1. Surviving Sepsis Campaign Guidelines for
Management of Severe Sepsis and Septic Shock
This is a summary of the Surviving Sepsis Campaign In patients requiring vasopressors, place an arterial Prone ARDS patients requiring potentially injurious levels
Guidelines for Management of Severe Sepsis and Septic catheter as soon as practical. of FiO2 or plateau pressure. Only prone patients not at
Shock condensed from Dellinger RP, Carlet JM, Masur H, high risk from positional changes.
et al: Surviving Sepsis Campaign guidelines for management Consider vasopressin in patients with refractory shock
of severe sepsis and septic shock. Crit Care Med 2004; despite adequate fluid resuscitation and high-dose con- To prevent ventilator-associated pneumonia maintain
32:858-871. This version does not contain the rationale ventional vasopressors. Vasopressin is not recommended mechanically ventilated patients in a semirecumbent
or appendices contained in the primary publication. as a replacement for norepinephrine or dopamine as a position (head of bed raised 45 degrees), unless con-
Please refer to the guidelines for additional information first-line agent. Administer vasopressin at infusion rates traindicated.
at www.survivingsepsis.org. of 0.01–0.04 units/minute in adults.
Use a weaning protocol and have mechanically ventilated
∆ Indicates one of the goals chosen for implementation in Inotropic Therapy patients undergo a spontaneous breathing trial (SBT), at
the Institute of Healthcare Improvement's change pack- Consider dobutamine in patients with low cardiac output least daily, to evaluate for ventilation discontinuation.
age, i.e. part of the “sepsis bundle.” despite fluid resuscitation. Continue to titrate vasopressor
to mean arterial pressure of 65 mm Hg or greater. SBT options include a low level of pressure support with
continuous positive airway pressure 5 cm H2O or a
Initial Resuscitation Do not increase cardiac index to achieve an arbitrarily T-piece. Prior to SBT, patients should: 1) be arousable;
∆ Begin resuscitation immediately in patients with predefined elevated level of oxygen delivery. 2) be hemodynamically stable without vasopressors;
hypotension or elevated serum lactate. Resuscitation 3) have no new potentially serious conditions; 4) have low
goals: Steroids ventilatory and end-expiratory pressure requirement; and
• Central venous pressure: 8–12 mm Hg ∆ Treat patients who still require vasopressors despite fluid 5) require FiO2 levels that can be safely delivered with a
• Mean arterial pressure ≥65 mm Hg replacement with hydrocortisone 200–300 mg/day, for face mask or nasal cannula.
• Urine output ≥0.5 mL.kg -1.hr -1 7 days in three or four divided doses or by continuous
• Central venous or mixed venous oxygen infusion. Consider extubation if SBT is successful.
saturation ≥70%
Optional: Sedation, Analgesia, and Neuromuscular
∆ If central venous oxygen saturation or mixed venous • Perform 250-microgram adrenocorticotropic Blockade in Sepsis
oxygen saturation of 70% is not achieved with a central hormone (ACTH) stimulation test and discontinue Use sedation protocols for critically ill mechanically
venous pressure of 8–12 mm Hg, then transfuse packed steroids in patients who are responders (increase ventilated patients. Measure the sedation goal with a
red blood cells to achieve a hematocrit of ≥30% and/or in cortisol of > 9 µg/dL). standardized subjective sedation scale.
administer a dobutamine infusion of up to a maximum of
20 µg.kg-1.min-1. • Decrease steroid dose if septic shock resolves. Target sedation to predetermined endpoints (sedation
score). Use either intermittent bolus sedation or continu-
Diagnosis • Taper corticosteroid dose at end of therapy. ous infusion sedation with daily interruption/lightening
Before starting antibiotics obtain two or more blood to produce awakening. Retitrate if necessary.
cultures. At least one blood draw should be percutaneous • Add fludrocortisone (50µg orally once a day)
and one should be through each vascular assist device to this regimen. Avoid neuromuscular blockers (NMBs), if at all possible.
that has been in place longer than 48 hours. Obtain If NMBs must be utilized for longer than the first 2 to 3
cultures from other sites as indicated – cerebrospinal fluid, Do not use corticosteroids >300 mg/day of hydrocorti- hours of mechanical ventilation, use either intermittent
respiratory secretions, urine, wounds, and other body fluids. sone to treat septic shock. bolus as required or continuous infusion with monitoring
of depth of block with train of four monitoring.
