diagnosis and management of refractory septic shock used in the Delphi process, the Steering Committee did not think it was feasible to involve patients and family members.
The scope of the project was developed through a qualitative evidence synthesis based on a focused search of published literature addressing septic shock. This search was done in PubMed, filtering by date from January 1, 2000, to December 31, 2024. The Steering Committee did not perform statistical pooling or meta-analysis, instead focusing on narrative synthesis. The review revealed a lack of standardized definition for refractory septic shock justifying the next steps for this consensus process.
Domains and statements for the first round of the Delphi survey were determined following in-depth discussions among the Steering Committee members and based on results of the evidence synthesis. The Delphi survey included the following six domains: 1) components of definition, 2) blood pressure targets, 3) markers of tissue perfusion, 4) fluid resuscitation, 5) vasoactive therapy, and 6) adjunct therapies.
The Delphi survey questionnaires were prepared using the web-based software, Surveylet. The survey included multiple-choice questions and statements rated on a 7-point Likert scale. An email invitation was sent to all experts to participate in the Delphi study. Questionnaires were distributed via email to those who accepted the invitation. To minimize bias and group pressure, the identities of the participants were kept confidential until the conclusion of the Delphi process.
The first round of the Delphi survey provided sufficient opportunity for open-ended responses in addition to the scaled responses, allowing experts to provide feedback on the statements, recommend changes, or suggest additional elements to be included in the definition. Survey responses were reviewed by the Steering Committee, and the survey was revised accordingly. The modified questionnaire was then redistributed to the experts in the next round, along with a consolidated summary report of the results and feedback of the previous round for review. Each question remained in the Delphi survey until the stability of the response was achieved.
Consensus and Stability
Consensus was considered achieved if 75% or more of the experts selected a particular option in a multiple-choice question or rated their agreement (scores of 5–7) or disagreement (scores of 1–3) on a 7-point Likert scale. The median and interquartile range (IQR) were used to describe the central tendency and variability of responses to Likert-scale items. The stability of the responses between two consecutive rounds, beginning with round two, was assessed using non-parametric tests (Chi-square [χ²] test or Kruskal–Wallis test), with a P value of < 0.05 indicating significant variation or instability. The statement continued in Delphi until stability was achieved. The closing criterion for the Delphi process was the stability of all clinical statements.
Expert Clinical Practice Statements and Definition of Refractory Septic Shock
The Steering Committee developed expert clinical practice statements based on statements that achieved both consensus and stability during the Delphi process. These statements formed the basis for drafting the definition of refractory septic shock. The result of the Delphi process and the draft manuscript were circulated among the experts for feedback and approval before submission for publication.
Project Steering Committee Members:
Project Methodologists:
Staff Partner: Hariyali Patel, MHA, Program Manager