The Sepsis Resuscitation And Management Bundles
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Transcript of The Sepsis Resuscitation And Management Bundles
Dr. Najm-us-saqibDr. Najm-us-saqibDepartment of Anaesthesia Department of Anaesthesia and intensive careand intensive careCombined Military Hospital Combined Military Hospital RawalpindiRawalpindi
The sepsis resuscitation and
management bundles
Sepsis:Sepsis:
SEPSISSuspected or proven infection Presence of at least 2 signs
• Temperature 38oC or 36oC• HR 90 beats/min• Respirations 20/min• WBC count 12,000/mm3 or 4,000/mm3 or >10%
immature bands
SepsisSepsisSIRSSIRSInfection /Infection /TraumaTrauma Severe SepsisSevere Sepsis
Infection
Acute organ dysfunction
Infection /Infection /TraumaTrauma SIRSSIRS SepsisSepsis Severe SepsisSevere Sepsis
Sepsis:Sepsis:
Septic shockSeptic shock
• SBP SBP << 90 mm Hg 90 mm Hg
• Reduction of 40 mm Hg or more Reduction of 40 mm Hg or more from baseline from baseline
• Oliguria Oliguria
• Lactic acidosisLactic acidosis
Common Common symptomssymptoms
Respiratory system dysfunctionRespiratory system dysfunction
Shock Shock
Renal system dysfunction Renal system dysfunction
The Institute for Healthcare The Institute for Healthcare Improvement (IHI)Improvement (IHI)
Surviving sepsis campaignSurviving sepsis campaign
Sepsis treatment Sepsis treatment bundlesbundles
ResuscitationResuscitation
ManagementManagement
Apply all elements in the bundle.Apply all elements in the bundle.
Resuscitation bundle Resuscitation bundle during the first 6 hoursduring the first 6 hours
1.1. Measure serum lactate level.Measure serum lactate level.
2.2. Blood cultures before antibiotic Blood cultures before antibiotic administration.administration.
3.3. Broad-spectrum antibiotics Within Broad-spectrum antibiotics Within
3 hours for emergency3 hours for emergency
1 hour for ICU admission1 hour for ICU admission
4.4. Hypotension Hypotension lactate > 4 mmol/Llactate > 4 mmol/L
Crystalloid 20 mL/kg (or colloid ) Crystalloid 20 mL/kg (or colloid )
Use VasopressorsUse Vasopressors
Maintain MAP Maintain MAP ≥≥ of 65 mm Hg of 65 mm Hg
Hypotension despite fluid Hypotension despite fluid resuscitationresuscitation5.5. Septic shock Septic shock
Lactate level > 4 mmol/L Lactate level > 4 mmol/L
CVP CVP ≥≥ 8 mm Hg 8 mm HgCentral venous oxygen saturation Central venous oxygen saturation ≥≥
70% 70% Mixed venous oxygen saturation Mixed venous oxygen saturation ≥≥
65% 65%
The sepsis The sepsis management bundle, management bundle, during the first 24 hoursduring the first 24 hours 1.1. Low-dose steroids Low-dose steroids
2.2. Activated drotrecogin alfa Activated drotrecogin alfa
3.3. Maintain glucose Maintain glucose
≥ ≥ the lower limit of normal the lower limit of normal but < 150 mg/dLbut < 150 mg/dL
4.4. In Plp < 30 cm H2OIn Plp < 30 cm H2O
ManagementManagementGoals during the first 6 hrs of resuscitationGoals during the first 6 hrs of resuscitation
CVP 8-12 mm HgCVP 8-12 mm HgMAP ≥ 65 mm HgMAP ≥ 65 mm HgUrine output ≥ 0.5 mL • kg-1 • hr -1Urine output ≥ 0.5 mL • kg-1 • hr -1Central venous oxygen saturation ≥ 70% Central venous oxygen saturation ≥ 70% Mixed venous ≥ 65%Mixed venous ≥ 65%
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
HCT of ≥ 30% HCT of ≥ 30%
Dobutamine infusion Dobutamine infusion
Grade 2C evidenceGrade 2C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
DiagnoDiagnosissisAppropriate cultures before Appropriate cultures before
antibiotic administrationantibiotic administration
Two blood culturesTwo blood culturesPercutaneous Percutaneous Vascular access device, Vascular access device,
Cultures of other sites Cultures of other sites Grade 1C evidenceGrade 1C evidence
Surviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Imaging Imaging studies studies Source of Source of
InfectionInfectionSamplingSampling
In unstable patients In unstable patients Bedside ultrasound Bedside ultrasound
Grade 1C evidenceGrade 1C evidence
Surviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Antibiotic TherapyAntibiotic Therapy
IV antibiotic therapy IV antibiotic therapy first hourfirst hour
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Cultures should not delay Cultures should not delay antimicrobial therapy antimicrobial therapy
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Initial empirical therapyInitial empirical therapy
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Antimicrobial regimen should be Antimicrobial regimen should be reassessed daily reassessed daily
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Combination therapy is Combination therapy is recommended for 3 -5 daysrecommended for 3 -5 days
Pseudomonas infectionsPseudomonas infections
Neutropenic patientsNeutropenic patients
De-escalation to the single therapy De-escalation to the single therapy as soon as the sensitivity is knownas soon as the sensitivity is known
