1. Surviving Sepsis Campaign
International Guidelines for Management
of Severe Sepsis & Septic Shock
Dr Rimita Dey & Dr Raja Basu
Department of Critical Care Medicine
Peerless Hospital & B K Roy Research Center
Kolkata
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R. Phillip Dellinger, Crit Care Med 2013; 41:580–637

2. Systemic Inflammatory Response Syndrome(SIRS)
To SEPTIC SHOCK

3. Diagnostic Criteria for Sepsis
Infection(documented or suspected)
& some of the following :
General Variables
Fever > 100.9 F Hypothermia < 96.8 F
Heart rate >90 Respiratory rate > 20
Altered Mental status Hyperglycemia >140
(absence of Diabetes)
Significant edema
or positive Fluid Balance ( >20 ml/kg over 24 hrs)

4. Inflammatory variables
Leucocytosis (WCC > 12000)
Leucopenia ( WCC < 4000)
Normal WCC with > 10 % immature forms
Plasma CRP > two SD above the normal
Plasma Procalcitonin > two SD above the normal
Hemodynamic Variables
Arterial Hypotension
( SBP < 90, MAP < 70, OR
an SBP decrease > 40 in adults OR
SBP Less than two SD below normal for age)
WCC- White Cell Count, CRP- C Reactive Protein, SD- Standard Deviation,
SBP- Systolic Blood Pressure, MAP- Mean Arterial Pressure

5. Organ Dysfunction Variables (Severe Sepsis Criteria)
Arterial Hypoxemia (PaO2 /FiO2 <300)
Acute Oliguria (UO< 0.5 ml/kg/hr for at least
2 hours despite fluid resuscitation)
Creatinine increase > 0.5 mg/dl
Coagulation abnormalities (INR> 1.5 or aPTT >60s)
Ileus (absent bowel sounds)
Thrombocytopenia ( < I lakh)
Hyperbilirubinemia ( > 4 mg/dl)
Tissue Perfusion Variables
HyperLactaemia ( > 1 mmol/L)
Decreased Capillary Refilling Time or Mottling

6. SURVIVING SEPSIS CARE BUNDLES
TO BE COMPLETED WITHIN 3 HOURS
1.Measure Lactate Levels
2.Obtain Blood Cultures prior to administration
of Antibiotics.
3.Administer broad spectrum Antibiotics
4.Administer 30ml/kg Crystalloid for low BP or
lactate level – 4

7. TO BE COMPLETED WITHIN 6 HOURS
5. Apply Vasopressors (for hypotension that does
not respond to the initial fluid resuscitation) to
maintain a MAP > 65.
6. In the event of persistent hypotension despite
volume resuscitation (septic Shock) Or
initial lactate being > 4
- Measure CVP & CVP saturation(ScvO2)
7. Remeasure Lactate levels if the initial lactate
was elevated.
MAP = Diastolic BP + (Systolic BP – Diastolic BP)
3

8. SURVIVING SEPSIS CARE BUNDLES

9. Initial Resuscitation
• Begin Resuscitation immediately in patients
with low BP or elevated serum lactate > 4;
DONOT delay pending ITU admission.
• Resuscitation Goals:
CVP 8-12 mm Hg
MAP > 65mm Hg
Urine output > 0.5ml/Kg/Hr
Central Venous O2 saturation >70%, or
mixed venous >65%.

10. If venous o2 saturation target is not achieved :
• Consider further fluids
• Transfuse Packed RBCs to achieve a
haematocrit of > 30%
And/ or
• Dobutamine infusion max 20 mic/kg/min
A higher target CVP of 12-15 mm Hg is
recommended in the presence of mechanical
ventilation or pre-existing decreased ventricular
compliance.

11. Diagnosis
Obtain appropriate Blood cultures before
starting antibiotics provided this does not
significantly delay antimicrobial administration
• obtain two or more blood cultures(BCs).
• one or more BCs should be percutaneous.
• one BC from each vascular access device in place
>48hrs.
• Culture other sites as clinically indicated (CSF, Ascitic
Fluid).
Perform imaging studies promptly in order to
Confirm & sample any source of infection; if safe
to do so.

12. Antibiotic Therapy
• Begin IV Antibiotics as early as possible, & always within the
first hour of recognizing severe sepsis and septic shock.(Grade 1B)
• Broad-spectrum : one or more agents active against likely
bacterial/ fungal pathogens & with good penetration into the
presumed source. (Grade 1B)
• Duration of therapy typically limited to 7-10 days; longer if
response is slow, undrainable foci of infection, or
immunogenic deficiencies & neutropenic patients, or
Bacteremia with S.Aureus. (Grade 2C)
• Use of low Procalcitonin level or similar biomarkers to assist
discontinuation of empiric antibiotics in patients who initially
appeared septic, but have no subsequent evidence of
infection. (Grade 2C)
• Antiviral initiated as early as possible in severe sepsis of viral
origin.