Antibiotic Therapy Do not use corticosteroids to treat sepsis in the absence
∆ Begin intravenous antibiotics within first hour of recog- of shock unless the patient’s endocrine or corticosteroid Glucose Control
nition of severe sepsis. history warrants. ∆ Maintain blood glucose <150 mg/dL (8.3mmol/L)
following initial stabilization. Use continuous insulin
Administer one or more drugs that are active against likely Recombinant Human Activated and glucose infusion. Monitor blood glucose every 30 – 60
bacterial or fungal pathogens. Consider microorganism Protein C (rhAPC) minutes until stabilized, then monitor every 4 hours.
susceptibility patterns in the community and hospital. ∆ rhAPC is recommended in patients at high risk of death
(APACHE II(≥25, sepsis-induced multiple organ failure, Include a nutritional protocol for glycemic control.
Reassess antimicrobial regimen 48–72 hours after septic shock, or sepsis-induced acute respiratory distress
starting treatment with the objective of using a narrow syndrome) and with no absolute contraindication related Renal Replacement
spectrum antibiotic. to bleeding risk or relative contraindication that outweighs Intermittent hemodialysis and continuous veno venous
the potential benefit of rhAPC. hemofiltration (CVVH) are considered equivalent.
Consider combination therapy for neutropenic patients CVVH offers easier management in hemodynamically
and those with Pseudomonas infections. Blood Product Administration unstable patients.
Following resolution of tissue hypoperfusion, and in the
Stop antimicrobial therapy immediately if the condition absence of significant coronary artery disease or acute Bicarbonate Therapy
is determined to be a noninfectious cause. hemorrhage, transfuse red blood cells when hemoglobin Do not use bicarbonate therapy for the purpose of
decreases to <7.0 g/dL (<70 g/L) to target a hemoglobin improving hemodynamics or reducing vasopressor
Source Control of 7.0 – 9.0 g/dL. requirements when treating hypoperfusion induced lactic
∆ Evaluate patient for a focus of infection amenable to acidemia with pH ≥7.15.
source control measures including abscess drainage or Do not use erythropoietin to treat sepsis-related anemia.
tissue debridement. Erythropoietin may be used for other accepted reasons. Deep Vein Thrombosis (DVT) Prophylaxis
Use either low-dose unfractionated heparin or low-mole-
Choose the source control measure that will cause the Do not use fresh frozen plasma to correct laboratory cular weight heparin. Use a mechanical prophylactic
least physiologic upset and still accomplish the clinical clotting abnormalities unless there is bleeding or planned device, such as compression stockings or an intermittent
goal. invasive procedures. compression device, when heparin is contraindicated.
Use a combination of pharmacologic and mechanical
Institute source control measures as soon as an infection Do not use antithrombin therapy. therapy for patients who are at very high risk for DVT.
focus in need of source countrol has been identified.
Administer platelets when counts are <5000/mm3 (5 X Stress Ulcer Prophylaxis
Remove intravascular access devices that are a potential 109/L) regardless of bleeding. Transfuse platelets when Provide stress ulcer prophylaxis. The preferred agents
infection source promptly after establishing other vascu- counts are 5000 to 30,000/mm3 (5–30 X 109/L) and there are H2 receptor inhibitors.
lar access. is significant bleeding risk. Higher platelet counts
(≥50,000/mm3 [50 X 109/L]) are required for surgery or Consideration for Limitation of Support
Fluid Therapy invasive procedures. Discuss advance care planning with patients and
(see initial resuscitation timing recommendations) families. Describe likely outcomes and set realistic
Mechanical Ventilation of Sepsis-Induced expectations.
