2012 surviving sepsis campaign guidelines syed
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2012 Surviving Sepsis
Campaign Guidelines
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AgendaUnderstand the scope of the sepsis epidemic1
Become familiar with the Surviving SepsisCampaign and the SCCM defined sepsis
bundles2
Recognize how time-criticaltherapies can save lives inthe emergency departments and ICUs
3
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Comparable GlobalEpidemiology
95 cases per 100,000
2 week surveillance
206 French ICUs 95 cases per 100,000
3 month survey
23 Australian/New
Zealand ICUs
51 cases per 100,000
England, Wales andNorthern Ireland.
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Severe Sepsis: Comparison With
Other Major Diseases
0
50
100
150
200
250
300
AIDS* Colon Breast
Cancer
CHF Severe
Sepsis
Cases/100,0
00
Incidence of Severe Sepsis Mortality of Severe Sepsis
0
50,000
100,000
150,000
200,000
250,000
AIDS* Severe
SepsisAMIBreast
Cancer
Deaths/Year
National Center for Health Statistics, 2001.
American Cancer Society, 2001. *American Heart Association. 2000.Angus DC
et al. Crit Care Med.2001
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Sepsis Epidemiology: Effect of the Aging Population
0
5
10
15
20
25
30
35
40
45
0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
Without Comorbidity
With Comorbidity
Overal
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Economics of Sepsis Severe Sepsis
$22,000 per case
US annual cost $16.7Billion
Nosocomial Sepsis
increased LOS - ICU 8 days, Hosp 24 days $40,890 per case
Angus CCM, 2001
Pittet JAMA, 1994
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Time Sensitive Interventions
AMI
StrokeTime is Brain
The sooner that treatment begins, the better are ones
chances of survival without disability.
TraumaThe Golden Hour
Requires immediate response and medical care on the scene.
Patients typically transferred to a qualified trauma center for care.
Door to PCI
Focus on the timely return of blood flow to the affected
areas of the heart.
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Severe Sepsis vs. Current Care Priorities
Care PrioritiesU.S.
Incidence# of Deaths Mortality Rate
AMI (1) 900,000 225,000 25%
Stroke (2) 700,000 163,500 23%
Trauma (3)
(Motor Vehicle)
2.9 million(injuries)
42,643 1.5%
Severe Sepsis (4) 751,000 215,000 29%
Source: (1) Ryan TJ, et al. ACC/AHA Guidelines for management of patients with AMI. JACC. 1996; 28: 1328-1428. (2) American HeartAssociation. Heart Disease and Stroke Statistics2005 Update. Available at: www.americanheart.org. (3) National Highway TrafficSafety Administration. Traffic Safety Facts 2003: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Report ingSystem and the General Estimates System. Available at http://www.nhtsa.dot.gov/. (4) Angus DC et al. Crit Care Med2001;29(7): 1303-1310.
http://www.nhtsa.dot.gov/http://www.nhtsa.dot.gov/ -
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Surviving Sepsis Campaign
Launched in Autumn 2002 as a collaborativeeffort of European Society of Intensive Care
Medicine, the International Sepsis Forum, andthe Society of Critical Care Medicine
Goal: reduce sepsis mortality by 25% in the next5 years
Guidelines revealed at SCCM in Feb 2004,REVISED 2008
Critical Care MedicineMarch 2004 32(3):858-87.
Website: survivingsepsis.org
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What is sepsis?
Sepsis, Septic Shock,
SIRS (systemic inflammatory responsesyndrome),
SSI (signs and symptoms of infection),
Septicaemia, Bacteraemia,Toxic Shock Syndrome,
Bloodstream infection etc, etc.
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Infection
Inflammatory response to
microorganisms, or
Invasion of normally steriletissues
Systemic Inflammatory
Response Syndrome (SIRS)
Systemic response to a
variety of processes
Sepsis
Infection plus
2 SIRS criteria
Severe Sepsis
Sepsis
Organ dysfunction
Septic shock Sepsis
Hypotension despite fluid
resuscitation
Bone RC et al. Chest.1992;101:1644-55.
