SurvivingSepsisGuidelinesUpdatedPreview from the 41th Society of Critical Care Medicine Meeting Jun 16, 2012http://pulmccm.org/2012/critical-care-review/surviving-sepsis-guidelines-updated-at-sccm-meeting/
SIRS Sepsis Severe Sepsis Septic Shock SIRS withSystemic Inflammatory Response Organ Dysfunction Severe Sepsis and Hypotension Sepsis plus Syndrome Infection • • Elevated Creatinine (>2)Hypotension that does NOT • Temp < 36 ° C or > 38.3 ° C respond to fluid (500 cc bolus) • Elevated INR (DIC) • HR > 90 • Altered Mental Status (GCS <12) • RR > 20 or PCO2 < 32 • Elevated Lactate (>4) • WBC < 4K or > 12K or bands > 10% • Hypotension that responds to fluid Bone et al. Chest 1992;101:1644
Guide to Recommendations’Strengths and SupportingEvidence1 = strong recommendation2 = weak recommendation or suggestionA = good evidence from randomized trialsB = moderate strength evidence from small randomized trial(s) or multiple good observational trialsC = weak or absent evidence, mostly driven by consensus opinion
New FluidResuscitationRecommendationsUsing crystalloids like normal saline as the initial fluid resuscitation for people with severe sepsis.The initial fluid challenge should be 1L or more of crystalloid, and a minimum of 30 mL/kg of crystalloid (2.1 L in a 70 kg) in the first 4-6 hours. (Grade 1A)
New FluidResuscitationRecommendationsIncremental fluid boluses should be continued as long as patients continue to improve hemo- dynamically (in blood pressure, delta pulse pressure, or both) (Grade 1C)
New FluidResuscitationRecommendationsAdding albumin to initial fluid resuscitation with crystalloid for severe sepsis and septic shock (Grade 2B)Don’t using hetastarches/ hydroxyethyl starches greater than 200 kDa in molecular weight (Grade 1B)
New Recommendations for Vasopressors, Inotropes Using norepinephrine (Levophed) as the first choice for vasopressor therapy (Grade 1B). Vasopressin 0.03 units / minute is an alternative to norepinephrine, or may be added to it (Grade 2A) When a second agent is needed, epinephrine is weakly-recommended vasopressor choice (Grade 2B)
New Recommendations for Vasopressors, Inotropes Dopamine was only recommended in highly selected patients whose risk for arrhythmias was felt to be very low and who had a low heart rate and/or cardiac output (Grade 2C) Dobutamine is strongly recommended (by itself or in addition to a vasopressor) for patients with cardiac dysfunction as evidenced by high filling pressures and low cardiac output, or clinical signs of hypoperfusion after achievement of restoration of blood pressure with effective volume resuscitation (Grade 1C)
Corticosteroid RecommendationsDon’t providing intravenous corticosteroid therapy to patients for whom fluid resuscitation and vasopressors can restore an adequate blood pressure. For those with vasopressor-refractory septic shock, they recommend IV hydrocortisone in a continuous infusion totaling 200 mg/24 hrs (Grade 2C)
Mechanical Ventilation for ARDSFor patients with ARDS due to severe sepsis: Using higher levels of PEEP (Grade 2C) Recruitment maneuvers for patients with severe hypoxemia while receiving high PEEP and FiO2 (Grade 2C) Prone positioning for patients with PaO2/FiO2 ratios < 100 despite such maneuvers (Grade 2C)
Other New Surviving SepsisGuidelinesUsing normalization of lactate levels as an alternate goal in early goal- directed therapy for severe sepsis, if central venous oxygenation monitoring is not available (Grade 2C)
Other New Surviving SepsisGuidelinesFor patients at risk for fungal infection as a source for severe sepsis, checking one of the newer assays for invasive candidiasis such as 1,3-beta-D-glucan, mannan, or anti-mannan ELISA antibody testing (Grade 2B/C)
Other New Surviving SepsisGuidelinesWhen no infection can be found during empiric antibiotic therapy, consider using a low procalcitonin level as a supportive tool for the decision to stop antibiotics (Grade 2C).
The Surviving Sepsis project was criticized in the mid 2000s when it was revealed that Eli Lilly (makers of since-discontinued Xigris) provided a reported ~90% of the funding, without disclosure by the committee. Others (including the committee itself) felt such criticism was unfounded and unfair.