Use crystalloids or colloids. Acute Lung Injury (ALI)/ARDS
∆ Avoid high tidal volumes coupled with high plateau
∆ Give fluid challenge to patients with suspected inade- pressures. Reduce tidal volumes over 1–2 hours to a low Sponsoring Organizations: American Association of Critical-Care
quate tissue perfusion at a rate of 500 –1000 mL of tidal volume (6 ml per kilogram of lean body weight) as Nurses; American College of Chest Physicians; American
crystalloids or 300–500 mL of colloids over 30 minutes a goal in conjunction with the goal of maintaining College of Emergency Physicians; American Thoracic Society;
and repeat if blood pressure and urine output do not end-inspiratory plateau pressures <30 cm H2O. Australian and New Zealand Intensive Care Society; European
increase and there is no evidence of intravascular volume Society of Clinical Microbiology and Infectious Diseases;
overload. If necessary, minimize plateau pressures and tidal volumes European Society of Intensive Care Medicine; European
by allowing PaCO2 to increase above normal. Respiratory Society; Infectious Disease Society of America;
Vasopressors International Sepsis Forum; Society of Critical Care Medicine;
Start vasopressor therapy when fluid challenge fails to Set a minimum amount of positive end-expiratory pressure Surgical Infection Society.
restore adequate blood pressure and organ perfusion, or (PEEP) to prevent lung collapse at end expiration.
transiently until fluid resuscitation restores adequate Set PEEP based on severity of oxygenation deficit and
perfusion. guided by the FiO2 required to maintain adequate oxy-
genation (ARDSnet guidelines) or titrate PEEP accord-
Either norepinephrine or dopamine administered through ing to bedside measurements of thoracopulmonary com-
a central catheter is the initial vasopressor of choice. pliance.
This wall chart distributed by the Society of Critical Care Medicine
Do not use low-dose dopamine for renal protection.
Revised June 2004
![Surviving Sepsis Campaign Guidelines for
Management of Severe Sepsis and Septic Shock
This is a summary of the Surviving Sepsis Campaign In patients requiring vasopressors, place an arterial Prone ARDS patients requiring potentially injurious levels
Guidelines for Management of Severe Sepsis and Septic catheter as soon as practical. of FiO2 or plateau pressure. Only prone patients not at
Shock condensed from Dellinger RP, Carlet JM, Masur H, high risk from positional changes.
et al: Surviving Sepsis Campaign guidelines for management Consider vasopressin in patients with refractory shock
of severe sepsis and septic shock. Crit Care Med 2004; despite adequate fluid resuscitation and high-dose con- To prevent ventilator-associated pneumonia maintain
32:858-871. This version does not contain the rationale ventional vasopressors. Vasopressin is not recommended mechanically ventilated patients in a semirecumbent
or appendices contained in the primary publication. as a replacement for norepinephrine or dopamine as a position (head of bed raised 45 degrees), unless con-
Please refer to the guidelines for additional information first-line agent. Administer vasopressin at infusion rates traindicated.
at www.survivingsepsis.org. of 0.01–0.04 units/minute in adults.
Use a weaning protocol and have mechanically ventilated
∆ Indicates one of the goals chosen for implementation in Inotropic Therapy patients undergo a spontaneous breathing trial (SBT), at
the Institute of Healthcare Improvement's change pack- Consider dobutamine in patients with low cardiac output least daily, to evaluate for ventilation discontinuation.
age, i.e. part of the “sepsis bundle.” despite fluid resuscitation. Continue to titrate vasopressor
to mean arterial pressure of 65 mm Hg or greater. SBT options include a low level of pressure support with
continuous positive airway pressure 5 cm H2O or a
Initial Resuscitation Do not increase cardiac index to achieve an arbitrarily T-piece. Prior to SBT, patients should: 1) be arousable;
∆ Begin resuscitation immediately in patients with predefined elevated level of oxygen delivery. 2) be hemodynamically stable without vasopressors;
hypotension or elevated serum lactate. Resuscitation 3) have no new potentially serious conditions; 4) have low
goals: Steroids ventilatory and end-expiratory pressure requirement; and
• Central venous pressure: 8–12 mm Hg ∆ Treat patients who still require vasopressors despite fluid 5) require FiO2 levels that can be safely delivered with a
• Mean arterial pressure ≥65 mm Hg replacement with hydrocortisone 200–300 mg/day, for face mask or nasal cannula.
