Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med[r]
(1)(2)Aim
● Discuss various components of the Surviving Sepsis
Guidelines
● Appraise evidence briefly
● Discuss critiques of the guidelines
● Identify strategies to apply guidelines with equipoise in
(3)Review of the 2018 update
(4)Definitions have changed
● Seps is : Life-threatening organ dysfunction
caused by dysregulated host response to infection
● Septic Shock: Subset of sepsis with
circulatory and cellular/metabolic
dysfunction associated with higher risk of mortality
(5)Clinical criteria (SEP-3 vs SIRS)
SEP definitions using qSOFA are not incorporated in the guidelines
Suggest use of qSOFA in place of SIRS criteria
(6)1 hour bundle
● Measure lactate level (repeat later if high)
● Obtain blood cultures before administering antibiotics ● Administer broad-spectrum antibiotics
● Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate ≥4 mmol/L
(7)Resuscitation: Changes from 2012
3 and hour bundles no longer endorsed
Dynamic indices of perfusion prefered over static numbers
More focus on acting quickly and monitoring response
(8)Critiques
30 ml/kg in hours is a very high fluid load Potentially dangerous in multiple clinical settings
Quality of evidence is low to moderate but recommendations
are classified as “Strong”
(9)Antibiotics and Source control
● Anatomic site for source control be identified/excluded
ASAP
● Antimicrobials be initiated as soon as possible after
recognition and within h for both sepsis and septic shock
● Empiric broad-spectrum therapy with one or more
antimicrobials to cover all likely pathogens Get cultures if no major delay
● De-escalation is encouraged as soon as feasible Shorter
courses recommended
(10)Problems
● No definite study to prove that short delays in antibiotics
worsens mortality Time to intervention studies are hard to replicate
● IDSA has NOT endorsed the hour window, procalcitonin
use, double coverage and days of antibiotics
● Attempt to focus on disease specific combination therapy
(11)Fluids
Use crystalloids and avoid colloids
Use dynamic indices and fluid challenges to assess responsiveness
Differentiate responsiveness from need for fluid Suggest albumin if crystalloid amount used is high
(12)Practical issues
● For the developing world mentioning albumin in a guideline
is a concern
● ALBIOS and SAFE trials don't show a major benefit for albumin Glycocalyx based models suggest no benefit
● Not all dynamic indices are equal Ultrasound based (aortic
doppler, IVC) or PLR based methods are attractive but have their flaws
(13)Vasopressors
Norepinephrine is first choice, target a MAP of 65 mmHg
Epinephrine and vasopressin (fixed dose) may be added (sequentially)
Dopamine in highly selected cases only - renal perfusion is not a good indication
Suggest use of arterial catheters
(14)Concerns
● Sequential pressors may not always be good May lead to
very high levels of one agent
● Epinephrine may raise lactate - but that may be a good
thing
● Arterial catheters may not be necessary and probably
should not be mandated The quality of evidence was
(15)Steroids
Suggest adding if fluids and pressors are not able to restore stability
Hydrocortisone 200 mg per day (continuous infusion)
Recommend against ACTH stim test
(16)Insights
Recent trial (ADRENAL) with hydrocortisone showed no difference in mortality
The APROCCHSS study showed benefit mortality with fludrocortisone + hydrocortisone
(17)Blood sugars
● Protocolized management
● Keep levels below 180
● Monitor every 1-2 hrs initially
(18)Blood products
● Transfusion trigger is 7.0 mg/dl ● Avoid erythropoetin
● Avoid FFP to correct lab abnormalities in the absence of
bleeding
● Platelet transfusion trigger is <10,000/mm^3 in the absence
(19)Mechanical Ventilation
● TV ml/kg and early proning for severe cases ● Suggest high rather than low PEEP
● No recommendation on NIV
● Suggest recruitment maneuvers ● Early NMBA for <48 hrs is ok
● Avoid beta agonists (if bronchospasm is absent), PA
catheters
(20)● Use weaning protocols, spontaneous breathing trials and
conservative fluid strategies
● Elevate head end by 30-45 degrees for VAP prevention
(21)Renal
If pH is above 7.15 avoid bicarbonate therapy
Either continuous or intermittent is acceptable
Oliguria and creatinine elevation are not good indication
CRRT may be preferred in unstable patients
(22)Nutrition
Avoid early parenteral nutrition if enteral feeding is possible
Early trophic feeding is acceptable Parenteral nutrition is not needed in the first days
Arginine/Omega FA, glutamine, selenium are not recommended
(23)VTE and Stress ulcer prophylaxis
● Use pharmacological means ● LMWH is preferred
● Combined mechanical and pharmacological is suggested
(weak evidence)
● Give SUP for patients at risk Avoid if no risk factors are
present
● PPI or H2B suggested
(24)Comments
● Evidence for SUP and VTE is changing
● SUP ICU (Nejm 2018) was a negative study for SUP in the ICU
● If nutrition and supportive care has improved then it is likely
(25)Goals of care
● Address goals of care as early as possible
● Discuss prognosis with patients and family
● Integrate goals of care into end of life care plan and
palliative care
(26)References
1 Jones, Alan E et al “Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial” JAMAvol 303,8 (2010): 739-46
2 Singer M, Deutschman CS, Seymour CW, et al The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA 2016;315(8):801-10
3 Rhodes A, et al Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Intensive Care Med 2017
4 Pepper DJ,et al Evidence Underpinning the Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Management Bundle (SEP-1): A Systematic Review Ann Intern Med
5 Gore DC, Jahoor F, Hibbert JM, DeMaria EJ Lactic acidosis during sepsis is related to increased pyruvate production, not deficits in tissue oxygen availability Ann Surg 1996;224(1):97-102
6 Does Central Venous Pressure Predict Fluid Responsiveness?*: A Systematic Review of the Literature and the Tale of Seven Mares Marik, Paul E et al CHEST , Volume 134
7 Sterling SA, Miller WR, Pryor J, Puskarich MA, Jones AE The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis Crit Care Med 2015;43(9):1907-15