Grade 2D evidenceGrade 2D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Duration of antibiotic therapy should be 7-10 Duration of antibiotic therapy should be 7-10 days days
Longer courses:Longer courses:– Slow clinical response Slow clinical response – Undrainable foci of infectionUndrainable foci of infection– Immunologic deficiencies Immunologic deficiencies
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
In Noninfectious causeIn Noninfectious cause
Antimicrobial therapy is stopped so that patient Antimicrobial therapy is stopped so that patient may not bemay not be
Infected with resistant pathogen Infected with resistant pathogen Drug-related adverse effectDrug-related adverse effect
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Source ControlSource Control
Specific anatomical diagnosis of infection Specific anatomical diagnosis of infection should be made within the first 6 hrs should be made within the first 6 hrs
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Patients should be evaluated for Patients should be evaluated for
Drainage Drainage DebridementDebridementRemoval of a potentially infected device Removal of a potentially infected device The definitive control of ongoing microbial The definitive control of ongoing microbial
contamination contamination
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
The least physiologic insult should be The least physiologic insult should be given given
Percutaneous Percutaneous Surgical drainageSurgical drainage
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Intravascular access devices should Intravascular access devices should be changed.be changed.
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Fluid Fluid TherapyTherapyFluid resuscitation Fluid resuscitation
– Natural/artificial colloids Natural/artificial colloids – Crystalloids Crystalloids
There is no evidence-based support for There is no evidence-based support for one type of fluid over another one type of fluid over another
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Central venous Central venous pressurepressureTarget CVP of ≥ 8 mm Hg Target CVP of ≥ 8 mm Hg
(12 mm Hg in mechanically ventilated (12 mm Hg in mechanically ventilated patients)patients)
Further fluid therapy is often required Further fluid therapy is often required
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Fluid challengeFluid challengeIn Hypovolemia In Hypovolemia
≥≥1000 mL of crystalloids 1000 mL of crystalloids 300-500 mL of colloids over 30 mins300-500 mL of colloids over 30 mins
More rapid and greater amounts of fluid may be More rapid and greater amounts of fluid may be needed in patients with septic shock.needed in patients with septic shock.
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
fluid resuscitation end fluid resuscitation end pointpointContinue fluid resuscitation as long as Continue fluid resuscitation as long as
the Hemodynamic improvement the Hemodynamic improvement continues continues
– Arterial pressure Arterial pressure – Heart rate Heart rate – Urine outputUrine output
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Reduce Rate of fluid Reduce Rate of fluid administrationadministration When cardiac filling pressures increase When cardiac filling pressures increase
Without Without
Hemodynamic improvement Hemodynamic improvement
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
VasopressVasopressorsors
MAP should be maintained ≥ 65 mm Hg MAP should be maintained ≥ 65 mm Hg
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
First choice First choice vasopressor agentvasopressor agent
Norepinephrine or dopamine Norepinephrine or dopamine
(Administered through a central catheter (Administered through a central catheter as soon as one is available) as soon as one is available)
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
EpinephrineEpinephrinePhenylephrinePhenylephrineVasopressin Vasopressin
Should not be administered as the initial Should not be administered as the initial vasopressor in septic shock vasopressor in septic shock
Grade 2C evidenceGrade 2C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Vasopressin 0.03 units/min may be Vasopressin 0.03 units/min may be added to norepinephrineadded to norepinephrine
Alternative agent in septic shock Alternative agent in septic shock Epinephrine Epinephrine
Grade 2B evidenceGrade 2B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Low dose dopamineLow dose dopamine
Low-dose dopamine should not be used for Low-dose dopamine should not be used for renal protection renal protection
Grade 2A evidenceGrade 2A evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Arterial Arterial lineline
If resources are available arterial line If resources are available arterial line should be placed as soon as practicalshould be placed as soon as practical
