The surviving sepsis campaign issued new guidelines in 2012, the last guidelines having been published in 2008.
These were developed by a consensus committee of 68 international experts representing 30 international organisations. They classify their recommendations into three groups;
- those directly targeting severe sepsis;
- those targeting general care of the critically ill patient and considered high priority in severe sepsis;
- paediatric considerations.
The surviving sepsis documentation is comprehensive and covers many of the areas concerned when treating this condition.
A. Initial resuscitation
1. During the first six hours of resuscitation, the goals of initial resuscitation of sepsis induced hypoperfusion should include all the following as a part of a treatment protocol:
a) CVP 8–12 mm Hg
b) MAP ≥ 65 mm Hg
c) Urine output ≥ 0.5 ml/kg/hr
d) Superior vena cava oxygenation saturation (Scvo2) or
mixed venous oxygen saturation (Svo2) 70% or 65%, respectively.
2. We suggest targeting resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion.
B. Screening for Sepsis and Performance Improvement
1. We recommend routine screening of potentially infected seriously ill patients for severe sepsis to increase the early identification of sepsis and allow implementation of early sepsis therapy.
2. Performance improvement efforts in severe sepsis should be used to improve patient outcomes.
1. We recommend obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay (> 45 minutes) in the start of antimicrobial(s) administration. (Both percutaneous and cultures drawn through each vascular device unless that device was inserted recently i.e. less than 48 hours).
2. Imaging studies to be performed promptly in attempts to confirm a potential source of infection.
D. Antimicrobial Therapy
1. The administration of effective intravenous antimicrobials within the first hour of recognition of septic shock and severe sepsis without septic shock should be the goal of therapy.
2. Initial empiric anti-infective therapy should include one or more drugs that have activity against all likely pathogens.
3. The antimicrobial regimen should be reassessed daily for potential deescalation to prevent the development of resistance, to reduce toxicity, and to reduce costs.
4. We suggest the use of low procalcitonin levels or similar biomarker is to assist the clinician in the discontinuation of empiric antibiotics in patients who appeared septic, but have no subsequent evidence of infection.
5. We suggest combination empiric therapy for neutropenic patients with severe sepsis and for patients with difficult to treat multidrug resistant bacterial pathogens.
6. Combination therapy, when used empirically in patients with severe sepsis, should not be administered for longer than 3 to 5 days.
7. We suggest that the duration of therapy typically be 7 to 10 days if clinically indicated.
8. Anti-viral therapy should be initiated as early as possible in patients with severe sepsis or septic shock of viral origin.
E. Source Control
1. A specific anatomical diagnosis of infection requiring consideration for emergent source control should be sought and diagnosed or excluded as rapidly as possible, and intervention be undertaken for source control within the first 12 hours after the diagnosis is made.
2. If intravascular access devices are a possible source of severe sepsis or septic shock, they should be removed promptly after other vascular access has been established.
F. Infection Prevention
1. Selective oral decontamination and selective digestive decontamination should be introduced and investigated as a method to reduce the incidence of ventilator associated pneumonia.
2. Oral chlorhexidine gluconate should be used as a form of oropharyngeal decontamination to reduce the risk of ventilator associated pneumonia in intensive care patients with severe sepsis.
G. Fluid Therapy of Severe Sepsis
1. Crystalloids should be used as the initial fluid of choice in the resuscitation of severe sepsis and septic shock.
2. We recommend against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock.
3. We suggest the use of albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids.
4. Patients with sepsis induced tissue hypoperfusion with suspicion of hypovolaemia should have an initial fluid challenge to achieve a minimum of 30 ml/kg of crystalloids. A portion of this may be albumin equivalent.
5. A fluid challenge technique should be applied wherein fluid administration is continued as long as various haemodynamic improvement either based on dynamic change in pulse pressure, stroke volume variation or static variables.
1. Vasopressor therapy should initially target a MAP of 65 mmHg.
2. Nor epinephrine should be the first choice vasopressor.
3. We suggest epinephrine when an additional agent is needed to maintain adequate blood pressure.
4. Vasopressin can be added to norepinephrine with the intent of raising MAP to target or decreasing nor epinephrine dosage.
5. Low-dose vasopressin is not recommended as the single initial vasopressor for treatment of sepsis induced hypertension.
6. Dopamine should be used as an alternative vasopressor or agent to ignore epinephrine only in highly selected patients.
I. Inotropic Therapy
1. A trial of dobutamine infusion may be administered or added to a vasopressor or in the presence of;
(a) myocardial dysfunction, or
(b) ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP.
1. If adequate fluid resuscitation and vasopressor therapy are able to restore haemodynamic stability then intravenous hydrocortisone should not be used as a treatment of adult septic shock. If this is not achievable, then intravenous hydrocortisone should be used at a dose of 200 mg per day.
