Summaryofthe2012SurvivingSepsisRecommendations

Dellingeretal.SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2012.CritCareMed.2013;41(2):580637

AnnotatedbyGeorgeChen,DOMPH(January25,2013)

TABLEOFCONTENTS

Definitions&DiagnosticTriggersforInitialResuscitationBundle SepsisDiagnosticCriteria INITIALRESUSCITATIONBUNDLE(mostimportantpage) DetailedNotationoftheAdult2012Recommendations DetailedNotationofthePediatric2012Recommendations ARDSNET&ALVEOLITrialVentilatorManagementProtocols

PAGE2

PAGE2

PAGE3

PAGE4

PAGE 9

PAGE 11

2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO1|P a g e

Summaryofthe2012SurvivingSepsisRecommendations
Delingeretal.SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2012.CritCareMed.2013;41(2):580637

AnnotatedbyGeorgeChen,DOMPH(January25,2013)

Definition&DiagnosticTriggersforstartingInitialResuscitationBundle(meetinganyofthe3boldeddefinitions) (Sepsis=infection+systemicmanifestationsofinfection) Severesepsis=sepsis+sepsisinducedorgandysfunctionortissuehypoperfusion(withanyofthebelowsigns) 1. Sepsisinducedhypotension=SBP<90mmHgorMAP<70mmHgorSBPdecrease>40mmHgorlessthan2 standarddeviationbelownormalforageintheabsenceofothercauseforhypotension 2. Lactateabovetheupperlimitofnormal 3. UoP<0.5mL/Kg/hrformorethan2hoursdespiteadequatefluidresuscitation 4. AcutelunginjurywithPaO2/FiO2<250intheabsenceofPNAasinfectionsource 5. AcutelunginjurywithPaO2/FiO2<200inthepresenceofPNAasinfectionsource 6. Cr>2mL/dL 7. TBili>2mg/dL 8. Platelet<100K 9. INR>1.5 Septicshock=persistentsepsisinducedhypotensiondespiteadequatefluidresuscitation. Sepsisinducedtissuehypoperfusion=Sepsisinducedhypotensiondespitefluidchallenge,or,BloodLactate 4mmol/L SepsisDiagnosticCriteria 1. Vitalsigns: a. Temperature:Fever>38.3Corhypothermia<36C b. HR:>90/min,ormorethan2standarddeviationabovenormalforage c. Tachypnea d. Alteredmentalstatus e. Significantedemaorpositivefluidbalance>20mL/Kgover24hrs f. Hyperglycemia>140mg/dLintheabsenceofdiabetesmellitus 2. Inflammatorymarkers: a. WBC:>12Kor<4K b. NormalWBCcountwith>10%immatureforms c. CRP>2standarddeviationabovenormalvalue d. Procalcitonin>2standarddeviationabovenormalvalue 3. Hemodynamic a. SBP<90mmHg,MAP<70mmHgorSBPdecrease>40mmHginadultsorlessthan2standarddeviation belownormalforage 4. Organdysfunction a. Arterialhypoxemia(PaO2/FiO2<300) b. AcuteOliguria(UoP<0.5mL/Kg/hrforatleast2hoursdespiteadequatefluidresuscitation) c. Crincrease>0.5mg/dLor44.2mol/L d. Coagulopathy:INR>1.5oraPTT>60sec e. Ileus(nobowelsounds) f. Thrombocytopenia:PLT<100K g. Hyperbilirubinemia:TBili>4mg/dL 5. Tissueperfusion a. Lactate>1mmol/L b. Decreasecaprefillormottling
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO2|P a g e

2012INITIALRESUSCITATIONBUNDLE
1. Completedwithin3hoursofdiagnosis a. DrawLactate b. 2setsofBloodcultures(bestdonewithin45minutes) c. Broadspectrumantimicrobials(bestdonewithin1hour) d. Atleast30mL/Kgcrystalloidfluidchallenge 2. Completewithin6hoursofdiagnosis a. VasopressortokeepMAP65mmHgifgoalsnotmetbyfluidchallenge,Norepinephrineisfirstchoice b. Ifpersistenthypotensiondespitefluidresuscitationorinitiallactate4mmol/L: i. CVP:goal812mmHg;1215mmHgforpatientswithmechanicallyventilationorintra abdominalpressure(duetocardiacfillingimpediment) ii. ScvO2:goal70%(or,SvO265%) c. Remeasurelactate:goalisnormalizinglactate d. (Othertargets:UoP0.5mL/Kg/hr,normalizinglactateasamarkerforimprovedtissuehypoperfusion)

