Surviving Sepsis Campaign3

7/30/2019 Surviving Sepsis Campaign3

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Surviving Sepsis Campaign2012 UPDATE


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HighlightsHistory

Methodology

Recommendations

New changes


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History


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MethodologyoCommittee Members

oDefinitions

oLiterature search

oGrading ( GRADE )

oConflict of Interest Policy


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Quality of EvidenceoGRADE system

o A (high) RCTs

o B (moderate) Downgraded RCTs or upgraded observational studies

o

C (low) Well-done observational studies with control RCTso D (very low) Downgraded controlled studies or expert opinion

based on other evidence

oStrenght of recommendation:

o Strong (grade 1) we recommend

o Weak (grade 2) we suggest


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DefinitionsoSepsis is defined as the presence (probable or documented) ofin

fection together with systemic manifestations of infection

oSevere sepsis is defined as sepsis plus sepsis-induced organ dysfunctionor tissue

hypoperfusion.

oSeptic shock is defined as sepsis-induced hypotension persisting

despite adequate fluid resuscitation.

oSepsis-induced tissue hypoperfusion is defined as infection-inducedhypot

ension, elevated lactate, or oliguria


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Diagnostic Criteria for

SepsisoGeneral variables

oFever (> 38.3C)

o

Hypothermia (core temperature < 36C)oHeart rate > 90/min1 or more than two sd above the normal value

for age

oTachypnea

oAltered mental status

oSignificant edema or positive fluid balance (> 20 mL/kg over 24 hr)oHyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the

absence of diabetes


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SepsisoInflammatory variables

oLeukocytosis (WBC count > 12,000 L1)

o

Leukopenia (WBC count < 4000 L1)oNormal WBC count with greater than 10% immature forms

oPlasma C-reactive protein more than two sd above the normal value

oPlasma procalcitonin more than two sd above the normal value


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SepsisoOrgan dysfunction variables

oArterial hypoxemia (Pao2/Fio2 < 300)

oAcute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despiteadequate fluid resuscitation)

oCreatinine increase > 0.5 mg/dL or 44.2 mol/L

oCoagulation abnormalities (INR > 1.5 or aPTT > 60 s)

o Ileus (absent bowel sounds)

oThrombocytopenia (platelet count < 100,000 L1)oHyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 mol/L)


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SepsisoTissue perfusion variables

oHyperlactatemia (> 1 mmol/L)

o Decreased capillary refill or mottling


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Severe Sepsis


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The recommendations


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Initial ResuscitationoGoals during the first 6 hrs of resuscitation:

oa) Central venous pressure 812 mm Hg

ob) Mean arterial pressure (MAP) 65 mm Hg

oc) Urine output 0.5 mL/kg/hr

od) Central venous (superior vena cava) or mixed venous oxygensaturation 70% or 65%, respectively (grade 1C).

o In patients with elevated lactate levels targetingresuscitation to normalize lactate (grade 2C).


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Diagnosiso Cultures as clinically appropriate before antimicrobial therapy if no significantdelay (> 45 mins) in the start of antimicrobial(s) (grade1C).

o At least 2 sets of blood cultures (both aerobic and anaerobic bottles) beobtained before antimicrobial therapy with at least 1 drawn percutaneously and1 drawn through each vascular access device, unless the device was recently(


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Antimicrobial Therapyo Administration of effective intravenous antimicrobials within the first hour ofrecognition of septic shock (grade 1B) and severe sepsis without septic shock (grade1C) as the goal of therapy.

o2a. Initial empiric anti-infective therapy of one or more drugs that have activity

against all likely pathogens (bacterial and/or fungal or viral) and that penetrate inadequate concentrations into tissues presumed to be the source of sepsis (grade 1B).

o2b. Antimicrobial regimen should be reassessed daily for potential deescalation(grade 1B).

o Use of low procalcitonin levels or similar biomarkers to assist the clinician in thediscontinuation of empiric antibiotics in patients who initially appeared septic, buthave no subsequent evidence of infection (grade 2C).


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Source Control

oA specific anatomical diagnosis of infection requiring consideration foremergent source control be sought and diagnosed or excluded as

rapidly as possible, and intervention be undertaken for source controlwithin the first 12 hr after the diagnosis is made, if feasible (grade 1C).


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Recommendations for Hemodynamic

Support and Adjunctive Therapy


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Fluid Therapy of Severe Sepsiso Crystalloids as the initial fluid of choice in the resuscitation of severesepsis and septic shock (grade 1B).

oInitial fluid challenge: 30 mL/kg of crystalloids (a portion of this may

be albumin equivalent). More rapid administration and greater amountsof fluid may be needed in some patients (grade 1C).

o Against the use of hydroxyethyl starches for fluid resuscitation ofsevere sepsis and septic shock (grade 1B).

o Albumin in the fluid resuscitation of severe sepsis and septic shockwhen patients require substantial amounts of crystalloids (grade 2C).


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Vasopressorso Vasopressor initially to target a (MAP) of 65 mm Hg (grade 1C).

oNorepinephrine as the first choice vasopressor (grade 1B).

o Epinephrine (added to and potentially substituted for norepinephrine) when anadditional agent is needed to maintain adequate blood pressure (grade 2B).

o Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intentof either raising MAP or decreasing NE dosage (UG).


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Vasopressors

o Dopamine as an alternative vasopressor agent to norepinephrine only in highlyselected patients (eg, patients with low risk of tachyarrhythmias and absoluteor relative bradycardia) (grade 2C).


