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Surviving Sepsis

Campaign
International
Guidelines for
Management of
Severe Sepsis and
Septic Shock: 2016
Intensive Care Medicine
doi: 10.1007/s00134-017-4683-6
Published online: 18 Jan 2017
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis

Initial Antibiotic
Resuscitation Diagnosis Therapy

Source
Fluid Therapy Vasopressors
Control

Corticosteroids
Glucose
Blood Product
Control

Bicarbonate
Therapy
Initial
Resuscitation
Initial Resuscitation
Sepsis and septic shock are medical emergencies,
and we recommend that treatment and
resuscitation begin immediately (best practice
statements, BPS).
In the resuscitation from sepsis-induced
hypoperfusion, at least 30 mL/kg of IV
crystalloid fluid be given within the first 3 h
(strong recommendation, low quality of
evidence).
Initial Resuscitation
Following initial fluid resuscitation, additional
fluids be guided by frequent reassessment of
hemodynamic status (BPS).
Remarks Reassessment should include a thorough
clinical examination and evaluation of available
physiologic variables (heart rate, blood pressure,
arterial oxygen saturation, respiratory rate,
temperature, urine output, and others, as available)
as well as other noninvasive or invasive monitoring,
as available.
Initial Resuscitation
An initial target MAP of 65 mmHg in patients
with septic shock requiring vasopressors (strong
recommendation, moderate quality of evidence).
Guiding resuscitation to normalize lactate in
patients with elevated lactate levels as a marker
of tissue hypoperfusion (weak recommendation,
low quality of evidence).
Application of Fluid Resuscitation in Adult Septic Shock
Sepsis-induced hypotension or lactate > 4 mmol/L
(Based on SSC bundle and CMS threshold)

No high flow oxygen and Pneumonia or ALI with high ESRD on hemodialysis
No ESRD on dialysis or CHF flow oxygen requirements or CHF

Rapid infusion Not intubated/ Intubated/


of 30 ml/kg mechanically ventilated mechanically ventilated Total of 30 ml/kg crystalloid*
Crystalloid* with frequent reassessment
of oxygenation
Consider Rapid infusion
If
intubaon/mechanical of 30 ml/kg
Yes
venlaon to facilitate crystalloid *
30 ml/kg crystalloid *
If no
Total of 30 ml/kg with
frequent reassessment of
oxygenaon

Considerations post 30ml/kg crystalloid infusion


1. Continue to balance fluid resuscitaon and vasopressor dose with attention to maintain tissue perfusion and minimize interstitial edema
2. Implement some combinaon of the list below to aid in further resuscitaon choices that may include addional fluid or inotrope therapy
blood pressure/heart rate response,
urine output,
cardiothoracic ultrasound,
CVP, ScvO2,
pulse pressure variaon
lactate clearance/normalizaon or
dynamic measurement such as response of flow to fluid bolus or passive leg raising
3. Consider albumin fluid resuscitaon, when large volumes of crystalloid are required to maintain intravascular volume.
Diagnosis
Diagnosis
Appropriate routine microbiologic cultures
(including blood) be obtained before starting
antimicrobial therapy in patients with
suspected sepsis or septic shock if doing so
results in no substantial delay in the start of
antimicrobials (BPS).
Remarks Appropriate routine microbiologic cultures
always include at least two sets of blood cultures
(aerobic and anaerobic).
Antimicrobial
Therapy
Antimicrobial Therapy
Administration of IV anti-microbials be initiated
as soon as possible after recognition and
within 1 h for both sepsis and septic shock
(strong recommendation, moderate quality of
evidence; grade applies to both conditions).
Antimicrobial Therapy
Empiric broad-spectrum therapy with one or
more antimicrobials for patients presenting
with sepsis or septic shock to cover all likely
pathogens (including bacterial and potentially
fungal or viral coverage) (strong
recommendation, moderate quality of
evidence).
Empiric antimicrobial therapy be narrowed once
pathogen identification and sensitivities are
established and/or adequate clinical
improvement is noted (BPS).
Antimicrobial Therapy
Antimicrobial treatment duration of 710 days is
adequate for most serious infections
associated with sepsis and septic shock (weak
recommendation, low quality of evidence).
Antimicrobial Therapy
Measurement of procalcitonin levels can be
used to support shortening the duration of
antimicrobial therapy in sepsis patients (weak
recommendation, low quality of evidence).
Procalcitonin levels can be used to support the
discontinuation of empiric antibiotics in
patients who initially appeared to have sepsis,
but subsequently have limited clinical
evidence of infection (weak recommendation,
low quality of evidence).
Source
Control
Source Control
A specific anatomic diagnosis of infection
requiring emergent source control be
identified or excluded as rapidly as possible in
patients with sepsis or septic shock, and that
any required source control intervention be
implemented as soon as medically and
logistically practical after the diagnosis is
made (BPS).
Source Control
Prompt removal of intravascular access devices
that are a possible source of sepsis or septic
shock after other vascular access has been
established (BPS).
Fluid Therapy
Crystalloids as the fluid of choice for initial
resuscitation and subsequent intravascular
volume replacement in patients with sepsis
and septic shock (strong recommendation,
moderate quality of evidence).
Against using hydroxyethyl starches (HESs) for
intravascular volume replacement in patients
with sepsis or septic shock (strong
recommendation, high quality of evidence).
Fluid Therapy
Using albumin in addition to crystalloids for
initial resuscitation and subsequent
intravascular volume replacement in patients
with sepsis and septic shock when patients
require substantial amounts of crystalloids
(weak recommendation, low quality of
evidence).
Vasopressors
Norepinephrine as the first choice vasopressor
(strong recommendation, moderate quality of
evidence).
Adding either vasopressin (up to 0.03 U/min) (weak
recommendation, moderate quality of evidence)
or epinephrine (weak recommendation, low
quality of evidence) to norepinephrine with the
intent of raising MAP to target, or adding
vasopressin (up to 0.03 U/min) (weak
recommendation, moderate quality of evidence)
to decrease norepinephrine dosage.
Vasopressors
Using dopamine as an alternative vasopressor
agent to norepinephrine only in highly
selected patients (e.g., patients with low risk
of tachyarrhythmias and absolute or relative
bradycardia) (weak recommendation, low
quality of evidence).
Against using low-dose dopamine for renal
protection (strong recommendation, high
quality of evidence).
Vasopressors
Using dobutamine in patients who show
evidence of persistent hypoperfusion despite
adequate fluid loading and the use of
vasopressor agents (weak recommendation,
low quality of evidence).
Vasopressors
All patients requiring vasopressors have an
arterial catheter placed as soon as practical if
resources are available (weak
recommendation, very low quality of
evidence).
Vasopressor Use for Adult Sepc Shock
(with guidance for steroid administraon)
Iniate norepinephrine (NE) and trate up to 35-90 g/min
to achieve MAP target 65 mm Hg