ACCP/SCCM Consensus Def ini t ions
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A systemic response to a nonspecific insult
Infection, trauma, surgery, massive transfusion, etc
Defined as 2 of the following:
Temperature >38.3 or 90 min-1
Respiratory rate >20 min-1
White cells 12
Acutely altered mental state
Hyperglycaemia (BM>7.7) in absence of DM
SIRSSEVERE SEPSIS
What is SIRS?
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Pneumonia 50%
Urinary Tract infection
Meningitis
Endocarditis
Device related
Central line
Cannula
Abdominal 25%Pain
DiarrhoeaDistension
Urgent laparotomy
Soft tissue/ musculoskeletal
Cellulitis
Septic arthritisFasciitis
Wound infection
What counts as an infection?
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SIRS due to an infection
what is Sepsis?
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Sepsis with organ dysfunction, hypoperfusion or hypotension
CNS: Acutely altered mental status
CVS: Syst < 90 or mean < 65 mmHg
Resp: SpO2>90% only with new/ more O2
Renal: Creatinine >177 mol/l
or UO 34 mol/l
Bone marrow: Platelets 2 mmol/l
Coagulopathy: INR>1.5 or aPTT>60secs
What is Severe Sepsis?
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Tissue perfusion is not adequate for the
tissuesmetabolic requirements
What is shock?
Septic Shock
Shock secondary to systemic
inflammatory response to a
new infection
Types of Shock
Cardiogenic
Neurogenic
Hypovolaemic
Anaphylacticand
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Tissue perfusion is not adequate for the
tissuesmetabolic requirements
For sepsis, shock is one of:
SBP < 90 mmHg
MBP < 65 mmHg after IV
fluidsDrop of < 40 mmHg
Lactate > 4 mmol/l
What is shock?
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The Sepsis Continuum
A clinical responsearising from anonspecific insult, with2 of the following:
T >38oC or 90 beats/min
RR >20/min
WBC >12,000/mm3or 10% bands
SIRS = systemic inflammatoryresponse syndrome
SIRS with a
presumed
or confirmed
infectiousprocess
Chest 1992;101:1644.
SepsisSIRSSevereSepsis
Septic
Shock
Sepsis with
organ failure
Refractory
hypotension
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Are any 2of the following SIRS criteria present and new to your patient?
Obs: Temperature >38.3 or 20 min-1
Heart rate >90 bpm Acutely altered mental state
Bloods: White cells 12x109/l Glucose>7.7mmol/l
(if patient is not diabetic)
If yes,
patient has SIRS
Severe Sepsis Screen ing Too l
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Is this likely to be due to an infection?For example
Cough/ sputum/ chest pain Dysuria
Abdo pain/ diarrhoea/ distension Headache with neck stiffness
Line infection Cellulitis/wound infection/septic arthritis
Endocarditis
If yes,
patient has SEPSIS
Start SEPSIS BUNDLE
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Severe Sepsis: Ensure Senior Doctor/ITU to
attend NOW!
Check for SEVERE SEPSIS
BP Syst < 90 / Mean < 65 mmHg
(after initial fluid challenge)
Lactate > 4 mmol/l
Urine output < 0.5 ml/kg/hr for 2 hrs
INR > 1.5
aPTT > 60 s
Bilirubin > 34 mol/l
O2 Needed to keep SpO2 > 90%
Platelets < 100 x 109/l
Creatinine > 177 mol/l or UO < 0.5 ml/kg/hr
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What is a Bundle?
Specifically selectedcare elements
From evidence basedguidelines
Implemented togetherprovide improved
outcomes compared toindividual elementsalone
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Initial Resuscitation
Protocolized, quantitative resuscitation of
patients with sepsis- induced tissue
hypoperfusion (defined in this document as
hypotension persisting after initial fluidchallenge or blood lactate concentration 4
mmol/L).
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Initial Resuscitation
Goals during the first 6 hrs of resuscitation:
Central venous pressure812 mm Hg
Mean arterial pressure(MAP) 65 mm Hg
Urine output 0.5 mL/kg/hr
Central venous (superior vena cava) or mixed venous
oxygen saturation 70% or 65%, respectively (grade 1C).
In patients with elevated lactate levels targetingresuscitation to normalize lactate (grade 2C).
