Surviving Sepsis Guidelines Updated: Preview from SCCM Meeting

Critical Care, Infectious Disease and SepsisAdd comments

Jun

162012
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The Surviving Sepsis Campaign is a collaboration between the U.S. Society of Critical Care Medicine (SCCM), the European Society of Intensive Care Medicine, and the International Sepsis Forum, whose recommendations on the management of sepsis are considered widely. At the 2012 SCCM meeting, the Surviving Sepsis committee revealed some of the planned revisions and additions in the upcoming 2012 updated Surviving Sepsis Guidelines. They will reportedly include:

Surviving Sepsis: New Fluid Resuscitation Recommendations

They gave a strong 1A recommendation for the use of crystalloids like normal saline as the initial fluid resuscitation for people with severe sepsis. They further advise that 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 or 154-pound person) in the first 4-6 hours.

Incremental fluid boluses should be continued as long as patients continue to improve hemodynamically (in blood pressure, delta pulse pressure, or both) (Grade 1C). They weakly recommended adding albumin to initial fluid resuscitation with crystalloid for severe sepsis and septic shock (Grade 2B). Authors strongly recommended not using hetastarches/hydroxyethyl starches greater than 200 kDa in molecular weight (Grade 1B).

They did not comment on the use of lower molecular weight hetastarches or the use of gelatins; trials are ongoing to evaluate these resuscitative agents.

Surviving Sepsis: New Recommendations for Vasopressors, Inotropes

Authors strongly recommend 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 their weakly-recommended vasopressor choice (Grade 2B). 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).

Surviving Sepsis: Corticosteroid Recommendations

Authors suggest not 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 a weak Grade 2C.

Surviving Sepsis: Mechanical Ventilation for ARDS

For patients with ARDS due to severe sepsis, the authors made several suggestions based on consensus opinion/weak evidence:

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 Guidelines

Some of the Surviving Sepsis committees other weak recommendations/suggestions included:

Using 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).

For patients at risk for fungal infection as a source for severe sepsis, checking one of thenewer assays for invasive candidiasis such as 1,3-beta-D-glucan, mannan, or antimannan ELISA antibody testing (Grade 2B/C).

When 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. The Surviving Sepsis website does not clearly show their current sources of funding, but they have set up a page to address any concerns about industry involvement. The name Surviving Sepsis Campaign is copyrighted by the Society for Critical Care Medicine.

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.

- From the 2012 Society of Critical Care Meeting.