2012INITIALRESUSCITATIONBUNDLEPEDIATRICS

2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO3|P a g e

ADULT2012SurvivingSepsisRecommendationsDetailedNotations Epidemiology 1. Newchangesmadeinthe2012recommendationsascomparedtothe2008SurvivingSepsisUpdateare: a. DroppedICUManagementBundle&BrokeupInitialResuscitationBundleinto2parts b. Pediatricsepsismanagementrecommendations 2. InitialResuscitationBundle(orwhatitwascalled,EarlyGoalDirectedTherapy),isasetofgoalstobemet withinfirst6hoursafterdiagnosis.Thesestepsoftreatmentsneedtostartrightaway.Donotwaittostartit whenthepatiententerstheICU. 3. Globalprevalenceofsepsispresentation: a. Hypotensionwithlactate4mmol/L(16.6%),Hypotensiononly(49.5%),Lactate4mmol/L(5.4%) b. Mortalityis46.1%,36.7%,30%,respectively 4. Meetingtheseinitialresuscitationsgoalswithinthefirst6hoursafterdiagnosisisassociatedwith15.9% absolutereductionin28daymortality.(14) 5. NotAvailable:Xigris,or,fhAPCshowedasignificantreductioninmortalityof24.7%inthePROWESStrialin 2001.In2008itsusewasdowngradedtoonlyseverelyillpatientswithAPACHEIIscore25orMOF.In2011, thePROWESSSHOCKtrialwith1,696patientsshowednomortalitybenefitsandthedrugwasw/dfrommarket. InfectiousDisease 1. MostcommonbugsinsepticshockareGramPositive>GramNegative>mixedflora>>candida/toxicshock 2. 2setsofbloodculturesdrawnpriortoantimicrobialtherapyandgiveantimicrobialswithin1hourofdiagnosis. (51)Get10mLperdraw.(53)Onesetofculturedrawnpercutaneouslyandonesetdrawnthrougheach vascularaccessdevice,unlessifthedevicewasinsertedwithin48hours. 3. Ifthebloodculturedrawnfromthevascularaccessdeviceturnspositive2hoursbeforetheperipheralblood culture,datasupportsthatthevascularaccessdeviceisthesourceoftheinfection.(36,51,52) 4. Initialempiricbroadspectrumantimicrobialtherapy(selectedtocoverallsuspectedorganism)within1hour afterrecognitionofsepticshockandseveresepsiswithoutsepticshock(68,69) 5. Mortalityriseseveryhourwithoutantimicrobials(15,68,7072) 6. Combineempirialtherapyforneutopenicpatients,MDRDoublecoverP.aeruginosawithextendedspectrum betalactamsandaminoglycosideorfluoroquinolone.ForStreppneumo,usebetalactamandmacrolide. 7. Antimicrobialregimentshouldbereassesseddailyfordeescalation.Empiriccombinationtherapyshouldnotbe administeredfor>35days.Deescalatetomostappropriatesingletherapypendingsusceptibilityassoonas possible. 8. Ifinvasivecandidiasissuspected,send1,3betaDglucanassay(2D),mannan&antimannanantibodyassay(2C) 9. Suspectviral,startantiviral.Testforseasonalvariations.CMVviremiaisabout1535%ofcriticallyillpatients, andconnotesapoorprognosis.ConsiderHSV. 10. Useprocalcitoninlevelorothermarkerstoconsiderdiscontinuationofempiricantibioticforthosewhowas initiallydiagnosedseptic,buthavenosubsequentevidenceofinfection. 11. Durationoftherapytypically710days.Longertherapyforpatientswithslowclinicalresponse,undrainablefoci ofinfection,S.aureusbacteremia,somefungalorviralinfections,immunedeficiencies[negativebloodcultures, VSS,afebrile,resolutionofsepsisandsepticshock,clinicalimprovement,sourcecontrol] 12. Noantimicrobialtherapyifpatientssevereinflammatorystateisnotduetoinfectiouscauses SourceControl 1. Infectionsourcecontrolandpickappropriateantimicrobialchoicewithinfirst12hoursofdiagnosis
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO4|P a g e