Screening for Sepsis and
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Screening for Sepsis and
Performance Improvement
Routine screening of potentially infected
seriously ill patients for severe sepsis to
allow earlier implementation of therapy
(grade 1C).
Hospitalbased performance improvement
efforts in severe sepsis (UG).
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Diagnosis
Culturesas clinically appropriate before
antimicrobial therapyif no significant delay
(> 45 mins) in the start of antimicrobial(s)
(grade 1C).
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Diagnosis
At least 2 sets of blood cultures (both aerobic
and anaerobic bottles) be obtained before
antimicrobial therapy with at least 1 drawn
percutaneouslyand 1 drawn through eachvascular access device, unless the device was
recently (
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Diagnosis
Use of the 1,3 beta-D-glucan assay (grade 2B),
mannan and anti-mannan antibody assays (2C), if
available and invasive candidiasis is in differential
diagnosis of cause of infection.
Imaging studies performed promptly to confirm a
potential source of infection (UG).
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Antimicrobial Therapy
Administration of effective intravenous antimicrobials within the firsthour of recognition of septic shock (grade 1B) and severe sepsiswithout septic shock (grade 1C) as the goal of therapy.
Initial empiric anti-infective therapy of one or more drugs that haveactivity against all likely pathogens (bacterial and/or fungal or viral) andthat penetrate in adequate concentrations into tissues presumed to bethe source of sepsis (grade 1B).
Antimicrobial regimen should be reassessed daily for potentialdeescalation(grade 1B).
Use of low procalcitonin levels or similar biomarkers to assist theclinician in the discontinuation of empiric antibiotics in patients whoinitially appeared septic, but have no subsequent evidence of infection(grade 2C).
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Antimicrobial Therapy
Combination empirical therapy for neutropenicpatients with severe sepsis (grade 2B) and forpatients with difficult-to-treat, multidrug resistantbacterial pathogens such as Acinetobacterand
Pseudomonas spp. (grade 2B).
For patients with severe infections associated withrespiratory failure and septic shock, combination
therapy with an extended spectrum beta-lactam andeither an aminoglycoside or a fluoroquinolone is forP. aeruginosa bacteremia (grade 2B).
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Antimicrobial Therapy
A combination of beta-lactam and macrolide forpatients with septic shock from bacteremicStreptococcus pneumoniae infections (grade 2B).
Empiric combination therapy should not beadministered for more than 35 days.
De-escalation to the most appropriate singletherapyshould be performed as soon as thesusceptibility profile is known (grade 2B).
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Antimicrobial Therapy
Duration of therapy typically 710 days; longer courses may
be appropriate in patients who have a slow clinical response,
undrainable foci of infection, bacteremia with S. aureus;
some fungal and viral infections or immunologic
deficiencies, including neutropenia (grade 2C).
Antiviral therapy initiated as early as possible in patients with
severe sepsis or septic shock of viral origin (grade 2C).
Antimicrobial agents should not be used in patients with
severe inflammatory states determined to be of
noninfectious cause(UG).
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Source Control
A specific anatomical diagnosis of infection requiring
consideration for emergent source control be sought and
diagnosed or excluded as rapidly as possible, and
intervention be undertaken for source control within
the first 12 hr after the diagnosis is made, if feasible(grade 1C).
When infected peripancreatic necrosis is identified as a
potential source of infection, definitive intervention isbest delayed until adequate demarcation of viable and
nonviable tissues has occurred (grade 2B).
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Source Control
When source control in a severely septic patient is
required, the effective intervention associated with the
least physiologic insult should be used (eg,
percutaneous rather than surgical drainage of an
abscess) (UG).
If i.v access devices are a possible source of severe
sepsis or septic shock, they should be removed promptly
after other vascular access has been established (UG).
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Infection Prevention
Selective oral decontamination and selectivedigestive decontamination should beintroduced and investigated as a method toreduce the incidence of ventilator-associatedpneumonia;
This infection control measure can then beinstituted in health care settings and regions
where this methodology is found to be effective(grade 2B).
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Infection Prevention
Oral chlorhexidine gluconate be used as a form of
oropharyngeal decontamination to reduce the risk of
ventilator-associated pneumonia in ICU patients with
severe sepsis (grade 2B).