2. Clinicians should take further treated patient from steroid therapy when vasopressors are no longer required.
3. Corticosteroids should not be administered for the treatment of sepsis in the absence of shock.
4. When low-dose hydrocortisone is given, we suggest using continuous infusion rather than repetitive bolus injections.
K. Blood Product Administration
1. Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischaemia, severe hypoxaemia, acute haemorrhage, or ischaemic coronary artery disease, we recommend red blood cell transfusions occur when the haemoglobin concentration decreases to < 7.0 g/dl.
2. We recommend not using erythropoietin is a specific treatment of anaemia associated with severe sepsis.
3. We suggest that fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures.
4. In patients with severe sepsis, we suggest that platelets be administered prophylactically when counts are ≤ 10,000/
mm3 (10 × 109/L) in the absence of apparent bleeding, as well when counts are ≤ 20,000/mm3 (20 × 109/L) if the patient has a significant risk of bleeding.
1. Intravenous immunoglobulins should not be used in adult patients with severe sepsis or septic shock.
O. Mechanical Ventilation of Sepsis Induced Acute Respiratory Distress Syndrome.
2. The initial upper limit goal for plateau pressures in a passively inflated lung be ≤ 30 cm H2O.
3. PEEP should be applied.
4. Strategies should be based on higher rather than lower levels of PEEP for patients with sepsis induced moderate to severe acute respiratory distress syndrome.
5. Recruitment manoeuvres should be used in sepsis patients with severe refractory hypoxaemia due to acute respiratory distress syndrome.
6. We suggest prone positioning in sepsis-induced ARDS patients with a Pao2/Fio2 ratio ≤ 100 mm Hg in facilities that have experience with such practices.
7. Mechanically ventilated sepsis patients should be maintained with the head of the bed elevated between 30 and 45°.
8. A weaning protocol should be in place and mechanically ventilated patients with severe sepsis should undergo spontaneous breathing trials regularly to evaluate the ability to discontinue mechanical ventilation.
9. Pulmonary artery catheters should not be used for patients with sepsis induced acute respiratory distress syndrome.
10. There should be a conservative fluid strategy for patients with established sepsis induced acute respiratory distress syndrome who do not have evidence of tissue hypoperfusion.
11. In the absence of specific indications such as bronchospasm, we recommend against the use of β2-agonists for treatment of patients with sepsis-induced ARDS.
P. Sedation, Analgesia and Neuromuscular Blockade in Sepsis
1. Continuous or intermittent sedation should be minimised in mechanically ventilated sepsis patients, targeting specific titration endpoints.
2. Neuromuscular blocking agents should be avoided if possible in the septic patient without ARDS due to the risk of prolonged neuromuscular blockade following discontinuation.
Q. Glucose Control
1. We recommend a protocolised approach to blood glucose management in ICU patients with severe sepsis, commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL. This approach should target an upper blood glucose level ≤ 180 mg/dL rather than an upper target blood glucose ≤ 110 mg/dL.
2. We recommend blood glucose values to be monitored every one to 2 hours until glucose values and insulin infusion rates are stable, then every four hours thereafter.
Renal Replacement Therapy.
1. Continuous renal replacement therapy is and intermittent haemodialysis or equivalent in patients with severe sepsis and acute renal failure because they achieve similar short-term survival rates will stop
2. The use of continuous therapies to facilitate management of fluid balance in haemodynamically unstable septic patients is suggested.
S. Bicarbonate Therapy
1. The use of sodium bicarbonate therapy for the purpose of improving haemodynamics or reducing vasopressor requirements is not recommended.
T. Deep Vein Thrombosis Prophylaxis
1. We recommend that patients with severe sepsis receive daily pharmacoprophylaxis against venous thromboembolism (VTE) (grade 1B). We recommend that this be accomplished with daily subcutaneous low-molecular weight heparin (LMWH) (grade 1B versus unfractionated heparin [UFH] twice daily and grade 2C versus UFH given thrice daily).
2. We suggest that patients with severe sepsis be treated with a combination of pharmacologic therapy and intermittent pneumatic compression devices whenever possible.
3. Septic patients who have a contraindication to heparin use should not receive pharmacoprophylaxis but receive mechanical prophylactic treatment instead.
U. Stress Ulcer Prophylaxis
1. H2 blockers or proton pump inhibitors should be given to the septic patient.
2. Patients without risk factors should not receive prophylaxis.
1. Oral or enteral feeding as tolerated rather than either complete fasting or provision of only intravenous glucose within the 48 hours after a diagnosis of severe sepsis or septic shock is recommended.
2. The patient should be given only low-dose feeding (e.g. up to 500 kcal per day), advancing only as tolerated.
3. The use of intravenous glucose and enteral nutrition rather than total parenteral nutrition alone or parenteral nutrition in conjunction with enteral feeding in the first seven days is suggested.
Originally posted 2013-02-07 20:09:02. Republished by Blog Post Promoter