This document provides current guidelines for the management of severe sepsis. It outlines definitions of sepsis, severe sepsis, and septic shock. For initial resuscitation within the first 6 hours, goals include a central venous pressure of 8-12 mmHg, mean arterial pressure above 65 mmHg, urine output of 0.5 mL/kg/hr, and lactate clearance. Fluid resuscitation should begin immediately for hypotension or lactate above 4 mmol/L, administering 30 mL/kg of crystalloids. Antibiotics should be given within 1 hour as broad-spectrum therapy. Vasopressors like norepinephrine should target a MAP above 65 mmHg. Steroids are recommended for septic shock

1. Current Strategy in
Management of
Severe Sepsis
KW HO

2. February 2013 issues of Critical Care
Medicine and Intensive Care Medicine.

3. Outline
Definitions
Investigations
Fluids
Antibiotics
Vasopressors
Steroids
Glucose

4.  Bone RC, et al. Chest 1992; 101: 1644-55

5.  Sepsis = presence (probable or documented) of
infection together with systemic manifestation of
infection
 Severe sepsis = sepsis + organ
dysfuction/tissue hypoperfusion
 Sepsis-induced hypotension = SBP<90
mmHg OR MAP<70 mmHg
 Septic Shock = sepsis-induced hypotension
persisting despite adequate fluid resuscitation
 Sepsis-induced tissue hypoperfusion =
infection-induced hypotension, elevated lactate,
or oliguria

6. Diagnostic Criteria of Sepsis

9. Severe Sepsis
 Sepsis-induced hypotension
 Lactate > upper limits laboratory normal
 Urine output < 0.5 mL/kg/hr for more than 2 hrs
despite adequate fluid resuscitation
 Acute lung injury with Pao2/Fio2 < 250 in the
absence of pneumonia as infection source
 Acute lung injury with Pao2/Fio2 < 200 in the
presence of pneumonia as infection source
 Creatinine > 2.0 mg/dL (176.8 μmol/L)
 Bilirubin > 2 mg/dL (34.2 μmol/L)
 Platelet count < 100,000 μL
 Coagulopathy (INR> 1.5)

10. Significance of Definitions
Mortality Rates
 3% No SIRS Criteria
 7% with 2 SIRS Criteria
 10% with 3 SIRS Criteria
 17% with 4 SIRS Cirteria
 18% with Sepsis
 29% with Severe Sepsis
 40% with Septic Shock

13. Blood C+S
 30–50 % of patients presenting with severe
sepsis or shock have positive blood cultures
 10 mls per bottle
 In patients with indwelling catheters (for more
than 48 hrs), at least one blood culture should
be drawn through each lumen of each
vascular access device (if feasible, especially
for vascular devices with signs of
inflammation, catheter dysfunction, or
indicators of thrombus formation). Obtaining
blood cultures peripherally and through a
vascular access device is an important
strategy. If the same organism is recovered
from both cultures, the likelihood that the
organism is causing the severe sepsis is
enhanced

14. CRP vs Procalcitonin
Advantage of Procalcitonin
 -it rises more quickly at the onset of inflammation
and
 -cleared more quickly as inflammation resolves
 -correlate more closely with the severity of sepsis
<0.05 ng/ml=normal
<0.05-0.5 ng/ml=low risk or local infection
0.5-2 ng/ml=mod risk of severe sepsis
2-10 ng/ml=high risk of severe sepsis
>10 ng/ml = septic shock

18. CRP vs Procalcitonin
 The utility of procalcitonin levels or CRP to
discriminate sepsis from other causes of generalized
inflammation (eg, postoperative, other forms of
shock) has not been demonstrated.
 No recommendation can be given for the use of
these markers to distinguish between severe
infection and other acute inflammatory states
 Giamarellos-Bourboulis EJ et al. J Crit Care 2004; 19:152–157
 Uzzan B et al. Crit Care Med 2006; 34:1996–2003
 Tang BM et al. Lancet Infect Dis 2007; 7:210–217

19. Q1)
What fluids and what BP targets are you
aiming for ?
A) NS- aim for SBP > 120
B) NS- aim for DBP > 80
C) NS- aim for MAP > 65
D) Gelafundin- aim for MAP > 65
E) Albumin man… sure problems settle

20. Q2)
What CVP targets are you aiming for ?
A) CVP 5-10 cmH20
B) CVP 8-12 cm H20
C) CVP 10-15 cm H20
D) CVP 8-12 mmHg
E) ???? mmHg or cm H20 ..