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Vasopressorso Phenylephrine is not recommended in the treatment of septic shockexcept in circumstances where (a) norepinephrine is associated with seriousarrhythmias, (b) cardiac output is known to be high and blood pressure

persistently low or (c) as salvage therapy when combinedinotrope/vasopressor drugs and low dose vasopressin have failed to achieveMAP target (grade 1C).

o Low-dose dopamine should not be used for renal protection (grade 1A).

o All patients requiring vasopressors have an arterial catheter placed as soonas practical if resources are available (UG).


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Inotropic Therapyo Dobutamine infusion up to 20 micrograms/kg/min be administered oradded to vasopressor (if in use) in the presence ofo myocardial dysfunction as suggested by elevated cardiac filling pressures

and low cardiac output

o ongoing signs of hypoperfusion, despite achieving adequate intravascularvolume and adequate MAP

(grade 1C).


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Corticosteroidso Not using intravenous hydrocortisone to treat adult septic shock patientsif adequate fluid resuscitation and vasopressor therapy are able to restorehemodynamic stability In case this is not achievable, we suggest

intravenous hydrocortisone alone at a dose of 200 mg per day (grade 2C).


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Blood Product Administrationo Once tissue hypoperfusion has resolved and in the absence of extenuatingcircumstances, such as myocardial ischemia, severe hypoxemia, acutehemorrhage, or ischemic heart disease, we recommend that red blood celltransfusion occur only when hemoglobin concentration decreases to


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Blood Product Administration

In patients with severe sepsis, administer platelets prophylactically whencounts are


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Mechanical Ventilation of Sepsis-InducedAcute Respiratory Distress Syndrome

(ARDS)oTarget a tidal volume of6 mL/kg predicted body weight .(grade 1A).

oUpper limit goal for plateau aiway pressures to be 30 cm H2O (grade 1B).

oPEEP to be applied to avoid alveolar collapse (grade 1B).

oHigher PEEP to be used for patients with sepsis- induced moderate or severeARDS (grade 2C).


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(ARDS)o Recruitment maneuvers be used in sepsis patients with severerefractory hypoxemia (grade 2C).

oProne positioning be used in sepsis-induced ARDS patients with aPao2/Fio2 ratio 100 mm Hg in facilities that have experience withsuch practices (grade 2B).

o30-45 degrees head of bed to limit aspiration risk and to prevent the

development of ventilator-associated pneumonia (grade 1B).


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(ARDS)o Against the routine use of the pulmonary artery catheter for patientswith sepsis-induced ARDS (grade 1A).

o A conservative rather than liberal fluid strategy for patients withestablished sepsis-induced ARDS who do not have evidence of tissuehypoperfusion (grade 1C).

o In the absence of specific indications such as bronchospasm, not using

beta 2-agonists for treatment of sepsis-induced ARDS (grade 1B).


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Glucose ControloTarget an upper blood glucose 180 mg/dL rather than an upper target bloodglucose 110 mg/dL (grade 1A).

o2. Blood glucose values be monitored every 12 hrs until glucose values and insulininfusion rates are stable and then every 4 hrs thereafter (grade 1C).


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INITIAL RESUSCITATION BUNDLE


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Recommendations: Special

Considerations in Pediatrics


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Sepsis in the pediatric Signs and symptoms of inflammation plus infection.

Hyper- or hypothermia (rectal temperature> 38.5 or < 35C)

Tachycardia (may be absent in hypothermic patients), One of the following indications of altered organ function:

altered mental status,

hypoxemia,

increased serum lactate level,

bounding pulses


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Initial Resuscitation


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Fluid Resuscitationo Initial resuscitation of hypovolemic shock begins with infusion ofisotonic crystalloids or albumin with boluses of up to 20 mL/kgcrystalloids (or albumin equivalent ) over 510 minutes,

otitrated to :o reversing hypotension

o increasing urine outputo normal capillary refill

o peripheral pulses

oIn non-hypotensive children with severe hemolytic anemia (severemalaria or sickle cell crises) blood transfusion is considered superior tocrystalloid or albumin bolusing (grade 2C).


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Inotropes/Vasopressors/Vasodilators

o Begin peripheral inotropic support until central venous access can be attainedin children who are not responsive to fluid resuscitation (grade 2C).

o Patients with low cardiac output and elevated systemic vascular resistancestates with normal blood pressure be given vasodilator therapies in addition toinotropes (grade 2C).


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Extracorporeal Membrane

Oxygenation (ECMO)o Consider ECMO for refractory pediatric septic shock and respiratoryfailure (grade 2C).


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CorticosteroidsoTimely hydrocortisone therapy in children with fluid refractory,catecholamine resistant shock and suspected or proven absolute (classic)adrenal insufficiency (grade 1A).


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Blood Products and Plasma

TherapiesoSimilar hemoglobin targets in children as in adults. During resuscitation of lowsuperior vena cava oxygen saturation shock (< 70%), hemoglobin levels of 10 g/dLare targeted. After stabilization and recovery from shock and hypoxemia then a lowertarget > 7.0 g/dL can be considered reasonable (grade 1B).

o Similar platelet transfusion targets in children as in adults (grade 2C).

o Use plasma therapies in children to correct sepsis-induced thrombotic purpura

disorders, including progressive disseminated intravascular coagulation, secondarythrombotic microangiopathy, and thrombotic thrombocytopenic purpura (grade 2C).


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Algorithm for time sensitive, goal-directed stepwise managementof hemodynamic support in infants and children


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Algorithm for time sensitive, goal-directed stepwise managementof hemodynamic support in infants and children


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New changes 2012oEarlyGoal Directed Therapy" ---> initial resusitation bundle.

o1ST line fluid is crystalloid no more colloid.

o1st line vassopressor is norepinephrine, no more dopamine.

oEpinephrine is the second additional agent

oPediatric sepsis management recommendations


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