8/4/2019 2008 Sepsis Guidelines

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N Begin resuscitation immediately in patients with hypotension orelevated serum lactate >4mmol/l; do notdelay pending ICUadmission. (1C)

N Resuscitation goals: (1C) Centralvenouspressure (CVP) 812mm Hg* Mean arterialpressure 65mm Hg Urine output 0.5 mL.kg-1.hr-1

Centralvenous(superior vena cava) oxygensaturation 70%,or mixed venous 65%

NN If venous O2 saturation target not achieved: (2C) consider further fluid transfuse packed red blood cells if required to haematocrit of 30%

and/or dobutamine infusion max 20 g.kg-1.min-1

* A higher target CVP of 12-15 mmHg is recommended in the presence ofmechanical ventilation or pre-existing decreased ventricular compliance.

N Obtain appropriate cultures before starting antibiotics providedthis does not significantly delay antimicrobial administration.(1C) Obtain two or more blood cultures (BCs) One or more BCs should be percutaneous One BC from each vascular access device in place >48 hours Culture other sites as clinically indicated

N Perform imaging studies promptly in order to confirm andsample any source of infection; if safe to do so. (1C)

N Begin intravenous antibiotics as early as possible, and alwayswithin the first hour of recognising severe sepsis (1D) and sep-tic shock. (1B)

N Broad-spectrum: one or more agents active against likely bacte-rial/fungal pathogens and with good penetration into presumedsource. (1B)

N Reassess antimicrobial regimen daily to optimise efficacy,prevent resistance, avoid toxicity & minimise costs. (1C)

NN Consider combination therapy in Pseudomonas infections. (2D)

NN Consider combination empiric therapy in neutropenic patients. (2D)

NN Combination therapy no more than 3-5 days and de-escalationfollowing susceptibilities. (2D)

N Duration of therapy typically limited to 710 days; longer ifresponse slow, undrainable foci of infection, or immunologicdeficiencies. (1D)

N Stop antimicrobial therapy if cause is found to be non-infec-tious. (1D)

N A specific anatomic site of infection should be establishedas rapidly as possible (1C) and within the first 6 hours of presen-tation. (1D)

N Formally evaluate patient for a focus of infection amenable tosource control measures (eg: abscess drainage, tissue debride-ment). (1C)

N Implement source control measures as soon as possible follow-ing successful initial resuscitation. (1C)

NN Exception: infected pancreatic necrosis, where surgical inter-vention best delayed. (2B)

N Choose source control measure with maximum efficacy andminimal physiologic upset. (1D)

N Remove intravascular access devices if potentially infected. (1C)

N Fluid-resuscitate using crystalloids or colloids. (1B)N Target a CVP of 8mmHg (12mmHg if mechanically vent-

ilated).(1C)N Use a fluid challenge technique while associated with a haemo-

dynamic improvement. (1D)

N Give fluid challenges of 1000 ml of crystalloids or 300500 mlof colloids over 30 minutes. More rapid and larger volumesmay be required in sepsis-induced tissue hypoperfusion. (1D)

N Rate of fluid administration should be reduced if cardiac fillingpressures increase without concurrent haemodynamic improve-ment. (1D)

N Maintain MAP 65mmHg.(1C)N Norepinephrine or dopamine centrally administered are the

initial vasopressors of choice.(1C)

N Epinephrine, phenylephrine or vasopressin should not beadministered as the initial vasopressor in septic shock. (2C) Vasopressin 0.03 units/min maybe subsequently added to norepineph-

rine with anticipation of an effect equivalent to norepinephrine alone.

N Use epinephrine as the first alternative agent in septic shockwhen blood pressure is poorly responsive to norepinephrineor dopamine.(2B)

N Do not use low-dose dopamine for renal protection.(1A)N In patients requiring vasopressors, insert an arterial catheter

as soon as practical. (1D)

N Use dobutamine in patients with myocardial dysfunction as

supported by elevated cardiac filling pressures and low cardiacoutput. (1C)

N Do not increase cardiac index to predetermined supranormallevels. (1B)

NN Consider intravenous hydrocortisone for adult septic shockwhen hypotension remains poorly responsive to adequate fluidresuscitation and vasopressors. (2C)

NN ACTH stimulation test is not recommended to identify the subsetof adults with septic shock who should receive hydrocortisone.(2B)

NN Hydrocortisone is preferred to dexamethasone. (2B)NN Fludrocortisone (50g orally once a day) may be included if

an alternative to hydrocortisone is being used which lackssignificant mineralocorticoid activity. Fludrocortisone is optionalif hydrocortisone is used. (2C)

NN Steroid therapy may be weaned once vasopressors are nolonger required. (2D)

N Hydrocortisone dose should be