Surviving Sepsis Guidelines Updated

Preview from the 41th Society of Critical Care Medicine Meeting

Jun 16, 2012

STOPSEPSIS

http://pulmccm.org/2012/critical-care-review/surviving-sepsis-guidelines-updated-at-sccm-meeting/

Systemic Inflammatory Response Syndrome

• Temp < 36 ° C or > 38.3 ° C• HR > 90• RR > 20 or PCO2 < 32• WBC < 4K or > 12K or bands > 10%

SepsisSepsisSIRSSIRS Severe SepsisSevere Sepsis Septic ShockSeptic Shock

SIRS with InfectionSepsis plus Organ Dysfunction

• Elevated Creatinine (>2)• Elevated INR (DIC)• Altered Mental Status (GCS <12)• Elevated Lactate (>4)• Hypotension that responds to fluid

Severe Sepsis and Hypotension• Hypotension that does NOT

respond to fluid (500 cc bolus)

Bone et al. Chest 1992;101:1644

2001;345:1368-77.

Guide to Recommendations’ Strengths and Supporting Evidence

1 = strong recommendation

2 = weak recommendation or suggestion

A = good evidence from randomized trials

B = moderate strength evidence from small randomized trial(s) or multiple good observational trials

C = weak or absent evidence, mostly driven by consensus opinion

New Fluid Resuscitation Recommendations

Using crystalloids like normal saline as the initial fluid resuscitation for people with severe sepsis.

The initial fluid challenge should be 1L or more of crystalloid, and a minimum of 30 mL/kg of crystalloid (2.1 L in a 70 kg) in the first 4-6 hours. (Grade 1A)

New Fluid Resuscitation Recommendations

Incremental fluid boluses should be continued as long as patients continue to improve hemo-dynamically (in blood pressure, delta pulse pressure, or both) (Grade 1C)

New Fluid Resuscitation Recommendations

Adding albumin to initial fluid resuscitation with crystalloid for severe sepsis and septic shock (Grade 2B)

Don’t using hetastarches/ hydroxyethyl starches greater than 200 kDa in molecular weight (Grade 1B)

New Recommendations for Vasopressors, Inotropes

Using norepinephrine (Levophed) as the first choice for vasopressor therapy (Grade 1B). Vasopressin 0.03 units / minute is an alternative to norepinephrine, or may be added to it (Grade 2A)

When a second agent is needed, epinephrine is weakly-recommended vasopressor choice (Grade 2B)

New Recommendations for Vasopressors, Inotropes

Dopamine was only recommended in highly selected patients whose risk for arrhythmias was felt to be very low and who had a low heart rate and/or cardiac output (Grade 2C)

Dobutamine is strongly recommended (by itself or in addition to a vasopressor) for patients with cardiac dysfunction as evidenced by high filling pressures and low cardiac output, or clinical signs of hypoperfusion after achievement of restoration of blood pressure with effective volume resuscitation (Grade 1C)

Corticosteroid Recommendations

Don’t providing intravenous corticosteroid therapy to patients for whom fluid resuscitation and vasopressors can restore an adequate blood pressure. For those with vasopressor-refractory septic shock, they recommend IV hydrocortisone in a continuous infusion totaling 200 mg/24 hrs (Grade 2C)

Mechanical Ventilation for ARDS

For patients with ARDS due to severe sepsis:

Using higher levels of PEEP (Grade 2C)

Recruitment maneuvers for patients with severe hypoxemia while receiving high PEEP and FiO2 (Grade 2C)

Prone positioning for patients with PaO2/FiO2 ratios < 100 despite such maneuvers (Grade 2C)

Other New Surviving Sepsis GuidelinesUsing normalization of lactate levels

as an alternate goal in early goal-directed therapy for severe sepsis, if central venous oxygenation monitoring is not available (Grade 2C)

Other New Surviving Sepsis GuidelinesFor patients at risk for fungal infection as a

source for severe sepsis, checking one of the newer assays for invasive candidiasis such as 1,3-beta-D-glucan, mannan, or anti-mannan ELISA antibody testing (Grade 2B/C)

Other New Surviving Sepsis GuidelinesWhen no infection can be found during

empiric antibiotic therapy, consider using a low procalcitonin level as a supportive tool for the decision to stop antibiotics (Grade 2C).

The Surviving Sepsis project was criticized in the mid 2000s when it was revealed that Eli Lilly (makers of since-discontinued Xigris) provided a reported ~90% of the funding, without disclosure by the committee.

Others (including the committee itself) felt such criticism was unfounded and unfair.