1. The document provides recommendations from the Surviving Sepsis Campaign for the management of septic shock and multiorgan failure. 2. Key recommendations include early goal directed therapy within the first 6 hours to achieve specific hemodynamic and tissue perfusion targets through fluid administration and vasopressors. 3. Early antibiotic administration along with identifying and controlling the infection source are also emphasized, as well as glycemic control, venous thromboembolism prophylaxis, and consideration of recombinant human activated protein C for severe cases.

1. SEPTIC SHOCK AND
MULTIORGAN FAILURE
RECOMMENDATIONS FROM THE
SURVIVING SEPSIS CAMPAIGN
(Crit Care Med 2008; 36:296-327)
Joe Heit, MSc, MD, FACP

2. DEFINITIONS: 1
SIRS: temperature - >38 or <36 degrees C
pulse - > 90
respirations - > 20
- or PaCO2 <32 torr
WBC - > 12,000 or < 4,000
- or < 10% bands (immature PMN)
SEPSIS: SIRS + evidence of infection

3. Infection
SIRS
Bacteria
Viral
Fungal
Protozoa
Trauma
Burns
Pancreatitis
Sepsis
Other

4. DEFINITIONS: 2
SEPSIS: SIRS + evidence of infection
SEVERE SEPSIS: sepsis + evidence of
organ dysfunction
SEPTIC SHOCK: sepsis + systolic
BP < 90 after adequate
volume replacement

5. DEFINITIONS: 3
MULTIORGAN FAILURE (MOF)
Evidence of dysfunction in more than one organ. No
universally recognized parameters, but the following
markers utilized often.
PO2/FiO2
Creatinine
Platelet count
Glascow coma score
Serum bilirubin
LACTATE

6. INSULT
Severe infection (sepsis)
SIRS
Inflammation
Proinflammatory system Antiinflammatory system
Cellular injury
MODS
Cellular repair
Recovery

7. MANAGEMENT
(SURVIVING SEPSIS CAMPAIGN GUIDELINES)
• Early goal directed therapy (first 6 hours)
• Diagnosis
• Antibiotics
• Source - identify and control measures
• Supportive strategies

8. EARLY GOAL DIRECTED
THERAPY
Low blood pressure = Shock

9. EGDT: Resuscitation for shock
(within the first 6 hours)
•CVP 8-12 cm (12-15cm if ventilated)
•MAP > 65 mm Hg
•MVO2 > 65% (>70% if from SVC)
•Urine Output > 0.5cc/Kg/hr

10. EGDT: resuscitation
(within the first 6 hours)
• Fluids can be crystalloids or colloids
– No evidence to prefer either choice
– Generally 1000cc NS or 300-500 cc colloids
• Transfuse to hematocrit of 30%
– Only within the first 6 hours
• Consider dobutamine if inadequate response to the
above interventions

11. DIAGNOSIS
• Appropriate cultures
– Include cultures from any intravascular devices if
present for > 48 hours (timed if possible)
– At least 2 blood cultures
• Imaging studies as clinically indicated

12. ANTIBIOTICS
• First challenge is to get appropriate cultures
• Second challenge is to balance these 2:
1. Initiation of antibiotics that are broad enough and effective
enough (mortality cost if initial antibiotics are not active enough
against pathogens)
2. Avoidance of unnecessarily broad and unnecessary numbers of
antibiotics
• Third challenge is to deescalate antibiotics as soon as
appropriate (usually after culture results)
• Fourth challenge is to avoid continuing antibiotics too
long (generally stop after 7-10 days)

13. SOURCE CONTROL
•4 D’s
–Drainage (chest, abdomen, joints)
–Debridement (devitalized/infected tissue)
–Device Removal (IV, urinary catheters, shunts, any
foreign body)
–Definitive control (usually means surgical resection)

14. FLUIDS
•Adequate vascular access
•Administer to goals - CVP, MAP, urine output
•We usually underestimate volume needed
–Remember EGDT recommendations
•FCCS guidelines allow administering fluids until something
good (meeting targets as above) or something bad (hypoxia starts
or worsens or chest exam worsens)
•Auto transfuse by lifting legs an quick, reversible way to give a
‘colloid’ challenge

15. VASOPRESSORS
When adequate fluids are not enough.
When early transfusion is not enough.
Even when dobutamine is not enough.
When all else fails,
VASOPRESSORS!

16. VASOPRESSORS
•First concern - adequate IV access; the risk and possible
diminished effectiveness of peripheral access for administration
makes central access a priority
•Second concern - Know which receptors you’re stimulating
with which drug
–SSC guidelines recommend dopamine or norepinephrine as first line
vasopressors for septic shock
–Vasopressin as a second line agent
–Epinephrine as a second line agent
–Neosynephrine as a third line agent

17. VASOPRESSORS
•Target MAP 65 mm Hg or greater
•Target should also be improved end organ
function and drop in serum lactate
central line, arterial line

18. STEROIDS
Short answers:
•No proven mortality benefit for steroids in septic shock or
MOF (CORTICUS study)
•Mortality cost for high dose steroids in septic shock
•Acceptable to utilize stress dose steroids (150-300 mg/day of
hydrocortisone if shock not responsive to all other
interventions
•ACTH stimulation tests should not be used

19. GLYCEMIC CONTROL
•Recommend Insulin to maintain glucose at < 150mg/dl
Optimal range for control not known
Optimal protocol for glycemic control not established
Only randomized control trial that showed decreased mortality with
tight control was in Cardiovascular surgery patients
Only RCT in a Medical ICU showed no decreased mortality with
tight glycemic control, but there was a morbidity benefit and a lower
LOS in the ICU and hospitalization
There was a mortality benefit with tight glycemic control I several
non-randomized trials

20. GLYCEMIC CONTROL
Cautions with tight glycemic control:
 Increased mortality with hypoglycemic events
 Fingerstick methods of glucose measurement
(point of care testing) may overestimate
actual blood glucose levels

21. GI PROPHYLAXIS
Recommendations are:
 All critically ill patients should receive GI
prophylaxis
 H-2 blockers first line
 Proton pump inhibitors second line
 Sulcrafate less effective than H-2 blockers or PPI

22. DVT PROPHYLAXIS
Recommendations are:
All patients with severe sepsis receive DVT
prophylaxis
•UFH or LMWH appropriately dosed
Mechanical compression devices used if UFH or
LMWH contraindicated

23. RENAL REPLACEMENT
Recommendations are:
No evidence of a mortality benefit when CRRT
compared to HD in this patient population
Some studies suggested that fluid management was
improved with CRRT

24. RECOMBINANT HUMAN
ACTIVATED PROTEIN C
Recommendations are:
Use in patients with MOF and/or APACHE II score >25
• 3 large trials (PROWESS, ADDRESS, ENHANCE)
• A RCT currently underway in Europe of rhAPC v. placebo
• Bleeding risk

25. BLOOD PRODUCT
ADMINISTRATION
Recommendations are:
Maintain Hgb 7-9 g/dl
•No mortality benefit with higher Hgb (10-12)
•Accumulating evidence of increased morbidity (nosocomial infection)
with blood product administration
Erythropoietin not be used in these patients unless anemia
secondary to other causes that have EPO indications (e.g.. Renal
failure)
Use FFP to correct bleeding or if planned procedures with
bleeding risk, NOT solely to correct elevated INR

26. THESE STEPS YOU CAN
INSTITUTE …
TOMORROW