surviving sepsis campaign give 5.14.04

7/30/2019 Surviving Sepsis Campaign Give 5.14.04

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Dellinger RP, Carlet JM, Masur H, et al. for the Surviving Sepsis CampaignManagement Guidelines Committee. Crit Care Med 2004; 32:858-873.

Surviving Sepsis Campaign

Guidelines for Management of SevereSepsis and Septic Shock


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Surviving Sepsis Campaign Guidelines

American Association of Critical-Care Nurses

American College of Chest Physicians

American College of Emergency Physicians

American Thoracic Society

Australian and New Zealand Intensive Care Society

European Society of Clinical Microbiologyand Infectious Diseases

European Society of Intensive Care Medicine

European Respiratory Society International Sepsis Forum

Society of Critical Care Medicine

Surgical Infection Society

Sponsoring Organizations

Dellinger, et. al. Crit Care Med 2004, 32: 858-873.


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Initial Resuscitation

Diagnosis

Antibiotic therapy

Source Control

Fluid therapy

Vasopressors

Inotropic Therapy

Steroids

Recombinant HumanActivated Protein C(rhAPC) [drotrecogin alfa(activated)]

Blood Product Administration

Mechanical Ventilation

Sedation, Analgesia, and NeuromuscularBlockade in Sepsis

Glucose Control Renal Replacement

Bicarbonate Therapy

Deep Vein Thrombosis Prophylaxis

Stress Ulcer Prophylaxis

Limitation of Support

Index



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- Central Venous Pressure 8-12 mm Hg (12-15 in ventilator pts)

- Mean arterial pressure > 65 mm Hg

- Urine output > 0.5 mL/kg/hr

- ScvO2 or SvO2 70%;if not achieved with fluid resuscitation during first 6 hours:

- Transfuse PRBC to hematocrit > 30% and/or- Administer dobutamine (max 20 mcg/kg/min) to goal

Resuscitation should begin as soon as severe sepsis or sepsisinduced tissue hypoperfusion is recognized

Elevated Serum lactate identifies tissue hypoperfusion in

patients at risk who are not hypotensive

Goals of therapy within first 6 hours are Grade B

Rivers E. N Engl J Med 2001;345:1368-77.

Initial Resuscitation


-
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11794169http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11794169http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11794169http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11794169


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PROTOCOL EARLY GOAL DIRECTED THERAPY


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49.2%

33.3%

0

10

20

30

40

50

60

Standard Therapyn=133

EGDTn=130

P = 0.01*

*Key difference was in sudden CV collapse, not MODS

28-day Mortality

Rivers E. N Engl J Med 2001;345:1368-77.

Early Goal-Directed Therapy Results


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Before the initiation of antimicrobial therapy, at least twoblood cultures should be obtained

At least one drawn percutaneously

At least one drawn through each vascular accessdevice if inserted longer than 48 hours

Other cultures such as urine, cerebrospinal fluid, wounds,respiratory secretions or other body fluids should beobtained as the clinical situation dictates

Other diagnostic studies such as imaging and samplingshould be performed promptly to determine the source and

causative organism of the infection may be limited by patient stability

Weinstein MP. Rev Infect Dis 1983;5:35-53

Blot F. J Clin Microbiol 1999; 36: 105-109.

Grade D

Grade E

Diagnosis


Grade D
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6828811http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9431930&itool=iconffthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9431930&itool=iconffthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9431930&itool=iconffthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9431930&itool=iconffthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6828811http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6828811http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6828811


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Start intravenous antibiotic therapy within the firsthour of recognition of severe sepsis after obtainingappropriate cultures

Empirical choice of antimicrobials should include oneor more drugs with activity against likely pathogens,both bacterial or fungal

Penetrate presumed source of infection

Guided by susceptibility patterns in the communityand hospital

Continue broad spectrum therapy until thecausative organism and its susceptibilities aredefined

Kreger BE. Am J Med 1980;68:344-355.