2. Wheninfectedperipancreaticnecrosisisidentifiedaspotentialsourceofinfection,definitiveinterventionis bestdelayeduntiladequatedemarcationofviableandnonviabletissueshasoccurred.(111,RCTshowed betteroutcomewithdelayedapproach) 3. Chooseleastphysiologicinsultinginterventionpossibleduringacutephase 4. Removeintravascularaccessdevicespromptlyifitissuspectedtobethesourceofinfection. Fluids 1. Initialfluidresuscitationwithcrystalloid,minimumof30mL/Kginadultsand20mL/Kginchildren.Consider additionofalbumininpatientsrequiringsubstantialamountsofcrystalloidstomaintainadequateMAP. a. Recommendagainsthetastarch.Artificialcolloidshasnoprovensurvivalbenefitsbutshowanincrease inriskofacutekidneyinjury(126128) b. CRYSTMAStrial:nodifferenceinmortalitybetweenHESvsNS.(Underpoweredtodetectthe6% differenceinabsolutemortalityobserved)(122) c. 6STrialGroup:6%increaseinmortalitybetweenHESvsLR(SickerpatientsinScandinavianstudy)(123) d. CHESTtrial:7,000criticallyillpatients.Nodifferencein90daymortalitybetweenHESvsNS,butthe needforrenalreplacementtherapywashigherintheHESgroup.(124) e. Metaanalysisof56RCTs:nodifferenceinmortalitybetweencrystalloidsvsartificialcolloids.(126) f. SAFEtrial:albuminwassafeandequallyaseffectiveasNS.(129) g. RCT:albuminisassociatedwith2.2%absolutereductionin28daymortality,butdidntachieve statisticalsignificance.(130) 2. Continuefluidchallengetechniqueaslongashemodynamicimprovement:basedondynamicvariables(change inpulsepressure,strokevolume)orstaticvariables(arterialpressure,HR) Vasopressor 1. NorepinepherineisthefirstchoicevasopressortokeepMAP65mmHg. 2. Epinephrineisthesecondadditionalagent,orsubstituteforNE,ifneededtomaintainMAP.Somestudies suggestthatitdecreasessplanchniccirculationandcausehyperlactatemia,butthereisnoclinicalevidence supportingthis.4RCTshownodifferenceinNEorEinmortality(142,147,154,155) 3. Vasopressin(0.03U/min)canbeaddedtonorepinephrinetoeitherraiseMAPtotarget,ortodecreaseNEdose. But,donotuseitastheinitialvasopressor.Dosehigherthan0.04U/minisonlyusedwhenconsideredas salvagetherapy.VASSTtrial,RCT,shownodifferenceinoutcomebetweenNEvsNE+V.Highdosevasopressin hasbeenassociatedwithcardiac,digital,andsplanchnicischemia,soshouldonlybeusedassalvage.(166,167) 4. Phenylephrineisnotrecommendedinsepticshockexcept:1.WhenNEisassociatedwithseriousarrhythmias, 2.COishigh,BPpersistentlylow,3.Assalvagetherapy(156) 5. Dopamineisnotrecommended,withgoodevidence,exceptinhighlyselectivecases.Itcausesmore tachycardiaandismorearrythmogenicthanNE.(153)Itmayaffectthehypothalamicpituitaryaxisandhave immunosuppressiveeffects.(148)Hasnoclinicallysignificantrenalbenefitorsurvivalbenefits,ICU/hospital lengthofstay,arrhythmiascomparetoNE(171,172) 6. Dobutamine20mcg/Kg/mincanbeaddedtovasopressorinthepresenceofmyocardialdysfunction(suggested byincreasedcardiacfillingpressureandlowcardiacoutput)orongoingsignsofhypoperfusion(cardiacindex andScvO2)despiteachievingadequateintravascularvolumeandgoalMAP(173,174) 7. Allpatientswithvasopressorsneedanarterialcatheter. 8. SuperiorvenacavaO2sat(ScvO2>70%)orMixedvenousoxygensaturation(SvO2>65%).Ifcannotachieveby 6hours,adddobutamineinfusiontomax20mcg/Kg/minorPRBCtransfusiontoahematocrit30%to maximizeoxygencarryingcapacity.
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO5|P a g e

