Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic...

Nabil Abouchala, MD, FCCP, FACPConsultant, Pulmonary and Critical Care Medicine

King Faisal Hospital & Research CenterRiyadh, Saudi Arabia

SURVIVING SEPSIS CAMPAIGN:

INTERNATIONAL GUIDELINES FOR

MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK:

2012A GUIDE TO THE GUIDELINES …

SURVIVING SEPSIS CAMPAIGN: HISTORY OF THE GUIDELINES…

Organizations involved

Number of participants

Process Publication

First2001

1 (ISF) 9 EBM: A-E Intensive care medicine (ICM) supplement, 2001

Second 2004

3 (ISF, ESIM, SCCM)

24 EBM: A-E CCM & ICM, 2004

Third 2008

16 55 GRADE CCM & ICM, 2008

Fourth 2012

30 (ISF, ESIM, SCCM, WFSICCM, WFPICCS, WFCCN, ISF, Sepsis Alliance, IFEM, APP, GSS, CSCC, …)

68 GRADE CCM & ICM, 2012

SURVIVING SEPSIS CAMPAIGN: HISTORY OF THE GUIDELINES…

2001

2004

2008 201

2

Crit Care Med 2013; 41:580–637

SURVIVING SEPSIS CAMPAIGN: INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK: 2012

1. Initial Resuscitation and Infection Issues 2. Hemodynamic Support and Adjunctive Therapy 3. Other Supportive Therapy of Severe Sepsis4. Special Considerations in Pediatrics

A. Initial Resuscitation

B. Screening for Sepsis & Performance Improvement

C. Diagnosis

D. Antimicrobial Therapy

E. Source Control

F. Infection prevention

1. Initial Resuscitation & Infection Issues

• Sepsis BundleA. Initial Resuscitation

• RRT and Use of Sepsis Bundle Protocol

B. Screening for Sepsis & Performance Improvement

• Use of the 1,3 beta-D-glucan assay, mannan and anti-mannan antibody assays

C. Diagnosis

• Use of an echinocandin if candidemia is suspected • Use of low procalcitonin levels or similar biomarkers to

assist the clinician in the discontinuation of empiric antibiotics

D. Antimicrobial Therapy

E. Source Control

• Oral chlorhexidine gluconate (CHG) for prevention of VAPF. Infection prevention

1. Initial Resuscitation & Infection Issues

LACTIC ACID CLEARANCE

JAMA. 2010;303(8):739

FLUID IN SEPTIC SHOCK, HOW MUCH ?

2012: IVF RECOMMENDATION Initial fluid challenge ≥ 1000 mL of

crystalloids or minimum of 30 mL/kg of crystalloids in the 1st 4-6 hours (Strong recommendation; Grade 1C).

Crystalloids is the initial fluid for resuscitation (Strong recommendation; Grade 1A).

Adding albumin to the initial fluid resuscitation (Weak recommendation; Grade 2B).

Against hydroxyethyl starches (hetastarches) with MW >200 dalton (Strong recommendation; Grade 1B).

Timing of Antibiotic Administration

Septic Shock: Timing of Antibiotics

Kumar Crit Care Med 2006

0.0

.20

.40

.60

.80

1.00

% Survival% Total receiving antibiotics

0 - .5 .5 – 1.01 - 2 2 - 3 3-4 4 - 5 5 - 6 6 - 9 9 - 1

212 - 2

424 - 3

6> 36

Percent

Time, hrs

14 ICUs; n = 2,731

Only 50% of patients in Septic Shock received antibiotics w/in 6 hrs.

G. Fluid Therapy of Severe Sepsis

H. Vasopressors

I. Inotropic Therapy

J. Corticosteroids

2. Hemodynamic Support and Adjunctive Therapy

ADRENERGIC AGENTSIsoproterenol

Dobutamine

Dopamine

Epinephrine

Norepinephrine

Phenylephrine

Beta

Alpha

WHICH INOTROPES TO USE? Norepinephrine as the first choice

( Grade 1B) Adding or substituting epinephrine when an

additional drug is needed (Strong recommendation; Grade 1B).

Vasopressin 0.03 units/min may be added (Weak recommendation; Grade 2A)

Dopamine only in highly selected patients at very low risk of arrhythmias or low heart rate (Weak recommendation; Grade 2C).

Dobutamine infusion be started or added with low cardiac output) or ongoing signs of hypoperfusion, even after adequate intravascular volume (Strong recommendation; Grade 1C)

NOREPINEPHRINE COMPARED WITH DOPAMINE IN SEVERE SEPSIS SUMMARY OF EVIDENCE

Adequate fluid resuscitation …

Crit Care Med 2007; 35:64–68

CHEST 2008; 134:172–178

PASSIVE LEG RAISING

PASSIVE LEG RAISING

PLR mimics fluid challenge

Unlike fluid challenge, no fluid is infused and the effects are reversible

and transient

CHALLENGING THE FRANK–STARLING CURVE WITH THE PASSIVE LEG RAISING (PLR)

Normal Heart

Failing Heart

STROKE VOLUME VARIATIONSVV = SV max – SV min / SV mean

• MV with TV >8 ML/Kg, no spontaneous breathing

• NSR• Difficult to interpret with: spont breathing,

arrhythmias, TV too low, lung compliance too low, on HFV

Limitation:

Preload

Stroke Volume

00

Higher PVI = More likely to respond to fluid administration24 %

10 % Lower PVI = Less likely to respond

to fluid administration

PLETH VARIABILITY INDEX (PVI) TO HELP CLINICIANS OPTIMIZE PRELOAD / CARDIAC OUTPUT

Maxime Cannesson, MD, PhD

• Crystalloids = Albumin• Against the use of hydroxyethyl starches• Hemodynamic response based on Dynamic

assessment

G. Fluid Therapy of Severe Sepsis

• Norepinephrine is 1st choice• Epinephrine 2nd

• Dopamine only in highly selected cases • Phenylephrine is not recommended• Low-dose dopamine should not be used for renal

protection

H. Vasopressors

I. Inotropic Therapy

• Not using IV hydrocortisone to treat adult septic shock unless …

• Use Hydrocortisone at 200 mg/day, preferably as IV infusion, to be tapered off

J. Corticosteroids

2. Hemodynamic Support and Adjunctive Therapy

Target MAP ≥ 65 …

K. Blood Product Administration Target Hemoglobin (7-9 g/dl) unless …

L. Immunoglobulins: Not recommended

M. Selenium: Not recommendedN. History of Recommendations Regarding Use of Recombinant Activated Protein CO. Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)P. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis

Q. Glucose Control

R. Renal Replacement Therapy

S. Bicarbonate Therapy

T & U. Prophylaxis: Deep Vein Thrombosis and Stress Ulcer

V. Nutrition

W. Setting Goals of Care

3. Other Supportive Therapy of Severe Sepsis



M. Selenium: Not recommendedN. History of Recommendations Regarding Use of Recombinant Activated Protein C




THE RISE AND FALL OF XIGRIS!

THE RISE AND FALL OF XIGRIS!

-6.5% +1.2%



M. Selenium: Not recommendedN. History of Recommendations Regarding Use of Recombinant Activated Protein CO. Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)P. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis

Q. Glucose Control




V. Nutrition

W. Setting Goals of Care


O. Mechanical Ventilation of Sepsis-Induced (ARDS)


1. Target a TV of 6 mL/kg predicted body weight (grade 1A vs. 12 mL/kg)2. Plateau pressures be measured in patients with ARDS be ≤30 cm H2O (grade 1B)3. (PEEP) be applied (grade 1B)4. Higher rather than lower levels of PEEP for moderate or severe ARDS (grade 2C)5. Recruitment maneuvers be used with severe refractory hypoxemia (grade 2C)6. Prone positioning be used Pao2/Fio2 ratio ≤ 100 mm (grade 2B)

7. HOB elevated to 30-45 (grade 1B)

8. (NIV) be used in minority of patients in whom the benefits of NIV (grade 2B)

9. Weaning protocol be in place

10. Against the routine use of the pulmonary artery catheter (grade 1A)

11. A conservative rather than liberal fluid strategy (grade 1C)

12. not using beta 2-agonists for treatment of sepsis-induced ARDS (grade 1B)

ARMA Trial

Intervention Control

TV (4-6 ml/Kg)PEEP 8.5

TV (10-12 ml/Kg)

PEEP 8.6

Reducing from 12 to 6 ml/kg VT saved lives

NNT 1214000 Lives Saved/Year

Consequences of Fluid Overload

FACTT: Fluid management Protocols

Conservative: CVP < 4 and PAOP < 8

Liberal: CVP 10 -14 and PAOP 14 -18

Wet First –Dry later

Approach that combines both adequate initial fluid resuscitation followed by conservative late-fluid management was associated with improved survival

CHEST 2009; 136:102–109

Wet First –Dry later

CHEST 2009; 136:102–109

JAMA. 2010;303(9):865-873

Higher PEEP is better in Moderate to Severe ARDS

(PO2/FiO2 ≤ 200 mmHg)

JAMA. 2010;303(9):865-873

Higher PEEP is better in Moderate to Severe ARDS

(PO2/FiO2 ≤ 200 mmHg)

Death in ICU 6.3 %

NNT 16Days off the MV-5 days JAMA. 2010;303(9):865-873

Survival with PAL

• (NMBAs) be avoided if possible without ARDS• Short course of NMBA (<48 hours) for early ARDS +

Pao2/Fio2<150 mm Hg

P. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis

Q. Glucose Control

• PPIs rather than H2RA (grade 2D)


V. Nutrition


Mortality

+1.5%

Daily energy intake

Rice at al. for the NHLBI ARDS Clinical Trials Network . JAMA. 2012

Same outcome

!

• (NMBAs) be avoided if possible without ARDS• Short course of NMBA (<48 hours) for early ARDS +

Pao2/Fio2<150 mm Hg

P. Sedation, Analgesia, and Neuromuscular Blockade in Sepsis

• Target an upper BG 140-180 mg/dL rather than ≤ 110 mg/dL (grade 1A)

Q. Glucose Control

• PPIs rather than H2RA (grade 2D)


• Avoid mandatory full caloric feeding in the first week but rather suggest low dose feeding (eg, up to 500 calories per day)

• No specific immunomodulating supplementation

V. Nutrition


TAKE HOME MESSAGE BE Goal Directed:

More and faster fluid No hetastarch Earlier Inotropes Use norepineprine and epinephrine over

dopamine Lactic acid clearance Dynamic SVV is better than CVP

Antimicrobials: Fast <1 hr, consider early antifungals, use

biomarkers to deescalate or stop ARDS:

Wet first, dry later Higher PEEP

Glucose control Not so tight (140-180 mg/dl = 8-10 mmol/l)

Nutrition Underfeed first week No supplement

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic...

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