Ibrahim EH. Chest 2000;118:146-155.

Hatala R. Ann Intern Med 1996;124-717-725.

Antibiotic Therapy

Grade E

Grade D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8633831http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10893372http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6987871http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&li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Reassess after 48-72 hours to narrow thespectrum of antibiotic therapy

Duration of therapy should typically be 7-10days and guided by clinical response

Some experts prefer combination therapyforPseudomonas infections or neutropenicpatients

Stop antimicrobials promptly if clinicalsyndrome is determined to be noninfectious

Antibiotic Therapy

Grade E

Grade E

Grade E

Grade E


Ali MZ. Clin Infect Dis 1997;24:796-809


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Evaluate patients for focus of infection amenableto source control measures

Drainage of an abscess or local focus ofinfection

Debridement of infected necrotic tissue

Removal of a potentially infected device

Definitive control of a source of ongoingmicrobial contamination

Source control methods must weigh benefits and

risks of the specific intervention

Jimenez MF. Intensive Care Med 2001;27:S49-S62.

Bufalari A. Acta Chir Belg 1996;96:197-200.

Source Control

Grade E

Grade E

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11307370http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8950379http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8950379http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8950379http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8950379http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11307370http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11307370http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11307370


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Once a focus of infection has been identified,source control should be implemented as soon aspossible following initial resuscitation

Especially important for patients with necrotizing softtissue infection or intestinal ischemia

If intravascular access devices are suspected to bethe source of infection, remove them promptly afterestablishing other vascular access

It may be reasonable to leave access devices in

place when patients develop sepsis of unknownsource, until the source of infection is determined

Moss RL. J Pediatr Surg 1996;31:1142-1146.

CDC. MMWR 2002;51:1-29.

Source Control (cont)

Grade E

Grade E

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8863251http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12233868http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12233868http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12233868http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12233868http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12233868http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8863251http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8863251http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8863251


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Source Control: Examples of Potential Sites

Drainage- Intra-abdominal abscess - Septic arthritis- Thoracic empyema - Pyelonephritis, cholangitis

Debridement- Necrotizing fasciitis - Mediastinitis

- Infected pancreatic necrosis - Intestinal infarction

Device Removal- Infected vascular catheter

- Urinary catheter

-Colonized endotracheal tube

Definitive Control- Sigmoid resection for diverticulitis

- Amputation for clostridial myonecrosis

- Cholecystectomy for gangrenous cholecystitis



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Fluid resuscitation may consist of natural orartificial colloids or crystalloids No evidenced-based support for one type of fluid

over another

Crystalloids have a much larger volume ofdistribution compared to colloids

Crystalloid resuscitation requires more fluid toachieve the same endpoints as colloid

Crystalloids result in more edema

Choi PTL. Crit Care Med 1999;27:200-210.

Cook D. Ann Intern Med 2001;135:205-208.

Schierhout G. BMJ 1998;316:961-964.

Fluid Therapy: Choice of Fluid

Grade C

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9934917http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11487488http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9550953http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9550953http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9550953http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9550953http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11487488http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11487488http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11487488http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9934917http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9934917http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9934917


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Fluid challenge in patients with suspectedhypovolemia may be given 500 - 1000 mL of crystalloids over 30 mins

300 - 500 mL of colloids over 30 mins

Repeat based on response and tolerance

Input is typically greater than output due tovenodilation and capillary leak

Most patients require continuing aggressive fluidresuscitation during the first 24 hours of management

Fluid Therapy: Fluid Challenge

Grade E



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Initiate vasopressor therapy if appropriate fluid challengefails to restore adequate blood pressure and organperfusion

Vasopressor therapy should also be used transiently in the face oflife-threatening hypotension, even when fluid challenge is in progress

Either norepinephrine or dopamine are first line agents tocorrect hypotension in septic shock

Norepinephrine is more potent than dopamine and may be moreeffective at reversing hypotension in septic shock patients

Dopamine may be particularly useful in patients with compromisedsystolic function but causes more tachycardia and may be morearrhythmogenic

LeDoux D. Crit Care Med 2000;28:2729-2732. Regnier B. Intensive Care Med 1977;3:47-53.