• Urine output ≥0.5 mL.kg -1.hr -1 7 days in three or four divided doses or by continuous
• Central venous or mixed venous oxygen infusion. Consider extubation if SBT is successful.
saturation ≥70%
Optional: Sedation, Analgesia, and Neuromuscular
∆ If central venous oxygen saturation or mixed venous • Perform 250-microgram adrenocorticotropic Blockade in Sepsis
oxygen saturation of 70% is not achieved with a central hormone (ACTH) stimulation test and discontinue Use sedation protocols for critically ill mechanically
venous pressure of 8–12 mm Hg, then transfuse packed steroids in patients who are responders (increase ventilated patients. Measure the sedation goal with a
red blood cells to achieve a hematocrit of ≥30% and/or in cortisol of > 9 µg/dL). standardized subjective sedation scale.
administer a dobutamine infusion of up to a maximum of
20 µg.kg-1.min-1. • Decrease steroid dose if septic shock resolves. Target sedation to predetermined endpoints (sedation
score). Use either intermittent bolus sedation or continu-
Diagnosis • Taper corticosteroid dose at end of therapy. ous infusion sedation with daily interruption/lightening
Before starting antibiotics obtain two or more blood to produce awakening. Retitrate if necessary.
cultures. At least one blood draw should be percutaneous • Add fludrocortisone (50µg orally once a day)
and one should be through each vascular assist device to this regimen. Avoid neuromuscular blockers (NMBs), if at all possible.
that has been in place longer than 48 hours. Obtain If NMBs must be utilized for longer than the first 2 to 3
cultures from other sites as indicated – cerebrospinal fluid, Do not use corticosteroids >300 mg/day of hydrocorti- hours of mechanical ventilation, use either intermittent
respiratory secretions, urine, wounds, and other body fluids. sone to treat septic shock. bolus as required or continuous infusion with monitoring
of depth of block with train of four monitoring.
Antibiotic Therapy Do not use corticosteroids to treat sepsis in the absence
∆ Begin intravenous antibiotics within first hour of recog- of shock unless the patient’s endocrine or corticosteroid Glucose Control
nition of severe sepsis. history warrants. ∆ Maintain blood glucose <150 mg/dL (8.3mmol/L)
following initial stabilization. Use continuous insulin
Administer one or more drugs that are active against likely Recombinant Human Activated and glucose infusion. Monitor blood glucose every 30 – 60
bacterial or fungal pathogens. Consider microorganism Protein C (rhAPC) minutes until stabilized, then monitor every 4 hours.
susceptibility patterns in the community and hospital. ∆ rhAPC is recommended in patients at high risk of death
(APACHE II(≥25, sepsis-induced multiple organ failure, Include a nutritional protocol for glycemic control.
Reassess antimicrobial regimen 48–72 hours after septic shock, or sepsis-induced acute respiratory distress
starting treatment with the objective of using a narrow syndrome) and with no absolute contraindication related Renal Replacement
spectrum antibiotic. to bleeding risk or relative contraindication that outweighs Intermittent hemodialysis and continuous veno venous
the potential benefit of rhAPC. hemofiltration (CVVH) are considered equivalent.
Consider combination therapy for neutropenic patients CVVH offers easier management in hemodynamically
and those with Pseudomonas infections. Blood Product Administration unstable patients.
