Severe sepsis

1. SSC 2021 Updates
Ventilation and additional therapy
DR. Mohamed Saber
ICU Physician
Meeqat General hospital - KSA
Part 3

2. Conservative oxygen targets (generally defined as PaO2 55–70
mmHg; SpO2 88–92%)
Types of respiratory failure:
Type 1 (Hypoxemic): PaO2 < 60 mmHg
Type 2 (Hypercapnic): PCO2 > 50 mmHg ± PaO2 < 60mmHg

3.  WOB mild improvement
 FiO2 95%-100%
 Can avoid NIV
complications
 Mild PAP
 Can improve WOB
 FiO2 up to100%
 NIV complications:
• Increased risk of gastric insufflation and
aspiration
• Facial skin breakdown
• Excessively high tidal volumes
• Patient discomfort related to inability to
eat or effectively phonate during therapy.
 PAP
Both therapies avoid the complications of intubation
and invasive mechanical ventilation

4. If NIV is used for patients with
sepsis-associated hypoxic
respiratory failure, we suggest
monitoring for an early
reduction in work of
breathing and close monitoring
NIV may be able to achieve similar
physiologic benefits including
improved gas exchange and reduced
work of breathing in select patients,
while avoiding complications
associated with intubation, invasive
ventilation, and accompanying
sedation.
In contrast, NIV can cause mask-
related discomfort, unrecognized
patient-ventilator asynchrony due to
leaks, and gastric insufflation.
The main risk of NIV for the
indication of acute respiratory failure
is the potential for delaying needed
intubation

5. According to Berlin definition (2012):
Mild ARDS (Previously Acute lung injury): PO2/FiO2 =
200-300
Moderate ARDS: PO2/FiO2 = 100-200
Severe ARDS: PO2/FiO2 < 100
Example: PaO2 = 90 mmHg on FiO2 60% (0.6)
So P/F ratio = 90/0.6 = 150 → Moderate ARDS

7. Recommended:
Set the ventilator to CPAP mode and
increase the pressure to 30–40 cm
H2O for 30–40 s
Not Recommended:
 Use pressure controlled ventilation
 Set respiratory rate to zero and turn off
apnea alarm
 increase PEEP to 40 cmH20 for 40 seconds

9. NBMA benefits:
 May improve chest wall compliance
 Prevent respiratory dyssynchrony
 Reduce peak airway pressures
 May reduce oxygen consumption by decreasing the work of breathing

13. Liberal (Hemoglobin threshold, < 9 g/dl)
Restrictive strategy (Hemoglobin threshold, < 7 g/gl)

17. Eligible patients are those with septic shock
(within 48 h of the onset of vasopressor therapy
and AKI
AKI is defined as oliguria (< 0.3 ml/kg/h for ≥
24 h), anuria for 12 h or more, or a serum
creatinine level 3 times baseline accompanied by
a rapid increase of ≥ 0.5 mg/dl.
Indications for
dialysis
Uremic complications
Refractory academia
Refractory fluid
overload
Hyperkalemia).

22. RECAP
1.No sufficient recommendation of using Target SpO2 88-92% in Adults with
sepsis-induced RF.
2.For adults with sepsis-induced RF: We suggest using HFNC > NIV
3.For adults with sepsis-induced RF: No sufficient recommendation for the use
of NIV over IPPV
4.Use of low Vt (<6ml/kg) in sepsis-induced ARDS
5.Use of low Vt (6-8ml/kg) in sepsis-induced RF without ARDS
6.For sepsis-induced ARDS: use an upper limit gal for pPlateau of 30 cm H2O
7.For sepsis-induced ARDS: use of Higher PEEP > Lower PEEP
8.For sepsis-induced moderate-severe ARDS: using traditional recruitment
maneuvers
9.We recommend against Against using incremental PEEP titration/strategy

23. 12.For adults with sepsis-induced severe ARDS: using VV ECMO when
conventional MV fails
13.For adults with septic shock: using IV 200mg hydrocortisone at
norepinephrine dose ≥ 0.25 mcg/kg/min at least 4 h after initiation.
14.For adults with sepsis or septic shock: we suggest against Polymexin B
hemoperfusion
15. No sufficient evidence to make a recommendation on the use of other blood
purification techniques.
16.For adults with sepsis or septic shock we recommend using Hb threshold <
7g/dl not Hb < 9 g/dl
17.For adults with sepsis or septic shock: We suggest using IVIG
15.For adults with sepsis or septic shock/at risk of GIB: We suggest using stress
Ulcer prophylaxis
16.For adults with sepsis or septic shock: we recommend using pharmacologic

24. 17.For adults with sepsis or septic shock and AKI who require renal replacement:
We suggest either continuous or intermittent renal replacement therapy.
18.We recommend against RRT without indication.
19.For adults with sepsis or septic shock: We recommend initiating insulin
therapy at a glucose of ≥ 180mg/dL
20.For adults with sepsis or septic shock: We suggest against using IV vitamin C.
21.For adults with sepsis or septic shock and hypoperfusion-induced lactic
academia We suggest against using Na HCO3
22.For adults with septic shock: pH ≤ 7.2 + AKI (AKIN score 2 or 3) We suggest
Using Na HCO3.
23.For adults with sepsis or septic shock: We suggest early (within 72 h)
initiation of enteral nutrition.