Martin C. Chest 1993;103:1826-1831. Martin C. Crit Care Med 2000;28:2758-2765.

DeBacker D. Crit Care Med 2003;31:1659-1667. Hollenberg SM. Crit Care Med 1999; 27: 639-660.

Vasopressors

Grade E

Grade D

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10966242&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=893773http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8404107http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10966247http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12794401http://www.sccm.org/professional_resources/guidelines/table_of_contents/Documents/Hemodynamic_Support.pdfhttp://www.sccm.org/professional_resources/guidelines/table_of_contents/Documents/Hemodynamic_Support.pdfhttp://www.sccm.org/professional_resources/guidelines/table_of_contents/Documents/Hemodynamic_Support.pdfhttp://www.sccm.org/professional_resources/guidelines/table_of_contents/Documents/Hemodynamic_Support.pdfhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12794401http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12794401http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12794401http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10966247http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10966247http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10966247http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8404107http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8404107http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8404107http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=893773http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=893773http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=893773http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10966242&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10966242&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10966242&itool=iconabstr


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Low dose dopamine should not be used for renalprotection in severe sepsis

An arterial catheter should be placed as soon aspractical in all patients requiring vasopressors

Arterial catheters provide more accurate and

reproducible measurement of arterial pressure inshock states when compared to using a cuff

Vasopressin may be considered in refractory shockpatients that are refractory to fluid resuscitation andhigh dose vasopressors

Infusion rate of 0.01-0.04 units/min in adults

May decrease stroke volume

Vasopressors (cont)

Grade B

Grade E

Grade E


Hollenberg SM. Crit Care Med 1999; 27:639-660.

Bellomo R. Lancet 2000; 356: 2139-2143.

Kellum J. Crti Care Med 2001; 29: 1526-1531.
http://www.sccm.org/professional_resources/guidelines/table_of_contents/index.asphttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11191541&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11505120&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11505120&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11505120&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11505120&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11191541&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11191541&itool=iconabstrhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11191541&itool=iconabstrhttp://www.sccm.org/professional_resources/guidelines/table_of_contents/index.asphttp://www.sccm.org/professional_resources/guidelines/table_of_contents/index.asphttp://www.sccm.org/professional_resources/guidelines/table_of_contents/index.asp


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In patients with low cardiac output despite adequatefluid resuscitation, dobutamine may be used toincrease cardiac output

Should be combined with vasopressor therapy in thepresence of hypotension

It is not recommended to increase cardiac index totarget an arbitrarily predefined elevated level

Patients with severe sepsis failed to benefit from increasingoxygen delivery to supranormal levels by use of dobutamine

Inotropic Therapy

Grade E

Grade A

Gattinoni L. N Eng J Med 1995;333:1025-1032.

Hayes MA. N Eng J Med 1994;330:1717-1722.



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Intravenous corticosteroids arerecommended in patients with septic shockwho require vasopressor therapy to maintainblood pressure Administer intravenous hydrocortisone 200-300 mg/day

for 7 days in three or four divided doses or bycontinuous infusion

Shown to reduce mortality rate in patients with relativeadrenal insufficiency

Steroids

Grade C

Annane, D. JAMA, 2002; 288 (7): 868

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12186604http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12186604http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12186604http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12186604http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12186604http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12186604


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May use 250 mcg ACTH stimulation test to identifyresponders and discontinue therapy in these patients

Responders can be defined as >9 mcg/dL increase incortisol 30-60 minutes post ACTH administration

Clinicians should not wait for ACTH stimulation testresults to administer corticosteroids

