The Surviving Sepsis Campaign was created in 2002 to reduce sepsis mortality through a 7 point agenda including developing guidelines, educating professionals, and improving diagnosis and ICU care. Sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated response to infection. Initial resuscitation goals include fluid resuscitation, vasopressors to maintain blood pressure and perfusion targets. Early, broad-spectrum antibiotics should begin within 1 hour along with blood cultures and source control. Other supportive therapies include mechanical ventilation, glucose control, DVT prophylaxis and early enteral nutrition.

1. International guidelines for
management of Septic shock
: Surviving Sepsis Campaign
Presenter
Dr Amit Karnik JRIII
Dept of Surgery General
KGMU LUCKNOW

2. Surviving Sepsis Campaign
• Inception in 2002 by SCCM, ESICM,ACCP,ACEP
• First edition in 2004
• Revision in 2008, 2012
• Original Goal : reduction of sepsis related
mortality by 25 % by 2009 via a 7 point
agenda
Surviving Sepsis Guidelines
A Continuous Move Toward Better Care of Patients With Sepsis
Daniel De Backer, MD1; Todd Dorman, MD, PhD2
Author Affiliations
JAMA. 2017;317(8):807-808. doi:10.1001/jama.2017.0059

3. Implementing
performance
improvement
programme
Developing
guidelines of Care
Improving ICU care
Appropriate use
of treatment
Educating
healthcare
professionals
Improving
diagnosis
Building
awareness
7 POINT
AGENDA

4. SEPSIS 3
SEPSIS
Infection
Dysregulated host response
Life threatening organ
dysfunction

5. Metabolic Abnormality
Cellular Abnormality
Circulatory Abnormality
ADD UP TO THE
MORTALITY OF
SEPSIS
SEPTIC
SHOCK

6. Evaluating Sepsis
• SIRS: Systemic inflammatory response syndrome
• SOFA: Sequential organ failure assessment score
• qSOFA: Quick SOFA

7. SIRS
• Two or more of
Temperature > 38 deg C or < 36 deg C
Heart rate > 90/Min
RR >20/Min or PaCO2 < 32 mm Hg
TLC> 12000/mm3 or <4000/mm3
Bone RC, Balk RA, Cerra FB, et al. American College of Chest Physicians/Society of Critical
Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines
for the use of innovative therapies in sepsis. Crit Care Med. 1992;20(6):864-874.

8. CHANGE IN CONCEPT
EMPHASIS ON
INFLAMMATORY
PROCESS
SIRS
INFLAMMATO
RY
NON
IMMUNOGE
NIC
Singer M, De Santis V, Vitale D, Jeffcoate W. Multiorgan failure is an adaptive,
endocrine-mediated, metabolic response to overwhelming systemic inflammation.
Lancet. 2004;364(9433):545-548

9. SOFA

10. Quick SOFA
ASSESSMENT QUICK SOFA SCORE
SBP < 100 mmHg 1
TACHYPNEA > 22/ MIN 1
GCS<15 1
qSOFA for Identifying Sepsis Among Patients With Infection
François Lamontagne, MD1,2; David A. Harrison, PhD2; Kathryn M. Rowan, PhD2
Author Affiliations
JAMA. 2017;317(3):267-268. doi:10.1001/jama.2016.19684

11. Sepsis and septic shock are medical emergencies
and hence treatment and resuscitation should
begin immediately.

12. INITIAL RESUSCITATION AND
INFECTION ISSUES
• Quantitative resuscitation of sepsis induced
tissue hypoperfusion.
• During first 6 hours of initial resuscitation the
goals to be achieved::

13. MAP > 65
mm Hg
CVP = 8- 12
mm Hg
URINE
OUTPUT >
0.5 ml/kg/hr
CENTRAL
VENOUS
OXYGEN
SATURATION
> 70%

14. HEMODYNAMIC SUPPORT
• Initial resuscitation : 30 ml/kg in first 3 hours
• Further fluid administration depending upon
reassessment of perfusion.
• Crystalloids should be the fluid of choice for initial
resuscitation and subsequent fluid needs.
• Albumin has been suggested if substantial
crystalloids are required

15. MAINTANING CIRCULATION
TARGET MAP SHOULD BE 65 mm Hg
NOR EPINEPHRINE : VASSOPRESSOR OF
CHOICE
ADD VASOPRESSIN OR EPINEPHRINE
TO NORAD TO ACHIEVE TARGET MAP

16. ABOUT OTHER VASOPRESSORS
• Phenylephrine use only if
Serious arrythmias with NORAD
High cardiac output with low BP
Failure to achieve target MAP with std
therapy.
Dopamine only in those who are at low risk of
arrhythmia or absolute bradycardia.