9. CVPusageismostreadilyavailable,thatswhyweuseit.However,itisconfoundedbypulmonaryHTN, limitationofstaticventricularfillingpressuremeasurementassurrogateofresuscitation 10. IfScvO2isnotavailable,itsoktouselactatetrendtonormalasasurrogateofresolutionoftissue hypoperfusion.(Noninferiorityin2RCT)20%decreaseinlactateandScvO270%withinfirst2hoursof diagnosisisassociatedwith9.6%absolutereductioninmortality.(35,36) Steroids 1. AvoidIVhydrocortisoneinadultsepticshockifIVFandvasopressorcanrestorehymodynamicstability. a. CORTICUStrial:LargeEuropeanRCT,nomortalitybenefitsofsteroids.(178) b. FrenchRCTwithverysickpatients:Steroidshowsignificantshockreversalandmortalityreductionin patientswithrelativeadrenalinsufficiencybasedonACTHstimtest.(175) c. Annaneetal,metaanalysisshowedsignificantmortalityreductionwithlowdosesteroid(179,180) d. Sligletal,metaanalysisshowednodifferenceinmortality,butdoesshowimprovedshockreversalwith lowdosesteroid.(181)Thesestudiesincludeddisproportionalamountoflowriskpatients. 2. DontuseACTHstimtesttoidentifywhoneedshydrocortisone.Noclearunderstandingofresponderandnon responders.Thereareprobablyotherconfoundingvariablespresent.Weknowthatetomidatesignificantly suppressesthehypothalamicpituitaryadrenalaxis.(185,186)anditsignificantlyincreasethe28daymortality whenusedpriortolowdosesteroid.(187) 3. Taperhydrocortisonewhenvasopressorsarenotneeded 4. Recommendusecontinuousinfusionofhydrocortisoneat200mg/ddose,ratherthanbolusinjectionstolimit hyperglycemiaandhypernatremiasecondarytothepeakeffect,whichisnotseenwiththecontinuousinfusion. (175,192) BloodProducts 1. Hgbtarget79g/dLintheabsenceofhypoperfusion,ischemicCAD,oracutehemorrhage.(193)PRBC transfusionincreasesO2delivery,butdoesntincreaseO2consumption.ThenewchangestatesthattheHgb thresholdof7ratherthanusingtargetHct30%withptswithlowScvo2<70%duringthefirst6hoursof resuscitation.(13) 2. RecommendedagainstusingEPOtotreatsepsisrelatedanemia.(198,199) 3. RecommendedagainstusingFFPtocorrectcoagulopathyintheabsenceofbleedingorplannedinvasive procedure.(200203) 4. Recommendedagainstuseofantithrombin.PhaseIIIclinicaltrialshownobenefitsonmortality,butincreased riskofbleedingwhenadministrationwithheparin.(206) 5. Platelettransfusion:prophylacticallywhen10Kwithoutbleeding,20Kwithhighriskofbleed,50Kifactive bleedorplannedsurgery. 6. Recommendedagainstuseofimmunoglobulins.Needmorestudiesinsepsispatients. 7. Recommendedagainstseleniumuse.Itisusedasanantioxidant.Thereisaconcentrationdependentreduction inmortality,butthereisnosignificantdifferenceinoutcome/mortality/antibioticuse/lengthofstay.(221) MechanicalVentilation,ARDS,VAP 1. UpdatedBerlinDefinition:ARDS:mild,moderate,severeisPaO2/FiO2300,200,100.(previouslylabeledALIor ARDS)(233) 2. ARDS:targettidalvolumeof6mL/Kgpredictedbodyweight(9%decreaseinallcausemortalitywhenventilate with6mL/Kgvs12mL/KginARDS);andtargetpassiveinspiratoryplateaupressureof30cmH2O.Lower plateaupressureisassociatedwithlowermortality.(245)
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO6|P a g e