After the resolution of septic shock, may decreasedosage of steroids

Consider tapering the dose of corticosteroids at the end

of therapy May add fludrocortisone to the hydrocortisone regimen

Steroids

Grade E

Annane, D. JAMA, 2002; 288 (7): 868



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61%

53%

0%

20%

40%

60%

80%

100%

53%

63%

0%

20%

40%

60%

80%

100%

Low-dose Steroids Placebo

Patients with Relative AdrenalInsufficiency (ACTH Test Non-

responders) (77%)

Patients Without Relative AdrenalInsufficiency (ACTH Test

Responders) (23%)

P=0.04 P=0.96

N=114 N=36 N=34N=115

28

-dayMortality

Annane, D. JAMA, 2002; 288 (7): 868

Steroids

Low-Dose Steroids: 28-day Mortality


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Doses of hydrocortisone >300 mg dailyshould NOT be used in septic shock orsevere sepsis for the purpose of treatingshock

In the absence of shock, corticosteroidsshould not be used for treatment of sepsis

Steroids

Grade A

Grade E

Bone RC. N Engl J Med 1987;653-658.

VA Systemic Sepsis Cooperative Study Group. N Engl J Med 1987;317:659-665.



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Red blood transfusion should occur only whenhemoglobin decreases to < 7 g/dL

Once tissue hypoperfusion has resolved and in theabsence of extenuating circumstances such assignificant coronary artery disease, acute hemorrhageor lactic acidosis

Target hemoglobin of 7 9 g/dL

Erythropoietin is not recommended for specifictreatment of anemia associated with severe sepsis

Unless septic patients have other accepted reasons foradministration of erythropoietin

Routine use of fresh frozen plasma to correctlaboratory clotting abnormalities in the absence ofbleeding or planned invasive procedures is notrecommended

Blood Product Administration

Grade B

Grade B

Grade E

Corwin HL. JAMA 2002;288:2827-2835.



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It is not recommended to use antithrombin for thetreatment of severe sepsis or septic shock

High dose antithrombin in a phase III trial did notdemonstrate a beneficial effect on 28-day mortality andwas associated with increased risk of bleeding whenadministered with heparin

Platelets should be administered when platelet countsare < 5000/mm3 regardless of apparent bleeding

Platelet transfusion may be considered when counts are5000 - 30,000/mm3 and there is a significant risk of

bleeding

Platelet counts 50,000/ mm3 are typically required forsurgery or invasive procedures

Blood Product Administration (cont)

Grade B

Grade E

Warren BL. JAMA 2001;286:1869-1878.



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High tidal volumes, > 6 ml/kg, coupled with highplateau pressures, > 30 cm H2O, should be avoided

Hypercapnia can be tolerated in patients with

ALI/ARDS if required to minimize plateau pressuresand tidal volumes

A minimum amount of positive end expiratorypressure should be set to prevent lung collapse at

end-expiration

Mechanical Ventilation of Sepsis-Induced Acute

Lung Injury (ALI)/ARDS

ARDSNet. N Eng J Med 2000;342:1301-1308.

Grade B

Grade C

Grade E



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Mortality* - Low vs Traditional Tidal Volume

31

39.8

0

10

20

30

40

50

M

ortality(%)

Low Tidal

Volume

TraditionalTidal

Volume

P=0.007

* death beforedischarge homeand breathing withoutassistance



ARDSNet. N Eng J Med 2000;342:1301-1308.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10793162http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10793162http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10793162http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10793162http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10793162


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In experienced facilities, prone positioning should beconsidered in ARDS patients requiring potentiallyinjurious levels of FiO2 or plateau pressure who arenot at high risk for adverse consequences to

positioning changes

Unless contraindicated, mechanically ventilatedpatients should be maintained semirecumbent withthe head of the bed raised to 45 to prevent ventilator

associated pneumonia



Drakulovic M. Lancet 1999;354:1851-1858.