22. Initial Resuscitation(First 6 Hours)
 Begin resuscitation immediately in
patients with hypotension or elevated
serum lactate 4 mmol/L
 Resuscitation goals
–CVP 8–12 mm Hg
–Mean arterial pressure > 65 mm Hg
–Urine output 0.5 mL/kg/hr
–Central venous (superior vena cava)
oxygen saturation 70% or mixed venous
65%
–Targets to lower lactate

23. Mortality Rate
 both hypotension and lactate ≥ 4 mmol/L
(46.1%)
 Hypotension alone (36.7%)
 Lactate ≥ 4 mmol/L alone (30%)

24. Fluid Therapy
Crystalloid
30ml/kg
More rapid or greater amounts may be
needed
Fluid challenge technique
Assess BP, HR, pulse pressure

25. What about Colloid??
 A meta-analysis of 56 randomized trials found no
overall difference in mortality between
crystalloids and artificial colloids (modified
gelatins, HES, dextran) when used for initial fluid
resuscitation
Perel P et al.Cochrane Database Syst Rev 2011; 3:CD000567
 Hydroxyethyl starches (HES) are NOT
recommended
---No difference in mortality
---Increased risks of RRT

26. What about Albumin???
 Add albumin to initial fluid resuscitation
with crystalloid when pts need a
substantial amount of crystalloid

27. Antibiotics
 Empirical antibiotics
Should be broad spectrum to cover the
likely pathogens
To be administered within first hour
 Antibiotics should be reassessed daily and
de-escalate to prevent resistance
 Typical duration 7-10 days
 Combinations of antibiotics may be needed for
pts with difficult-to-treat or multi-drug
resistant pathogens

29. Vassopressors & Inotropic Therapy
 Target MAP > 65mmHg
 First choice: Noradrenaline
 Adrenaline can be added when additional
agent is required
 Vasopressin can be added to
noradrenaline
---0.03 unit/min

30.  Dopamine
as an alternative to noradrenaline only in
pts with low risks of tachyarrythmias and
bradycardias
Not be used for renal protection
 Dobutamine
Especially in the presence of myocardial
dysfunction as suggested by elevated
cardiac filling pressures and low cardiac
output

31. Noradrenaline Dopamine
Increases vasoconstriction Increases stroke volume and
heart rate
Little change in heart rate Causes more tachycardia and
more arrhythmogenic
More potent – more useful in
reversing hypotension
Less potent

32. Steroid….To give or not to give??
 IV hydrocortisone be given to adult septic
shock patients if blood pressure is
inadequate with appropriate fluid
resuscitation and vasopressor therapy
 IV hydrocortisone not be given to adult
septic shock patients if blood pressure is
adequate with appropriate fluid
resuscitation and vasopressor therapy

33.  Corticosteroid therapy
o IV hydrocortisone 200mg/day in
continuous infusion
 Corticosteroids should not be administered
in the absence of shock
 Only when fluids and vasopressors are
inadequate to restore haemodynamic
instability

34. Blood Sugar Control
 Commencing insulin dosing when two
consecutive blood glucose levels are > 10
mmol/L.
 This approach should target an upper blood
glucose level ≤ 10mmol/L rather than an
upper target blood glucose ≤ 6.2 mmol/L
(1A).
 Blood glucose values be monitored every 1 to
2 hrs until glucose values and insulin infusion
rates are stable, then every 4 hrs thereafter
(1C).

35. THANK YOU