13. • Reassess antimicrobial regimen daily to optimize
efficacy, prevent resistance, avoid toxicity &
minimize costs.
– Consider combination therapy in Pseudomonas & Acenetobacter
infection
– Treat with an extended spectrum Beta-lactum & either an
aminoglycoside or a fluroquinolone for Pseudomonas bacteremia.
– A combination of Beta-lactum & Macrolide for patients with
Streptococcus Pneumoniae infections
– Consider combination empiric therapy in neutropenic patients
– Combination therapy no more than 3-5 days &
de-escalation following susceptibilities.
• Antimicrobials should NOT be used in patients with
severe inflammatory states determined to be of
noninfectious cause.

14. Source Identification & control
• A specific anatomic site of infection should be
established as rapidly as possible & within the first 6
hours of presentation.
• Formally evaluate patient for a focus of infection
amenable to source control measures (e.g. abscess
drainage, tissue debridement)
• Implement source control as soon as possible
following successful initial resuscitation.
– Exception : infected pancreatic necrosis, where surgical
intervention is best delayed.
• Remove Intravascular access devices if potentially
infected.

15. Infection Prevention
• Selective oral decontamination and selective
digestive decontamination should be
introduced and investigated as a method to
reduce the incidence of ventilator-associated
pneumonia.
• Oral chlorhexidine gluconate be used as a
form of oropharyngeal decontamination to
reduce the risk of ventilator-associated
pneumonia in ICU patients. (Grade 2B)

16. Fluid Therapy

17. Crystalloids Solutions

18. Vasopressors

19. • Dopamine as an alternative to NA is
recommended only for patients with low risk of
tachyarrhythmia & absolute or relative
bradycardia.
• Phenylephrine is NOT recommended for septic
shock except in (Grade 1C)
– NA associated serious arrhythmias
– C.Output is known to be high but BP is low
– As salvage therapy when combined vasopressor-inotrope
drugs & low dose vasopressin have all failed to achieve MAP.
• Do NOT use low dose dopamine for Renal
Protection.(Grade 1A)
• All patients requiring Vasopressors should have
an arterial catheter placed as soon as practical.

20. Ionotropic Therapy
• A trial of Dobutamine infusion of up to
20microgm/kg/min may be administered
alone or added to vasopressor in presence of
–Myocardial dysfunction suggested by
elevated cardiac filling pressures & low
cardiac output, or
–Ongoing signs of hypo perfusion, despite
achieving intravascular volume & adequate
MAP. (Grade 1C)

21. Corticosteroids
• Do NOT use IV Hydrocortisone to treat adult septic
shock if adequate fluid resuscitation & vasopressor
therapy is able to restore hemodynamic stability.
Incase this is not achieved IV Hydrocortisone alone
@ 200mg IV OD may be used.(Grade 2C)
• ACTH stimulation test is NOT to be used to identify
adults with septic shock receiving Hydrocortisone.
• When Hydrocortisone is given, use continuous flow.
• Steroid therapy may be weaned when vasopressors
are no longer required.
• Do NOT use corticosteroids to treat sepsis in the
absence of shock.

22. Blood Product Administration
• Transfuse Red Blood Cells when Hb decreases to < 7
& target a Hb of 7-9 in adults.(Grade 1B)
• Higher Hb level may be required in presence of
myocardial ischemia, severe hypoxemia, or acute
hemorrhage.
• Erythropoietin not recommended as a treatment of
sepsis related severe anemia.(Grade 1B)
• FFP should only be used to correct clotting
abnormalities in the presence of bleeding or
planned invasive procedures. (Grade 2D)
• Antithrombin should not be used for the treatment
of severe sepsis. (Grade 1B)

24. Mechanical ventilation in Sepsis
induced ARDS
• Target a Tidal volume of 6ml/kg of predicted body
wt.(vs. 12ml/kg). (Grade 1A)
• Plateau pressure should be measured in pts with
ARDS & Target an initial upper limit pressure <30
cm H2o in a passively inflated lung.
• PEEP should be applied to avoid alveolar collapse
at end expiration (atelectrauma). (Grade 1B)
• Higher rather than lower levels of PEEP should be
used in sepsis associated ARDS. (Grade 2C)

25. • Recruitment maneuvers should be used in sepsis
patients with severe refractory hypoxemia.
• Prone positioning should be considered in ARDS
pts requiring potentially injurious levels of FiO2 or
plateau pressures.
• Ventilated pts should be positioned at 30-45’
head elevation to limit aspiration risk & VAP.(Grade
1B)
• NIV should be in only that minority of ARDS
patients with mild to moderate hypoxemic
respiratory failure. The pts need to be
haemodynamically stable, comfortable easily
arousable, able to protect /clear their airway &
expected to recover rapidly.