Grade E

Grade C



27/44


A weaning protocol should be in place andmechanically ventilated patients should undergospontaneous breathing trial when they satisfy the

following criteria:

- Arousable

- Low ventilatory and end expiratory pressurerequirements

- No new potentially serious conditions

- Hemodynamically stable without vasopressors- Requiring levels of FiO2 that could be delivered

with a face mask or nasal cannula



Esteban A. Am J Respir Crit Care Med 1999;159:512-518.

Ely EW. N Engl J Med 1996;335:1864-1869.

Esteban A. Am J Respir Crit Care Med 1997;156:459-465.

Grade A

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9927366http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8948561http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9279224http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9279224http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9279224http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9279224http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8948561http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8948561http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8948561http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9927366http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9927366http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9927366


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Protocols should be used when sedation of critically

ill mechanically ventilated patients is required

The protocol should include the use of a sedationgoal, measured by a standardized subjective sedationscale

Intermittent bolus or continuous infusion sedation

are recommended to predetermined end points

With daily interruptions/lightening of continuousinfusion sedation with awakening and retitration, if

necessary

Sedation, Analgesia, and

Neuromuscular Blockade in Sepsis

Brook AD. Crit Care Med 1999;27:2609-2615.

Grade B

Grade B



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Neuromuscular blockers should be avoided in theseptic patient due to the risk of prolongedneuromuscular blockade

If needed for more than the first hour of mechanicalventilation, either intermittent bolus as required orcontinuous infusion with monitoring of depth of blockwith train of four monitoring should be used

Sedation, Analgesia, and

Neuromuscular Blockade in SepsisGrade E



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Following initial stabilization of patients with severesepsis, maintain blood glucose to < 150 mg/dL

Best results obtained when blood glucose wasmaintained between 80 and 110 mg/dL

Glycemic control strategy should include a nutritionprotocol with the preferential use of the enteral route

Minimize the risk of hypoglycemia by providing acontinuous supply of glucose substrate

Accomplished by using 5% or 10% dextrose IV infusion

and followed by initiation of feeding preferably byenteral route

Glucose Control

van den Berghe G. N Engl J Med 2001;345:1359-1367.

Grade D

Grade E



31/44


10.9%

7.2%

0%

5%

10%

15%

8.0%

4.6%

0%

5%

10%

15%

Mortality During IntensiveCare In-Hospital Mortality

Mortality(%)

p = 0.01p < 0.04 (adjusted)

n=783 n=765

Conventional Intensive Insulin

n=783 n=765

van den Berghe G. N Engl J Med 2001;345:1359-1367.

Glucose Control Intensive Insulin


32/44


Continuous hemofiltration offers easier managementof fluid balance in hemodynamically unstable septicpatients

Renal Replacement

Mehta RL. Kidney Int 2001;60:1154-1163

Kellum J. Intensive Care Med 2002;28:29-37.

Grade BContinuous venovenous hemofiltration andintermittent hemodialysis are considered equivalentin acute renal failure (in the absence ofhemodynamic instability)


S S C G


33/44


No difference revealed in vasopressor requirementsor hemodynamic variables between bicarbonate andnormal saline for treating hypoperfusion-inducedacidemia

Effects of bicarbonate therapy at pH levels < 7.13have not been studied

Bicarbonate Therapy

Cooper DJ. Ann Intern Med 1990;112:492-498.

Mathieu D. Crit Care Med 1991;19:1352-1356.

