Sepsis and septic shock management guidelines 2019

Sepsis and Septic Shock
management guidelines 2019
Speaker - Razi Shahid
Modrater- Dr Mukesh Prasad
29/01/2020
1
• Surviving Sepsis
Campaign Guidelines
• Crit Care Med 2017;
45(3): 486-552
• Published: 3/16/2017
• https://www.sccm.org/Su
rvivingSepsisCampaign/
Guidelines/Adult-Patients
• October 2019

2236
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
5.Antimicrobial therapy
6.Source Control
7.Fluid Therapy
8.Inotropes and vasopressors
9.Steroid Therapy
10.Supportive Therapy
a)Blood Products
b)Platelets
c)Mechanical Ventilation
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
g)Deep vein thrombosis
h)Nutrition
11.GOALS OF CARE
12.Adjuvant therapies in sepsis
a)Activated protein C
b)Immunoglobulins

Definition (3rd International Consensus
Definitions for Sepsis and Septic Shock)
• Sepsis is now defined as life-threatening organ
dysfunction caused by a dysregulated host response to
infection.
• Septic shock is a subset of sepsis with circulatory and
cellular/metabolic dysfunction associated with a higher
risk of mortality
• Organ Dysfunction: Increase of 2 or more points in
SOFA Score (Sepsis-related/Sequential Organ Failure
Assessment)
3
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
12.Adjuvant therapies in
sepsis

Infection: the invasion of normally
sterile tissue by organisms resulting in
infectious pathology
4
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

5
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Surviving Sepsis Guidelines 2016
7
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

8
Surviving Sepsis Guidelines 2019

2019 update to SSC bundle of care
1. Measure lactate level:
• Represent tissue hypoperfusion
• If initial lactate >2 mmol/L → Remeasured within 2-4 hours
to guide
2. Blood Cultures: At least 2 sets(aerobic and anaerobic)
before starting antibiotics, or not more than 45 minutes of
therapy.
• 2 samples:
• One from percutaneous access
• One from previously(>48 hours) inserted vascular access
device
9
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

3. Administer broad spectrum antibiotics
4. Administer IV Fluids
• Crystalloid 30 ml/kg to be completed within 3 hours of recognition.
5. Vasopressors:
• Urgent restoration of an adequate perfusion pressure to the vital organs
should not be delayed.
• Should be commenced in 1st hour if MAP is not ≥ 65 mm Hg after
fluid resuscitation
10

Initial Resuscitation Goals within first 6
hours
• CVP - 8-12 mm Hg
• MAP ≥ 65 mm Hg
• Urine Output - ≥ 0.5 ml/kg/hr.
• Central Venous (SVC) or Mixed Venous Oxygen Saturation 70% or
65% respectively
• In patients with elevated lactate, target to decrease lactate
11

Antimicrobial therapy
• Should be started within 1st hour of recognition of sepsis
or septic shock.
• Regimen should be reassessed daily for potential de-
escalation.
• Use of low Procalcitonin levels or similar biomarkers to
assist the clinician in the discontinuation of empiric
antibiotics in patients who initially appeared septic, but
have no subsequent evidence of infection.
• Combination empirical therapy→ neutropenic and severe
sepsis, difficult to treat, multidrug- resistant bacterial
pathogens(Acinetobacter and Pseudomonas)
12
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

• Severe infections associated with respiratory failure and septic shock
(Pseudomonas) → combination therapy : extended beta lactam and
aminoglycosides/fluoroquinolones
• Strep. Pneumoniae : Beta-lactam with macrolides
• Emperic combination therapy should not be administered for >3-5
days → de-escalation to appropriate single therapy.
• Duration of therapy: 7-10 days (longer for slower response)
13

Source Control
• Source of infection should be diagnosed or
excluded as early as possible (< 12 hours)
• If peripancreatic necrosis present: delay definitive
intervention
• Drainage (Percutaneous >> Surgical) of abscess
• Remove IV access devices if found as source
14
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Fluid Therapy
• Crystalloid (RL, NS) as fluid @ 30 ml/kg within 3
hours
• Goal is to reach target MAP (≥ 65 mm Hg )
• Albumin:
• Used in fluid refractory septic shock and if >0.2
mcg/kg/min of Norad is required
• Dose: 100-200ml of 20% Human Albumin within
30-60 minutes
15
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Crystalloids or Albumin
• In the absence of hemorrhagic shock, we suggest using
isotonic crystalloids rather than colloids (albumin or
starches) as initial management for expansion of
intravascular volume in patients at risk for AKI or with
AKI. (2B)
• SAFE: In patients in the ICU, use of either 4 percent
albumin or normal saline for fluid resuscitation results in
similar outcomes at 28 days.
• ALBIOS : 20% albumin vs saline: no difference in
mortality in 28 & 90 days.
1. N Engl J Med 2004;350:2247-56.
2. Hyperoncotic colloids and acute kidney injury: a meta-analysis of randomized
trials: Albumin renoprotectiveCrit Care 2010;14(5):R191.
3. N Engl J Med 2014; 370:1412-1421 16
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Inotropes and vasopressors
• Target MAP ≥ 65 mm Hg
• Noradrenaline - 1st Choice
• Adrenaline: when additional agent is needed
• Vasopressin 0.03 units-0.04 units/min: added to NE
with intent of either raising MAP or decrease Norad dose
• Low dose vasopressin not recommended
• Dopamine: alternative to Norad only in selected
patients
• Patients with low risk of tachycardia or absolute
relative bradycardia
17
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