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Fluids
Why?
To reduce organ dysfunction and
multi-organ failure
By optimising tissue oxygen delivery
By increasing organ perfusion
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DO2 = Oxygen delivery to the tissue
CaO2= Amount of O2 in arterial blood
Fluid therapy improves cardiac output by increasing
venous return to the heart
CaO2= ([Hb] x SaO2x 1.34) + (PaO2x 0.0225)
DO2= CaO2x CO
Optimising oxygen delivery
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Fluid Therapy of Severe Sepsis
Crystalloidsas the initial fluid of choice inthe resuscitation of severe sepsis and septicshock (grade 1B).
Against the use of HESfor fluid resuscitationof severe sepsis and septic shock (grade 1B).
Albuminin the fluid resuscitation of severesepsis and septic shock when patients requiresubstantial amounts of crystalloids (grade 2C).
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Fluid Therapy of Severe Sepsis
Initial fluid challenge in patients with sepsis-induced tissuehypoperfusion with suspicion of hypovolemia to achieve aminimum of 30 mL/kg of crystalloids(a portion of this may bealbumin equivalent).
More rapid administration and greater amounts of fluid may beneeded in some patients (grade 1C).
Fluid challenge technique be applied wherein fluid
administration is continued as long as there is hemodynamicimprovement either based on dynamic(eg, change in pulsepressure, stroke volume variation) or static(eg, arterialpressure, heart rate) variables (UG).
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Vasopressors
Vasopressor therapy initially to target a meanarterial pressure (MAP) of 65 mm Hg (grade 1C).
Norepinephrineas the first choice vasopressor(grade 1B).
Epinephrine(added to and potentiallysubstituted for norepinephrine) when anadditional agent is needed to maintain adequateblood pressure (grade 2B).
Vasopressin0.03 units/minute can be added tonorepinephrine (NE) with intent of either raisingMAP or decreasing NE dosage (UG).
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Vasopressors
Low dose vasopressin is not recommended as single initial
vasopressor for treatment of sepsis-induced hypotension
.vasopressin doses higher than 0.030.04 units/minute
should be reserved for salvage therapy (failure to achieve
adequate MAP with other vasopressor agents) (UG).
Dopamineas an alternative vasopressor agent to
norepinephrine only in highly selected patients (eg, patients
with low risk of tachyarrhythmias and absolute or relativebradycardia) (grade 2C).
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Vasopressors
Phenylephrineis not recommended in thetreatment of septic shock exceptin circumstanceswhere
(a) NEis associated with serious arrhythmias,(b) cardiac output is known to be highand bloodpressure persistently low or
(c) as salvage therapy when combined
inotrope/vasopressor drugs and low dosevasopressin have failed to achieve MAP target(grade 1C).
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Vasopressors
Low-dose dopamine should not be used for
renal protection(grade 1A).
All patients requiring vasopressors have an
arterial catheterplaced as soon as practical if
resources are available (UG).
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Inotropic Therapy
A trial of dobutamine infusion up to 20mcg/kg/min be administered or added tovasopressor (if in use) in the presence of:-
(a) myocardial dysfunction as suggested byelevated cardiac filling pressures and lowcardiac output,
(b) ongoing signs of hypoperfusion, despiteachieving adequate intravascular volume andadequate MAP (grade 1C).
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Inotropic Therapy
Not using a strategy to increase cardiac index to
predetermined supranormal levels (grade 1B).
C i id
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Corticosteroids
Not using intravenous hydrocortisone to treatadult septic shock patients if adequate fluidresuscitationand vasopressortherapy are able torestore hemodynamic stability.
In case this is not achievable, i.v hydrocortisonealone at a dose of 200 mg per day (grade 2C).
Not using the ACTH stimulation test to identifyadults with septic shock who should receivehydrocortisone (grade 2B).
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Corticosteroids
In treated patients hydrocortisone taperedwhen
vasopressors are no longer required (grade 2D).
Corticosteroids not be administered for the treatment of
sepsis in the absence of shock (grade 1D).