Grade CBicarbonate is not recommended for the purpose of

improving hemodynamics or reducing vasopressor

requirements for the treatment of hypoperfusion

induced lactic acidemia with pH 7.15


S i i S i C i G id li


34/44


Use a mechanical prophylactic device or intermittentcompression in patients with contraindications toheparin

Use a combination of pharmacological andmechanical therapy in very high risk patients (eg,severe sepsis and history of DVT)

Belch JJ, Scott Med J 1981;26:115-117

Samama MM, N Engl J Med 1999;341:793-800

Deep Vein Thrombosis (DVT) Prophylaxis

Grade ADVT prophylaxis with either low-dose unfractionated

heparin or low molecular weight heparin should be

used in severe sepsis patients




35/44


H2 receptor blockers are more efficacious than

sucralfate and are the preferred agents Proton pump inhibitors compared to H2 blockers have

not been assessed

Stress Ulcer Prophylaxis

Bresalier RS et al. Am J Med 1987;83:110-116

Borrero et al. Am J Med 1985;79:62-64

Grade AStress ulcer prophylaxis should be given to all patientswith severe sepsis




36/44


Decisions for less aggressive support or withdrawal ofsupport may be in the patients best interest

Consideration for Limitation of Support

Grade EAdvance care planning, including the communication oflikely outcomes and realistic goals of treatment, shouldbe discussed with patients and families




37/44


Future Direction

Implement a core set of SSC guideline recommendations inhospitals

- Joint effort with the Institute of Healthcare Improvement (IHI) to deploy achange bundle

- Perform chart review to identify and track changes in practice and clinical

outcome

Create a dynamic, electronic, Web-based guideline process

- Channel new evidence through the committee, revise SSC guidelines asneeded, obtain sponsoring organization approval

- Note changes in the electronic guidelines- Electronic guidelines available for all sponsoring organization Web-sites

Anticipate formally updating guidelines in an annual process




38/44


Summary of SSC Guidelines

Initiative Grade

DVT prophylaxis with low dose heparins ormechanical devices

A

Stress ulcer prophylaxis, preferably with H2

blockers

A

Do not use more then 300 mg/dayhydrocortisone

A

Weaning protocol with spontaneous breathingtrials

A

Do not increase cardiac index to supranormal A

Early initial resuscitation to goals B

Red blood cell transfusion/dobutamine to goals B



39/44



Initiative Grade

Do not use low dose dopamine for renalprotection

B

rh Activated Protein C [drotrecogin alfa

(activated)] in patients with high risk of death

B

RBC transfusion if hemoglobin


40/44



Initiative Grade

Sedation protocols with goal and assessmentscale

B

Daily interruption/lightening if using continuous

IV sedation

B

Use colloids or crystalloids C

Corticosteroids for 7 days in septic shockpatients on vasopressors

C

Permissive hypercapnia to minimize plateaupressures and tidal volumes

C

Do not use bicarbonate if pH 7.15 inhypoperfusion lactic acidemia

C

Semirecumbent positioning to avoid VAP (headof bed at 45-degrees)

C



41/44



Initiative Grade

Cultures before beginning antibiotic therapy D

Initial empirical broad spectrum anti-infectives D

Norepinephrine or dopamine first choicepressors

D

Diagnostic Studies to determine source E

Start IV antibiotics within first hour E

Reassessment of antimicrobials in 48-72 hrs E

Stop antimicrobials if determine noninfectioussyndrome

E



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Initiative Grade

Evaluate for and provide source control E

Weigh risk vs benefit of source control methods E

Provide rapid source control as appropriate E

Establish new and then remove IV device if sourceof infection

E

Fluid challenge for suspected hypovolemia E

Start vasopressors if nonresponsive to fluidchallenge

E



43/44



Initiative Grade

Arterial catheter to measure BP in shock E

Vasopressin if refractory to other pressors E

Dobutamine if low cardiac output E

Consider addition of fludrocortisone E

Do not routinely use FFP in absence of bleeding orplanned procedures

E

Do not use antithrombin E

Platelet transfusions E



44/44



Initiative GradeUse PEEP to prevent lung collapse, set at minimumamount

E

Prone positioning in ALI/ARDS E

Avoid neuromuscular blockers EMaintain blood glucose < 150 mg/dL E

Nutrition protocol, preferably enteral when glycemiccontrol strategy initiated

E

Consider limitation of support when appropriate,including frequent discussions with family and patient

E