Following resolution of tissue hypoperfusion, and in the
Stop antimicrobial therapy immediately if the condition absence of significant coronary artery disease or acute Bicarbonate Therapy
is determined to be a noninfectious cause. hemorrhage, transfuse red blood cells when hemoglobin Do not use bicarbonate therapy for the purpose of
decreases to <7.0 g/dL (<70 g/L) to target a hemoglobin improving hemodynamics or reducing vasopressor
Source Control of 7.0 – 9.0 g/dL. requirements when treating hypoperfusion induced lactic
∆ Evaluate patient for a focus of infection amenable to acidemia with pH ≥7.15.
source control measures including abscess drainage or Do not use erythropoietin to treat sepsis-related anemia.
tissue debridement. Erythropoietin may be used for other accepted reasons. Deep Vein Thrombosis (DVT) Prophylaxis
Use either low-dose unfractionated heparin or low-mole-
Choose the source control measure that will cause the Do not use fresh frozen plasma to correct laboratory cular weight heparin. Use a mechanical prophylactic
least physiologic upset and still accomplish the clinical clotting abnormalities unless there is bleeding or planned device, such as compression stockings or an intermittent
goal. invasive procedures. compression device, when heparin is contraindicated.
Use a combination of pharmacologic and mechanical
Institute source control measures as soon as an infection Do not use antithrombin therapy. therapy for patients who are at very high risk for DVT.
focus in need of source countrol has been identified.
Administer platelets when counts are <5000/mm3 (5 X Stress Ulcer Prophylaxis
Remove intravascular access devices that are a potential 109/L) regardless of bleeding. Transfuse platelets when Provide stress ulcer prophylaxis. The preferred agents
infection source promptly after establishing other vascu- counts are 5000 to 30,000/mm3 (5–30 X 109/L) and there are H2 receptor inhibitors.
lar access. is significant bleeding risk. Higher platelet counts
(≥50,000/mm3 [50 X 109/L]) are required for surgery or Consideration for Limitation of Support
Fluid Therapy invasive procedures. Discuss advance care planning with patients and
(see initial resuscitation timing recommendations) families. Describe likely outcomes and set realistic
Mechanical Ventilation of Sepsis-Induced expectations.
Use crystalloids or colloids. Acute Lung Injury (ALI)/ARDS
∆ Avoid high tidal volumes coupled with high plateau
∆ Give fluid challenge to patients with suspected inade- pressures. Reduce tidal volumes over 1–2 hours to a low Sponsoring Organizations: American Association of Critical-Care
quate tissue perfusion at a rate of 500 –1000 mL of tidal volume (6 ml per kilogram of lean body weight) as Nurses; American College of Chest Physicians; American
crystalloids or 300–500 mL of colloids over 30 minutes a goal in conjunction with the goal of maintaining College of Emergency Physicians; American Thoracic Society;
and repeat if blood pressure and urine output do not end-inspiratory plateau pressures <30 cm H2O. Australian and New Zealand Intensive Care Society; European
increase and there is no evidence of intravascular volume Society of Clinical Microbiology and Infectious Diseases;
overload. If necessary, minimize plateau pressures and tidal volumes European Society of Intensive Care Medicine; European
by allowing PaCO2 to increase above normal. Respiratory Society; Infectious Disease Society of America;
Vasopressors International Sepsis Forum; Society of Critical Care Medicine;
Start vasopressor therapy when fluid challenge fails to Set a minimum amount of positive end-expiratory pressure Surgical Infection Society.
restore adequate blood pressure and organ perfusion, or (PEEP) to prevent lung collapse at end expiration.
transiently until fluid resuscitation restores adequate Set PEEP based on severity of oxygenation deficit and
perfusion. guided by the FiO2 required to maintain adequate oxy-
genation (ARDSnet guidelines) or titrate PEEP accord-
Either norepinephrine or dopamine administered through ing to bedside measurements of thoracopulmonary com-
a central catheter is the initial vasopressor of choice. pliance.
This wall chart distributed by the Society of Critical Care Medicine
Do not use low-dose dopamine for renal protection.
Revised June 2004](https://image.slidesharecdn.com/guidelinespostersepticshock-120120093645-phpapp01/85/guidelines-poster-septic-shock-1-320.jpg)