When hydrocortisone is given, use continuous flow
(grade 2D).
l d d d i i i
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Blood Product Administration
Once tissue hypoperfusion has resolved and in
the absence myocardial ischemia, severe
hypoxemia, acute hemorrhage, or IHD
guideline recommends red blood cell
transfusion occur only when Hb concentration
decreases to
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Blood Product Administration
Not using erythropoietin as a specific treatment of anemiaassociated with severe sepsis (grade 1B).
Fresh frozen plasma not be usedto correct laboratoryclotting abnormalities in the absence of bleeding or plannedinvasive procedures (grade 2D).
Not using antithrombin for the treatment of severe sepsisand septic shock (grade 1B).
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Blood Product Administration
In patients with severe sepsis, administer platelets
prophylactically when counts are 50,000/mm3 [50 x 109/L]) are advised
for active bleeding, surgery, or invasive procedures (grade 2D).
I l b li
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Immunoglobulins
Not using intravenous immunoglobulins
in adult patients with severe sepsis or septic
shock (grade 2B).
S l i
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Selenium
Not using intravenous selenium for the
treatment of severe sepsis (grade 2C).
History of Recommendations Regarding Use of
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y g g
Recombinant Activated Protein C (rhAPC)
A history of the evolution of SSC
recommendations as to rhAPC (no longer
available) is provided.
Mechanical Ventilation of Sepsis-Induced Acute
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p
Respiratory Distress Syndrome (ARDS)
Target a tidal volume of 6 mL/kg predicted body weight in patientswith sepsis-induced ARDS (grade 1A vs. 12 mL/kg).
Plateau pressures be measured in patients with ARDS and initial
upper limit goal for plateau pressures in a passively inflated lung be
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Mechanical Ventilation of Sepsis-Induced Acute
Respiratory Distress Syndrome (ARDS)
Recruitment maneuvers be used in sepsis patientswith severe refractory hypoxemia (grade 2C).
Prone positioning be used in sepsis-induced ARDSpatients with a P:F ratio < 100 mm Hg in facilities that
have experience with such practices (grade 2B). That mechanically ventilated sepsis patients be
maintained with the head of the bed elevated to 3045 degreesto limit aspiration risk and to prevent the
development of ventilator-associated pneumonia(grade 1B).
M h i l V il i f S i I d d A
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Mechanical Ventilation of Sepsis-Induced Acute
Respiratory Distress Syndrome (ARDS)
Noninvasive mask ventilation (NIV) be used in
that minority of sepsis-induced ARDS patients in
whom the benefits of NIV have been carefullyconsidered and are thought to outweigh the
risks (grade 2B).
M h i l V til ti f S i I d d A t
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Mechanical Ventilation of Sepsis-Induced Acute
Respiratory Distress Syndrome (ARDS)
A weaning protocol be in place and that mechanically ventilatedpatients with severe sepsis undergo spontaneous breathing trialsregularly to evaluate the ability to discontinue mechanical ventilationwhen they satisfy the following criteria:
a) arousable; b) hemodynamically stable (without vasopressor agents);
c) no new potentially serious conditions;
d) low ventilatory and end-expiratory pressure requirements;
e) low Fio2 requirements which can be met safely delivered with a
face mask or nasal cannula.
If the spontaneous breathing trial is successful, consideration shouldbe given for extubation (grade 1A).
M h i l V til ti f S i I d d A t
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Mechanical Ventilation of Sepsis-Induced Acute
Respiratory Distress Syndrome (ARDS)
Againstthe routine use of the pulmonary arterycatheter for patients with sepsis-induced ARDS(grade 1A).
A conservative rather than liberal fluid strategyfor patients with established sepsis-induced ARDSwho do not have evidence of tissuehypoperfusion (grade 1C).
In the absence of specific indications such asbronchospasm, not using beta 2-agonistsfortreatment of sepsis-induced ARDS (grade 1B).
Sedation, Analgesia, and
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, g ,Neuromuscular Blockade in Sepsis
Continuous or intermittent sedation beminimizedin mechanically ventilated sepsispatients, targeting specific titration endpoints
(grade 1B). Neuromuscular blocking agents (NMBAs) be
avoided if possible in the septic patientwithout ARDS due to the risk of prolonged
neuromuscular blockade followingdiscontinuation.