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Inotropic TherapyInotropic Therapy
Dobutamine Dobutamine
Myocardial dysfunctionMyocardial dysfunction
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
cardiac index cardiac index
predetermined supranormal levels predetermined supranormal levels
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
CorticosteroidsCorticosteroids
Intravenous hydrocortisone Intravenous hydrocortisone
adultadult
poorly responsivepoorly responsive
Grade 2D evidenceGrade 2D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
SteroidsSteroids
ACTH stimulation testACTH stimulation test
Grade 2B evidenceGrade 2B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
SteroidsSteroids
Hydrocortisone Hydrocortisone
Dexamethasone Dexamethasone
Grade 2B evidenceGrade 2B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
SteroidsSteroids
Oral fludrocortisone (50 µg)Oral fludrocortisone (50 µg)++
Steroid (no significant Steroid (no significant mineralocorticoid activity) mineralocorticoid activity)
Grade 2C evidenceGrade 2C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
SteroidSteroidssWean from steroid therapy when Wean from steroid therapy when
Vasopressors are no longer Vasopressors are no longer required required
Grade 2D evidenceGrade 2D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Doses Doses
> 300 mg of hydrocortisone> 300 mg of hydrocortisone ××
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Corticosteroids should not be Corticosteroids should not be administered in the absence of administered in the absence of
shock.shock.
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Recombinant Human Recombinant Human Activated Protein C Activated Protein C (rhAPC)(rhAPC)Adult patients with severe sepsis should Adult patients with severe sepsis should
receive rhAPCreceive rhAPC
High risk of deathHigh risk of deathAPACHE II score ≥ 25 APACHE II score ≥ 25 Multiple organ failure Multiple organ failure
Grade 2B evidenceGrade 2B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
should not receive rhAPCshould not receive rhAPC
Low risk of death Low risk of death APACHE II < 20 APACHE II < 20 One organ failureOne organ failure
Grade 1A evidenceGrade 1A evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Blood Product Blood Product AdministrationAdministrationOnce tissue hypoperfusion has resolved and in the Once tissue hypoperfusion has resolved and in the
absence ofabsence ofMyocardial ischemiaMyocardial ischemiaSevere hypoxemia Severe hypoxemia Acute hemorrhage Acute hemorrhage Cyanotic heart disease Cyanotic heart disease Lactic acidosisLactic acidosisRBC transfusionRBC transfusion
Hb < 7.0 g/dLHb < 7.0 g/dL
Target Hb 7.0-9.0 g/dL in adults Target Hb 7.0-9.0 g/dL in adults Grade 1B evidenceGrade 1B evidence
Surviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Erythropoietin should not be used Erythropoietin should not be used as a specific treatment of anemia as a specific treatment of anemia
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Fresh frozen plasmaFresh frozen plasma
Should not be given in the Absence of Should not be given in the Absence of
– Bleeding Bleeding – Planned invasive procedures Planned invasive procedures
Grade 2D evidenceGrade 2D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
AntithrombinAntithrombin
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Platelet transfusionPlatelet transfusionTransfusion requiredTransfusion required
< 5000/mm3 < 5000/mm3
May be considered when counts areMay be considered when counts are 5000-30,000/mm3 5000-30,000/mm3 significant risk of bleedingsignificant risk of bleeding
≥ ≥ 50,000/mm3 is required 50,000/mm3 is required surgery surgery invasive proceduresinvasive procedures
Grade 2D evidenceGrade 2D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Mechanical Ventilation Mechanical Ventilation
Sepsis-Induced ALI/ARDSSepsis-Induced ALI/ARDS
Target a tidal volume of 6 mL/kg Target a tidal volume of 6 mL/kg
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Plateau pressure ≤ 30 cm H2O Plateau pressure ≤ 30 cm H2O
Permissive hypercapniaPermissive hypercapnia
PEEPPEEP
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Prone positioningProne positioningHigh Fio2 High Fio2 Increased Plateau pressure Increased Plateau pressure
Not at high riskNot at high risk In experienced facilitiesIn experienced facilities
Grade 2CevidenceGrade 2CevidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Head of the bed elevated Head of the bed elevated
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Head of bed be elevated approx Head of bed be elevated approx 30-45° 30-45°
Grade 2C evidenceGrade 2C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Non invasive Non invasive ventilationventilation