26. • Use a weaning protocol & a spontaneous breathing trial (SBT)
regularly to evaluate the potential for discontinuing mechanical
ventilation. (Grade 1A)
• SBT options include a low level of pressure support with CPAP 5 or a
T-piece.
• Before SBT pts should be
– Arousable
– Haemodynamically stable
– Have no new potentially serious conditions
– Have low ventilatory & end-expiratory pressure requirement
– Require FiO2 that can be safely delivered with a face mask or nasal cannula.
• Do Not use a pulmonary catheter for the routine monitoring of pts
with ARDS . (Grade IA)
• Use a conservative rather than liberal fluid strategy for ARDS pts
without any evidence of tissue hypo perfusion.
• Do NOT use beta 2-agonists for the treatment of sepsis induced ARDS
unless there is specific indication such as bronchospasm.

27. Sedation, Analgesia & Neuromuscular
Blocking Agents(NBMAs)
• Continuous or intermittent sedation should be minimized
in mechanically ventilated sepsis pts targeting specific
titration endpoints. (Grade 1B)
• NBMAs should be avoided if possible in septic pts without
ARDS.(due to risk of prolonged NM blockade following
discontinuation)
• If NMBAs are needed, either intermittent bolus as required
or continuous infusion with Train of Four monitoring of the
depth of blockade is advised. (Grade 1C)
• A short course of NMBA of NOT greater than 48hrs for pts
with early sepsis induced ARDS & a PaO2/ FiO2 < 150 is
advised.

28. Glucose Control
• In patients with severe sepsis start insulin dosing
when 2 consecutive blood sugar reading are > 180.
• A protocolized approach should target an upper level
of < 180 rather than a upper target blood glucose
level of < 110. (Grade 1A)
• Blood glucose monitoring every 1-2 hrs until glucose
values & insulin infusion rates are stable & thereafter
every 4hrs. (Grade 1C)
• Use IV insulin in pts with severe sepsis.
• Interpret with caution low glucose levels obtained
with point of care testing as these techniques may
overestimate arterial blood or plasma glucose values

29. Renal Replacement Therapy
& Bicarbonate
• CRRT & Intermittent HD are equivalent in Severe
Sepsis and ARF. (Grade 2B)
• Use continuous therapies to facilitate
management of fluid balance in hemodynamically
unstable septic pts.
• Do NOT use Sodium Bicarbonate for the purpose
of improving hemodynamics or reducing
vasopressor requirements when treating hypo
perfusion induced lactic acidemia with a pH>7.15
(Grade 2B)

30. DVT Prophylaxis
• Pts with severe sepsis should receive daily
phamacoprophylaxis against VTE. (Grade 1B)
• Use once daily S/C LMWH (vs BD dosing of UFH & vs TDS
dosing of UFH). (Grade 1B)
• If CrCl <30 use Dalteparin. (Grade 1A)
• Whenever possible treat with a combination of
pharmacological therapy & intermittent pneumatic
compression.
• Where heparin is C/I (low platelets, severe
coagulopathy, active bleeding or recent ICH) mechanical
prophylactic treatment (compression stocking or
devices) should be used.

31. Stress Ulcer Prophylaxis
• Use H2 Blocker or Proton Pump Inhibitor in pts
who have bleeding risk factors. (Grade 1B)
• When stress ulcer prophylaxis is needed use PPI
rather than H2 RA.
• Pts without risk factors should not receive
prophylaxis

32. Nutrition
• Give oral or enteral feeding, as tolerated rather than
either complete fasting or only IV glucose within the first
48 hrs of diagnosing severe sepsis.
• Avoid mandatory full caloric feeding in the first week
instead suggest low dose feeding (e.g. upto 500 calories
per day) then advancing only as tolerated.
• Use IV glucose & Enteral Nutrition rather than TPN alone
or Parenteral nutrition in conjugation with enteral
feeding during the first 7 days of diagnosis.
• Use nutrition with no specific immunomodulating
supplementation (rather than nutrition providing specific
immunomodulating supplementation) in severe sepsis.

33. Setting Goals of Care
• Discuss prognosis & goals of care with
patients & their families.
• Incorporate goals of care into the treatment &
end-of-life planning, utilizing the palliative
care principles, where possible.
• Address goals of care as early as feasable, but
no later than within 72 hrs of admission.

34. THANK YOU