17. Unresponsive shock
• Assessment of cardiac function.
• Dobutamine infusion @ 20mcg/kg/min in case
of MI or ongoing hypoperfusion despite
adequate intravascular fluid replacement.

18. SOURCE CONTROL
• At least 2 sets of blood cultures prior to anti
microbial therapy
• Imaging studies.
1 SET DRAWN
PERCUTANEOUSLY
1 SET FROM
VASCULAR ACCESS

19. ANTIMICROBIAL THERAPY
• Iv administration within 1 hr of recognition.
• Empirical broad spectrum antibiotics.
• Reassess antibiotic therapy daily.

20. Rationale behind empirical therapy*
• Control of immediate sepsis is paramount
• Only 30 % culture reports are positive
• 25 % patients remain culture negative all the
time, but mortality rates doesn’t change.
Ranieri VM, Thompson BT, Barie PS, Dhainaut JF, Douglas IS, Finfer S, et al. Drotrecogin alfa
(activated) in adults with septic shock. N Engl J Med. 2012 May 31. 366(22):2055-64. [Medline].

21. • Generally 7-10 day regime is followed.
• Longer duration regime may be followed in
case of neutropenia, slow clinical response or
undrainable foci of infection.
• Use of procalcitonin levels as marker.

22. COMBINATION EMPIRICAL THERAPY
( 3 to 5 days only)
MDR organisms
like pseudomonas
Septic shock from
pneumococci
Associated with
respiratory failure

23. • Use of aminogycoside in antibiotic
experienced patient rather than FQs or
cephalosporins.
• Use of Vancomycin or linezolid should be
considered (MRSA).
• FDA aprroved new drugs for skin related
sepsis : Ortivancin, Dalbavancin and tedizolid.

24. About Corticosteroids*
• Use of IV steroids is discouraged if fluid
replacement and vasopressors restore
normalcy.
• CORTICUS found no difference in mortality
among patients with use of iv steroids
• If at all needed ; dose of hydrocortisone :: 200
mg/d in 4 divided doses. Discourages Dexa
Kalil AC, Sun J. Low-dose steroids for septic shock and severe sepsis: the use of Bayesian statistics
to resolve clinical trial controversies. Intensive Care Med. 2011 Mar. 37(3):420-9. [Medline].

25. Other supportive therapies
PRBC transfusion only if Hb < 7
gm/dl
Adequate tissue
perfusion
No acute
hemorrhage
Severe
hypoxemia
absent
ERYTHROPOIETIN
SHOULDN’T BE
USED

26. Mechanical ventilation ARDS
Tidal volume > 6
ml/kg
High PEEP to
avoid alveolar
collapse
Propped up
position
DISCOURAGES
USE OF B2
AGONISTS

27. WEANING OFF FROM VENTILATOR
AROUSABLE
HEMODYNAMICALLY
STABLE
SUCCESSFUL
SPONTANEOUS
BREATHING TRIAL

28. GLUCOSE CONTROL
• Commencing insulin when two consecutive
blood glucose readings are more than
180mg/dl.
• Target upper blood glucose level <180mg/dl
rather than 110 mg/dl.
• Monitor every 2 hrly until levels are stable.

29. Other considerations
• SSC suggests against the use of RRT just for raised creatinine or
oliguria.
• Administration of early enteral feeding within 48 hrs of diagnosis of
sepsis.
• Discourage use of TPN alone or in conjunction with enteral feed in
first 7 days.
• Avoid full calorie diet in the initial period.
• Advance enteral feeds as tolerated.
• DVT prophylaxis.