Mild-moderate hypoxemiaMild-moderate hypoxemiaWith stable Hemodynamics With stable Hemodynamics Who are able to protect the airwayWho are able to protect the airwayClear secretionsClear secretionsAnticipated to recover rapidlyAnticipated to recover rapidly
Grade 2B evidenceGrade 2B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Spontaneous breathing trialSpontaneous breathing trial
Pressure support Pressure support CPAP (~5 cm H2O)CPAP (~5 cm H2O)T-pieceT-piece
Discontinue mechanical ventilationDiscontinue mechanical ventilation
ArousableArousableHemodynamically stableHemodynamically stableNo new serious conditions No new serious conditions Low pressures Low pressures Low Fio2 requirementsLow Fio2 requirements
Grade 1A evidenceGrade 1A evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Pulmonary artery catheter Pulmonary artery catheter for patients with ALI/ARDS for patients with ALI/ARDS
Grade 1A evidenceGrade 1A evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Conservative fluid strategy Conservative fluid strategy
Acute lung injury Acute lung injury
(Tissue hypoperfusion) (Tissue hypoperfusion)
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Sedation, AnalgesiaSedation, Analgesia
Sedation protocolsSedation protocolsSedation goal Sedation goal
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Intermittent bolus sedation Intermittent bolus sedation
Continuous infusion sedation Continuous infusion sedation (to predetermined end points) (to predetermined end points)
Daily interruption/lightening of Daily interruption/lightening of continuous infusion sedation continuous infusion sedation
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Neuromuscular Neuromuscular Blockade in SepsisBlockade in Sepsis
NMBAs can be given asNMBAs can be given asIntermittent bolus Intermittent bolus Continuous infusion Continuous infusion
Avoid NMBAs if possibleAvoid NMBAs if possible
Monitoring with train-of-fourMonitoring with train-of-four
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Glucose ControlGlucose Control
Intravenous insulin therapy to Intravenous insulin therapy to reduce blood glucose levels reduce blood glucose levels
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Validated protocol for insulin dose Validated protocol for insulin dose adjustments adjustments
Targeting glucose levels to the Targeting glucose levels to the < 150 mg/dL < 150 mg/dL
Grade 2C evidenceGrade 2C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Give glucose calorie source to patientGive glucose calorie source to patient
Monitor every 1-2 hrs until stable Monitor every 1-2 hrs until stable Then every 4 hrly Then every 4 hrly
Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Renal ReplacementRenal Replacement Continuous renal replacement therapyContinuous renal replacement therapyIntermittent hemodialysis Intermittent hemodialysis
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Continuous therapies Continuous therapies Hemodynamically unstable septic patients Hemodynamically unstable septic patients
Grade 2D evidenceGrade 2D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Bicarbonate TherapyBicarbonate Therapy
Do not use sodium bicarbonate Do not use sodium bicarbonate When pH ≥ 7.15 When pH ≥ 7.15
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Deep Vein Thrombosis Deep Vein Thrombosis ProphylaxisProphylaxis
Low-dose UFHLow-dose UFH 2-3 times per day 2-3 times per dayLMWHLMWHMechanical deviceMechanical device
Graduated compression stockingsGraduated compression stockings
Intermittent compression devicesIntermittent compression devices
Grade 1A evidenceGrade 1A evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
HHigh-risk igh-risk
Pharmacologic Pharmacologic LMWH LMWH
Mechanical therapy Mechanical therapy
Grade 2C evidenceGrade 2C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Stress Ulcer Stress Ulcer ProphylaxisProphylaxisH2 blocker H2 blocker
Grade 1A evidenceGrade 1A evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Proton pump inhibitor Proton pump inhibitor
Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Selective Digest Tract Selective Digest Tract Decontamination (SDD)Decontamination (SDD)
Approved by the entire committee Approved by the entire committee
Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines
for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008
Although this document is static, the Although this document is static, the optimum treatment of severe sepsis optimum treatment of severe sepsis and septic shock is a dynamic and and septic shock is a dynamic and evolving process. evolving process.
New interventions will be proven and, as New interventions will be proven and, as stated in the current stated in the current recommendations, these interventions recommendations, these interventions may need modification in the future. may need modification in the future.
Thank youThank you