3. ARDSnet:goaltoreduceTvover12hoursfrominitialvalue,onceachieved6mL/Kgandplateaupressureisstill >30cmH2O,itsoktoreducetidalvolumetoaslowas4mL/Kg.Needtomaintainminuteventilation 4. Permissivehypercapneawithvolumeassistedorventilationassistedventilationok,aslongasthereareno contraindications,suchasincreasedICP.Bicarbortromethaineinfusionmaybeusefultofacilitatepermissive hypercapneawithparticularventilatorstrategy. 5. HightidalvolumesandplateaupressuresmaycauseARDS.Nosinglemodeofventilationhasconsistentlyshow advantageascomparedtoanyothermodeswhenrespectingtheprinciplesoflungprotectiveventilation. 6. UseatleastminimalPEEPtopreventatelectotrauma(failuretokeeprecruitedalveoliopen).(233)Usually PEEP>5cmH2Oisneeded.Minimizingendexpiratoryalveolarcollapsehelpminimizeventilatorinducedlung injurywhenhighplateaupressuresareinuse. 7. HigherratherthanlowerlevelsofPEEPforsepsisinducedmoderateorsevereARDS,PaO2/FiO2200mmHg haddecreasedmortalitywithhigherPEEP.(258) 8. RecruitmentmaneuversinsepticpatientswithsevererefractoryhypoxemiaduetoARDS.Pronepositioningin sepsisinducedARDSpatientwithPaO2/FiO2100mmHg.(263266)Othertechniquesarehighfrequency oscillatoryventilation,APRV,extracorporealmembraneoxygenation.(271) 9. ConservativefluidstrategyforwithARDSwhodoesnothavetissuehypoperfusion.Studyshowedthatthey usedCVP<4mmHgreducedICUstay,butnochangeonmortality.(299) 10. RecommendedagainstbronchodilatorsinpatientwithARDSandnobronchospasm.Rateofdeathbefore dischargeis23%inINHalbuterolgroupvs17.7%inplacebogroup.(301)BALTI2trial,patientwithIV salbutamoltreatedpatienthadincreased28daymortality.Earlyterminationoftrial.(302) 11. HOBelevation3045degreesinmechanicallyventilatedpatients,decreaseriskofaspirationandVAP.50%of intubatedpatientinsupinepositiondevelopesVAP,versus9%insemirecumbentposition.(276) 12. Selectiveoral(chlorhexidine)andGIdecontaminationshouldbeusedtoreduceVAP 13. RecommendedagainstSwanGanzCatheter Sedation,NeuromuscularBlockade 1. Sedationandventilationweaningprotocols.SpontaneousBreathingTrialcriteria:arousable,hemodynamically stable,novasopressors,nonewpotentiallyseriouscondition,lowventilatorandPEEPrequirement,lowFiO2 requirementwhichcanbemetwithfacemaskorNC,[offsedation,RSBI<105(Tv/RR),(+)cuffleak,onminimal ventsettings(CPAP:PS8,FiO230%,goodTv),lowsecretions,resolutionofthereasonforintubation] 2. Minimizeuseofeitherintermittentbolussedationorcontinuousinfusionsedationtargetspecifictitration endpoint.Benefitofeitherintermittentversuscontinuousinfusionofsedationisnotestablished.Less sedation,intermittentboluseshaveassociateddecreaseinventilatordays.(281,305,308,309) 3. AvoidneuromuscularblockerwithoutARDSduetoincreasedriskofprolongedblockade 4. Shortcourse(lessthan48hrs)ofneuromuscularblockerforpatientswithearlyARDSandPaO2/FiO2<150 mmHg.Usetrainoffourmonitoringfordepthdecreasesoverparalysis. Insulin 1. Startinsulindripprotocolwhen2consecutiveBG>180mg/dL.Glucosegoal180mg/dL,not110mg/dL.BG monitoringevery12houruntilstablethenq4hrsafter.CapillaryBGmaynotbeasaccurateasbloodBG.NICE SUGARtrialshowincreasemortalitywithtightBGcontrol.(331) RenalReplacementTherapy 2. Equivocal:continuousvenovenoushemofiltrationversusintermittenthemodialysis 3. Usecontinuousmethodstomanagefluidbalanceinhemodynamicallyunstablesepticpatients
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO7|P a g e