MAP target MAP target not achieved


achieved and judged
poorly responsive to NE

Add vasopressin up to
Connue norepinephrine alone or
0.03 units/min to achieve
add vasopressin 0.03 units/min
MAP target*
with ancipaon of decreasing
norepinephrine dose

MAP target MAP target


* Consider IV steroid administraon achieved not achieved
** Administer IV steroids
*** SSC guidelines are silent on phenylephrine
Notes: Add epinephrine up to
Consider dopamine as niche vasopressor in the presence 20-50 g/min to achieve MAP
of sinus bradycardia. target**
Consider phenylephrine when serious tachyarrhythmias
occur with norepinephrine or epinephrine.
Evidence based medicine does not allow the firm
establishment of upper dose ranges of norepinephrine, MAP target MAP target
epinephrine and phenylephrine and the dose ranges achieved not achieved
expressed in this figure are based on the authors
interpretaon of the literature that does exist and personal
preference/experience. Maximum doses in any individual Add phenylephrine up to
paent should be considered based on physiologic response 200-300 g/min to
and side effects. achieve MAP target***
Corticosteroids
Corticosteroids
Against using IV hydrocortisone to treat septic
shock patients if adequate fluid resuscitation
and vasopressor therapy are able to restore
hemodynamic stability. If this is not achievable,
we suggest IV hydrocortisone at a dose of 200
mg per day (weak recommendation, low
quality of evidence).
Blood Products
Blood Product Administration
RBC transfusion occur only when hemoglobin
concentration decreases to <7.0 g/dL in adults
in the absence of extenuating circumstances,
such as myocardial ischemia, severe
hypoxemia, or acute hemorrhage (strong
recommendation, high quality of evidence).
Blood Product Administration
Prophylactic platelet transfusion
when counts are <10,000/mm3 in the absence
of apparent bleeding and
when counts are <20,000/mm3 if the patient
has a significant risk of bleeding.
Higher platelet counts (50,000/mm3) are
advised for active bleeding, surgery, or
invasive procedures (weak recommendation,
very low quality of evidence).
Glucose Control
Glucose Control
A protocolized approach to blood glucose
management in ICU patients with severe
sepsis commencing insulin dosing when 2
consecutive blood glucose levels are >180
mg/dL. This protocolized approach should
target an upper blood glucose 180 mg/dL
rather than an upper target blood glucose
110 mg/dL (strong recommendation, high
quality of evidence).
Glucose Control
Blood glucose values be monitored every 12
hrs until glucose values and insulin infusion
rates are stable and then every 4 hrs
thereafter in patients receiving insulin
infusions (BPS).
Bicarbonate
Therapy
Bicarbonate Therapy
Against the use of sodium bicarbonate therapy
to improve hemodynamics or to reduce
vasopressor requirements in patients with
hypoperfusion-induced lactic acidemia with
pH 7.15 (weak recommendation, moderate
quality of evidence).