• Phenylephrine: Not recommended except: NE is a/w serious
arrythmias
• Cardiac output is known to be high as BP persistently low
• Salvage therapy when combined inotropes/vasopressor drugs have
failed
• Dobutamine: Upto 20 mcg/kg/min in presence of:
• Myocardial dysfunction as suggested by elevated cardiac filling
pressures and low cardiac output
• Ongoing signs of hypoperfusion, despite achieving adequate
intravascular volume and adequate MAP
• All patients requiring vasopressors have an arterial catheter placed
18

Comparison of Dopamine and Norepinephrine in
treatment of shock
• Adverse events were more with dopamine(arrhythmias-AF) than NE
1. De Baker D et al : N ENGL J MED;2010(SOAP investigators)
prospective,randomised,double blind multicentre trial
19

• Vasopressin
• Pro
• ↑ BP, less arrhythmias, spares vasopressors, improves renal function
• Con
• ↓CO, impairs liver function, promotes gut ischemia, high doses detrimental
20

Steroid Therapy
• NOT recommended to treat septic shock if fluids or
vasopressors can maintain MAP (Hemodynamic stability)
• If this is not achievable, Inj. Hydrocortisone 200 mg/day
Hydrocortisone therapy for patients with septic shock.
No mortality benefit with steroid therapy for patients in septic
shock with relative adrenal insufficiency (non-responders to a
corticotropin test). In the hydrocortisone group, shock was
reversed earlier than in the placebo group; however, there were
more episodes of superinfection, including new sepsis and septic
shock.
1. Sprung CL, Annane D, Keh D, et al; CORTICUS Study Group: N Engl J Med
2008; 358:111–124
21
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Other Supportive Therapy
• Infection Prevention:
• Limited patient contact
• Hand washing
• Prevent Ventilator associated pneumonia
• Propped Up position
• Chlorhexidine mouth wash
• We suggest placement of post-pyloric feeding tubes in
critically ill patients with sepsis or septic shock with
feeding intolerance or who are considered to be at high risk
of aspiration.
22
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Blood Products
• Once tissue hypoperfusion has resolved
• RBC transfusion only if Hb <7 g/dl
• NOT to use erythropoietin, antithrombin
• FFP not to be used to correct lab clotting
abnormalities in absence of bleeding or planned
invasive procedure.
23
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Administer platelets prophylactically
if:
• Platelets < 10,000/uL in absence of apparent
bleeding
• Platelets < 20,000/uL if risk of bleeding
• Platelets < 50,000/uL if active bleeding, surgery
24
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Mechanical Ventilation of Sepsis induced
ARDS
• Target TV 6 ml/kg predicted body weight
• Head end of bed 30-45 ° elevated
• Plateau pressures initial upper limit goal in passively inflated lung
≤ 30 cm water
• Apply PEEP
• For Severe Hypoxemia: use recruitment maneuvers
• Prone Positioning: PaO2/FiO2 ratio ≤ 100 mm Hg
• In absence of specific indications (bronchospasms) DONOT use
beta-2 agonists in sepsis induced ARDS
• Avoid NMBAs as possible but a short course(<48 hr) can be used
in early sepsis induced ARDS and a PaO2/FiO2 ratio ≤ 150 mm Hg
25
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

In this multicenter, double-blind trial, 340 patients
presenting to the intensive care unit (ICU) with an onset of
severe ARDS(Pa02/FiO2<150,PEEP> 5 cm) within the
previous 48 hours were randomly assigned to receive, for 48
hours, either cisatracurium besylate (178 patients) or placebo
(162 patients). The crude 90-day mortality was 31.6% in the
cisatracurium group and 40.7% in the placebo group
(P=0.08). The rate of ICU-acquired paresis did not differ
significantly between the two groups.
1. ACURASYS Study Investigators NEJM 2010
26
Neuromuscular Blockers in Early Acute
Respiratory Distress Syndrome