4. Typicaldoseofcontinuousrenalreplacementis2025mL/Kg/hrofeffluentgeneration. IVSodiumBicarbonate 1. RecommendedagainstusingBicarbtoimprovehemodynamics,reducingvasopressorrequirementinpatient withhypoperfusioninducedlacticacidosispH7.15. DVTProphylaxis 2. DVTprophylaxisrecommended.CrCl<30mL/min,usedalteparinorUFH.AlsouseBilatSCD.9RCTandmeta analysisshowbenefitofreductioninDVTandPE.(390,391) 3. CCCtrial:nodifferenceinasymptomaticDVTbetweenheparin5000IUBIDvsLMWHdalteparin5000IUqDay. But,LMWHisassociatedwithsignificantlylowerdiagnosedPE.(392)MetaanalysisshowthatUFHTIDis betterthanBIDtopreventVTE,butBIDisassociatedwithlowerbleedingrisk. 4. ConcurrentuseofSCDsandLMWHorUFHissuperiortoanythingalone.(398) StressUlcerProphylaxis 1. GIprophylaxisrecommendedtopreventUGIBfromstressulcers,onlyforthosewithbleedingrisks.PPI>H2RA. NoPPIifnobleedingrisks.(415417) Nutrition 2. POorenteralfeedrecommendedovercompletefastingorsoloIVglucosewithinfirst48hoursafterdiagnosis. Thoughnomortalitybenefitswereseeninstudies,butmanybenefitsinsecondaryoutcomesinreductionof infectiouscomplications,reducelengthofmechanicalventilation,reducedICUandhospitalstay. 3. Avoidmandatoryfullcaloricfeedingwithinfirstweek.Startwithlowdosefeedingof500caloriesperdayand advanceastolerated.Thisispermissiveunderfeedingortrophicfeedingisagoodstrategy.(433,434) 4. First7days,useIVglucoseplusenteralnutritionratherthanTPNaloneorparenteralnutritionwithenteral feeding.Severalstudiessuggestparenteralnutritionisassociatedwithincreaseriskforinfectioncomparedto enteralnutritionorIVglucose. ImmunemodulatingSupplements 1. Recommededagainstuseofimmunomodulatingsupplementation,arginine,glutamine,omega3,antioxidants. Nobenefitandcancauseharm.(445448) 2. Arginineisthoughttobereducedinsepsis,leadtoreducenitricoxidesynthesisandenhancesuperoxideand peroxynitriteproduction.Butitcanleadtovasodilationandhyptension.Nogooddataforbenefit. 3. Glutamineisreducedincriticalillness.Supplementationcanreducegutatrophyandpermeabilityandpossibly reducebacterialtranslocation.Itcanalsoenhanceimmunecellfunction,decreaseproinflammatorycytokine productionandhigherlevelsofglutathioneandantioxidativecapacity.(452,453)6trialsfailtoshowmortality benefit.But,sometrialshowreductionininfectiousmorbidities.(461,462,465)Nosolidbenefitorharm. 4. Omega3:reduceproinflammatoryprostaglandins,leukotrienes,andthromboxanes.Nodatawithsolidbenefit orrisk. GoalofCare 1. Recommendedtoaddressgoalofcare,prognosis,andendoflifeplanningasearlyaspossible,necessarywithin 72hoursofICUadmission
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO8|P a g e