Sedation Analgesia and
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Sedation, Analgesia, and
Neuromuscular Blockade in Sepsis
If NMBAs must be maintained, eitherintermittent bolus as required or continuousinfusion with train-of-four monitoring of the
depth of blockade should be used (grade 1C).
A short course of NMBA of not greater than48 hours for patients with early sepsis-induced ARDS and a Pao2/Fio2 < 150 mm Hg(grade 2C).
Glucose Control
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Glucose Control
A protocolized approach to blood glucosemanagement in ICU patients with severesepsis commencing insulin dosing when 2
consecutive blood glucose levels are >180mg/dL.
This protocolized approach should target anupper blood glucose 180 mg/dL rather than
an upper target blood glucose 110 mg/dL(grade 1A).
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Glucose Control
Blood glucose values be monitored every 12hrs until glucose values and insulin infusionrates are stable and then every 4 hrs
thereafter (grade 1C). Glucose levels obtained with point-of-care
testing of capillary blood be interpreted withcaution, as such measurements may not
accurately estimate arterial blood or plasmaglucose values (UG).
Renal Replacement Therapy
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Renal Replacement Therapy
Continuous renal replacement therapies and
intermittent hemodialysis are equivalent in
patients with severe sepsis and acute renal
failure (grade 2B). Use continuous therapiesto facilitate
management of fluid balance in
hemodynamically unstable septic patients(grade 2D).
Bicarbonate Therapy
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Bicarbonate Therapy
Not using sodium bicarbonate therapy for
the purpose of improving hemodynamics or
reducing vasopressor requirements in
patients with hypoperfusion-induced lacticacidemia with pH 7.15 (grade 2B).
Deep Vein Thrombosis Prophylaxis
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Deep Vein Thrombosis Prophylaxis
Patients with severe sepsis receive dailypharmacoprophylaxis against venous thromboembolism(VTE) (grade 1B).
This should be accomplished with daily subcutaneous low-molecular weight heparin (LMWH) (grade 1B versus twicedaily UFH, grade 2C versus three times daily UFH).
If creatinine clearance is
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Deep Vein Thrombosis Prophylaxis
Septic patients who have a contraindication forheparin use(eg, thrombocytopenia, severecoagulopathy, active bleeding, recent intracerebralhemorrhage) not receive pharmacoprophylaxis
(grade 1B), but receive mechanical prophylactictreatment, such as graduated compression stockingsor intermittent compression devices (grade 2C),unless contraindicated.
When the risk decreases start pharmacoprophylaxis(grade 2C).
Stress Ulcer Prophylaxis
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Stress Ulcer Prophylaxis
Stress ulcer prophylaxis using H2 blocker or
proton pump inhibitor be given to patients
with severe sepsis/septic shock who have
bleeding risk factors (grade 1B). When stress ulcer prophylaxis is used, proton
pump inhibitors rather than H2RA(grade 2D)
Patients without risk factors do not receiveprophylaxis (grade 2B).
Nutrition
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Nutrition
Administer oral or enteral (if necessary)feedings, as tolerated, rather than eithercomplete fasting or provision of onlyintravenous glucose within the first 48 hours
after a diagnosis of severe sepsis/septic shock(grade 2C).
Avoid mandatory full caloric feeding in the first
weekbut rather suggest low dose feeding (eg, upto 500 calories per day), advancing only astolerated (grade 2B).
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Nutrition
Use intravenous glucose and enteral nutritionrather than total parenteral nutrition (TPN)alone or parenteral nutrition in conjunction withenteral feeding in the first 7 days after a diagnosis
of severe sepsis/septic shock (grade 2B).
Use nutrition with no specificimmunomodulating supplementationrather
than nutrition providing specificimmunomodulating supplementation in patientswith severe sepsis (grade 2C).
Setting Goals of Care
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Setting Goals of Care
Discuss goals of care and prognosis withpatients and families(grade 1B).
Incorporate goals of care into treatment and
end-of-life care planning, utilizing palliativecare principles where appropriate (grade 1B).
Address goals of care as early as feasible, but
no later than within 72 hours of ICU admission(grade 2C).
ED Critical Care Bringing Upstairs
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ED Critical Care Bringing Upstairs
Care, Downstairs
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THANk YoU