ECMO
Efficacy and economic assessment of conventional ventilatory support
versus extracorporeal membrane oxygenation for severe adult
respiratory failure (CESAR): a multicentre randomised controlled trial
Conclusion
6 month survival without disability: 63% ECMO group vs. 47%
conventional group.
Quality-adjusted life years at 6 months: ECMO group showed a
gain of 0.03 gain
1. Lancet. 2009 Oct 17;374(9698):1330
27

• If 2 consecutive blood glucose levels are >180 mg/dl,
commence insulin dosing
• Target: ≤ 180 mg/dl
• Glucose monitoring every 1-2 hours until glucose values
and insulin rates are stable and then every 4 hours
thereafter.
A blood glucose target of 180 mg or less per deciliter
resulted in lower mortality than did a target of 81 to 108 mg
per deciliter.
1. The NICE-SUGAR Study Investigators N Engl J Med 2009
28
Glucose Control in Critically Ill
Patients
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

We suggest against the use of sodium bicarbonate
therapy to improve hemodynamics or to reduce
vasopressor requirements in patients with
hypoperfusion-induced lactic acidemia with pH ≥
7.15 (weak recommendation, moderate quality of
evidence).
NOT to be used if pH ≥ 7.15
29
Bicarbonate
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

STRESS ULCER PROPHYLAXIS
1.We recommend that stress ulcer prophylaxis be given to
patients with sepsis or septic shock who have risk factors
for gastrointestinal (GI) bleeding (strong recommendation,
low quality of evidence).
2.We suggest using either proton pump inhibitors (PPIs) or
histamine-2 receptor antagonists (H2RAs) when stress ulcer
prophylaxis is indicated (weak recommendation, low
quality of evidence).
3.We recommend against stress ulcer prophylaxis in
patients without risk factors for GI bleeding (BPS)
4.We suggest the use of prokinetic agents in critically ill
patients with sepsis or septic shock and feeding intolerance
(weak recommendation, low quality of evidence).
30
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Deep vein thrombosis prophylaxis
1. Patients with severe sepsis receive daily low-
molecular weight heparin (LMWH) versus twice
daily UFH.
2. If creatinine clearance is <30 mL/min use UFH
3. Those who have a contraindication for heparin
use should receive mechanical prophylactic
treatment, such as graduated compression
stockings or intermittent compression devices.
31
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Nutrition
1. • Oral or enteral feeding as tolerated within the
first 48 hours of diagnosis
2. • Low dose feeding(upto 500 calories/day) in 1st
week, advancing only as tolerated.
3. • Use IV glucose and enteral nutrition rather than
TPN alone in first 7 days
4. Address goal of care as early as possible, but no
later than 72 hours of admission in ICU
32
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

GOALS OF CARE
1-We recommend that goals of care and prognosis be
discussed with patients and families.
2 - We recommend that goals of care be incorporated
into treatment and end-of-life care planning, utilizing
palliative care principles where appropriate (strong
recommendation, moderate quality of evidence).
3 - We suggest that goals of care be addressed as
early as feasible, but no later than within 72 h of ICU
admission.
33
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

• Activated protein C (drotrecogin alfa)
• Inhibit the production of inflammatory cytokines
(TNF-α, IL-1, IL- 6)
1. ADDRESS TRIAL
Abraham E, Laterre PF, Garg R, et al; N Engl J Med 2005; 353:1332–
1341- 28-day mortality rate from all causes was 17% on placebo vs. 18.5%
on APC(STOPPED EARLY FOR FUTILITY)
34
Adjuvant therapies in sepsis
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Immunoglobulins
1. IgM was decreased only when patients deteriorated
from severe sepsis to septic shock. Serial
measurements in these patients, beginning from the
early start of vasopressors, showed that the
distribution of IgM over time was significantly
greater for survivors than for non-survivors.
2. SSC - We suggest not using intravenous
immunoglobulins in adult patients with severe sepsis
or septic shock.
35
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Ulinastatin
1. Intravenous administration of ulinastatin
(human urinary trypsin inhibitor) in severe
sepsis: a multicenter randomized controlled
study.
2. Intravenous administration of ulinastatin
reduced mortality in patients with severe
sepsis.
1. Karnad DR, Bhadade R, Verma PK, Moulick ND, Daga MK, Chafekar ND,
Iyer S (2014) Intensive Care Med 40:830–838.
36
1.Definition
2.Pathology
3.SOFA scoring
4.Guidelines
a) 2016
b) 2019
6.Source Control
7.Fluid Therapy
9.Steroid Therapy
a)Blood Products
b)Platelets
d)Glucose Control
e)Bicarbonate
f)Stress Ulcer
h)Nutrition
11.GOALS OF CARE
b)Immunoglobulins

Sepsis and septic shock management guidelines 2019

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