PEDIATRICS2012SurvivingSepsisRecommendationsDetailedNotations 1. Background,newbornandchildrenarenotsmalleradults: a. Incidenceismuchlowerthanadult.Mortalityis2%inhealthychildren,8%inchildrenwithchronic illness(497).BPisnotagoodmarker.ChildrentendtovasoconstrictandincreaseHRtomaintainBP. Oncehypotensionhappens,childrencrashfast.Fluidresuscitationinhypovolemicshockiskeyforboth normotensiveandhypotensivechildren.Fluidoverloadinchildrenshowsupashepatomegalyandrales. Ifthesesignsareabsent,therecouldbealargefluiddeficit;theinitialfluidresuscitationcanbe4060 mL/Kgormore.Ifthesesignsarepresent,thenusediuretics. 2. Initialresuscitation: a. Respiratorydistressorhypoxemia:usefacemaskO2,highflownasalcannula,nasopharyngealCPAP. b. Initialtreatmentendpoint:caprefill<2sec,normalBPforage,normalHRwithnodifferentialbetween peripheralandcentralpulses,warmextremities,UoP>1mg/Kg/hr,normalmentalstate,ScvO270%, Cardiacindexbetween3.36.0L/min/m2.Lactateisnothelpfulinchildren,theyareusuallynormal eveninseveresepsisandsepticshock. c. Evaluateforreversiblecauses:pneumothorax,pericardialtamponade,endocrineemergencies 3. Antibioticsandsourcecontrol a. Obtainbloodculturespriortoantimicrobial.Startantimicrobialswithin1hourofdiagnosis.Consider MDR,andotherrisk.Duetosmallveins,oktogiveIMorPOfirstpriortovenousorIOaccess. b. Clindamycinandantitoxintherapyfortoxicshocksyndromewithrefractoryhypotension.Childrenare morepronetotoxicshockbecauseoftheirlackofcirculatingantibodiestotoxins.Signsoftoxicshockin childrencanberefractoryhypotensionwithdiffusederythroderma. c. Earlyaggressivesourcecontrol d. C.diffcolitistreatedwithenteralantibiotics.POvancomycinforseveredisease. 4. Initialfluidchallenge: a. 20mL/Kgincrystalloidoralbuminover510minutes.Ifhepatomegalyorralesexist,theninotropic supportshouldbestarted,notfluids.Innonhypotensivechildrenwithseverehemolyticanemia(severe malariaorsicklecellcrises)bloodtransfusionissuperiortocrystalloidsoralbumin. 5. RefractoryHypotension: a. StartperipheralinotropicsupportuntilCVCobtainedforfluidunresponsivepatients.Patientwithlow cardiacoutputandelevatedSVRandnormalBPshouldbegivenvasodilatorinadditiontoinotropic agents.Thiscanreverseshock.TypeIIIphosphodiesteraseinhibitors(amrinone,milrinon,enoximone) andcalciumsensitizerlevosimendancanbehelpfulinovercomingreceptordesensitization.Other vasodilatorscanhelp:nitrosovasodilators,prostacyclin,fenoldopam.Pentoxifyllinehasbeenusedin2 RCTinnewbornstoreducemortalityinseveresepsis. 6. ConsiderECMOforrefractoryshockandrespiratoryfailure.73%survivalbenefitfornewbornsand39%for olderchildren.(572) 7. TimelyIVhydrocortisoneif:fluidrefractory,catecholamineresistantshockandsuspectedorprovenabsolute adrenalinsufficiency.25%childrenwithsepticshockhaveabsoluteadrenalinsufficiency.Initialinfusionis stressdoseat50mg/m2/24hr,but50mg/Kg/daymayneedtobeusedtoreverseshock.Deathfromabsolute adrenalinsufficiencyandsepticshockoccurswithin8hoursofpresentation.(578583) 8. Duringresuscitation,keepHgbgoal>10g/dLforthosechildrenwithScvO2<70%inthefirst72hrsofPICU admissionshowsurvivalbenefits.(511)WhenstableandstillhypoxemicthenHgbgoal>7g/dL.Same platelet/FFP/Cryotransfusiongoalasadults. 9. Lungprotectivemechanicalventilation,considermethodssimilartoadults 10. Sedation,needclearlyestablishedgoalsandprotocols 11. Hyperglycemia:
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO9|P a g e

12.

13.

14.

15.

a. GoalBG180mg/dL.Glucoseinfusionshouldaccompanyinsulininfusioninnewbornsandchildren becausesomehyperglycemicchildrenmakenoinsulinatallandsomeareinsulinresistant.Infantstend todevelophypoglycemiawhentheyareonIVF.TheyneedIVglucoseof46mg/Kg/minorD10NS. Newbornmayneed68mg/Kg/minofglucose. Fluidoverload: a. Usediureticstoreversefluidoverloadwhenshockhasresolved.Ifnotsuccessful,thenusecontinuous venovenoushemofiltration(CVVH)orintermittentdialysistoprevent>10%totalbodyweightfluid overload. DVTProphylaxis: a. NorecommendationofDVTprophylaxisinprepubertalchildren.MostDVTsinchildrenareassociated withcentralvenouscatheters. StressUlcerProphylaxis: a. NorecommendationofStressUlcerprophylaxis.StudyshownclinicallysignificantGIBsoccuratsame rateasadults.PPIorH2RAarecommoninmechanicallyventilatedpatients. Nutrition: a. Enteralnutritionastolerated,otherwise,parenteralisok.D10NSprovidestheglucoserequirementfor newbornsandchildren.

2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO10|P a g e


2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO11|P a g e