maternal_survival_sepsis_guidelines_mgmh_20_2.pptx

MANAGEMENT OF SEPSIS AND
SEPTIC SHOCK
Padmaja Durga
Professor
Department of Anesthesiology and Intensive Care
Nizam’s Institute of Medical Sciences
Hyderabad

CASE PRESENTATION
• 26 yo, G2P1, hospitalised with preterm rupture of membranes at
32 weeks
• Betamethasone was administered for fetal lung maturity
• Day 3: felt warm with heart racing
• Vital signs: T = 97.8F, HR 130/min; RR 22/min; BP 115/62;
FHR=160/min
• Contractions every 3 minutes
• Cervical exam 3/80/-1

CASE #1 (CONT)
• WBC = 22,000/mm3
• Patient screen positive but no sepsis confirmation performed due
to no fever or clear source of infection
• Elevated WBC attributed to betamethasone 4 days prior
• 2 hrs later- cesarean performed for non-reassuring fetal heart rate
tracing

CASE #1 (CONT)
• Infant Apgar- 6/8
• In recovery room, temperature 101.8F, HR 120/min; BP 88/40
(MAP 56 mm Hg); RR 36
• Rapid Response Team (RRT) called
• IV fluids at 30 mL/kg + zosyn (piperacillin and tazobactam)
administered
• Lactate = 9 mmol/L, urine output 10 mL/hr

CASE #1 (CONT)
• Patient bleeding at incision site
• Patient transferred to ICU and stabilized on broad spectrum
antibiotics and supportive care

FINAL DIAGNOSIS:
• Septic shock due to chorioamnionitis with bacteremia with Group B
streptococci and E. coli

CASE #1: LESSONS LEARNED
• No fever initially but patient met initial screening criteria for sepsis
• With lack of sepsis confirmation testing, missed opportunities for
earlier treatment with fluids and broader spectrum antibiotics to
avoid progression to septic shock
• Elevated white count explained away as due to betamethasone

MANAGING MATERNAL SEPSIS:
EA R LY WA R N IN G C R ITER IA TO EC MO
• Scope of Discussion
• Vulnerability Of Pregnant Women To Sepsis
• The Utility Of Early Warning Criteria In The Identification Of The Septic
Parturient
• The Immediate Resuscitation and Antibiotic Management Of Suspected
Sepsis,
• Latest Understanding In The Ventilatory Management Of Parturient With
Sepsis.

MATERNAL SEPSIS- THE GROWING
MENACE
• Approximately 75,000 pregnant women die each year because of
sepsis
• Great majority of these deaths occur in low-income countries
• Maternal mortality from sepsis has increased in the last 15 years to
an incidence rate of 1.13 per 100,000 cases, nearly doubling in
incidence from 0.65 per 100,000 cases 15 years ago.
• The incidence of severe sepsis 21 per 100,000 deliveries

LEADING CAUSES OF MATERNAL
SEPSIS
Antepartum
Intrapartum/
Immed. Postpartum
Post-discharge
Septic abortion
Chorioamnionitis/
intraamniotic infection
Pneumonia/influenz
a
Chorioamnionitis/
intraamniotic
infection
Endometritis Pyelonephritis
Pneumonia/
influenza
Pneumonia/influenza
Wound Infection/
Necrotizing Fasciitis
Pyelonephritis Pyelonephritis Mastitis
Appendicitis
Wound Infection/
Necrotizing Fasciitis
Cholecystitis

RISK FACTORS FOR SEPSIS IN
PREGNANCY
• Antenatal
• Obesity
• Anemia
• Immunosuppression
• Diabetes
• History of pelvic infection
• History of Group B streptococcal infection,
• Invasive procedures such as amniocentesis and cervical cerclage,
prolonged rupture of membranes
• Group A streptococcal infection in close contacts

RISK FACTORS FOR SEPSIS IN
PREGNANCY
• Puerperal
• Induction of labour
• Instrumented or caesarean delivery
• Preeclampsia
• Postpartum haemorrhage
• Mastitis

WHY ARE PREGNANT WOMEN MORE
SUSCEPTIBLE TO SEPSIS?
• Increased Susceptibility
• Immunosuppressed state
• Asymptomatic bacteremia
• Predisposition to pyelonephritis
• Changes in vaginal pH and flora
• Increased interventions

WHY IS THE RESPONSE TO SEPSIS
SEVERE?
• Increased Severity
• Rapid myocardial dysfunction
• Predisposition to pulmonary edema and ARDS
• Poor metabolic compensation for acidemia
• Increased oxygen consumption

THE IMPACT OF MATERNAL SEPSIS
• Fatality rate of 7% to 8%..
• Severe sepsis with organ involvement has a 20% to 40% mortality
rate
• Increases to 60% in the presence of septic shock

SEPSIS
• Sepsis is life-threatening organ dysfunction caused by a
dysregulated host response to infection
• Early identification and appropriate management in the initial hours
after the development of sepsis improve outcomes.
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic
Shock 2021, published in Critical Care Medicine (DOI: https://doi.org/10.1097/
CCM.0000000000005337)

DEFINITION OF SEPSIS
• Sepsis is defined as life-threatening organ dysfunction caused by a
dysregulated host response to infection.
• Organ dysfunction can be identified as an acute change in total SOFA score
2 points consequent to the infection
• Patients with septic shock can be identified with a clinical construct
of sepsis with persisting hypotension requiring vasopressors to
maintain MAP 65 mm Hg and having a serum lactate level >2
mmol/L (18 mg/dL) despite adequate volume resuscitation
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3): 2016

OBSTETRIC SPECIFIC CONSENSUS
DEFINITION (2017)
• “Maternal sepsis is a life-threatening condition defined as organ
dysfunction resulting from infection during pregnancy, childbirth,
post-abortion, or postpartum period.”

SEPSIS IN PREGNANCY
• Sepsis and septic shock be considered medical emergencies and
treatment and resuscitation begin immediately (GRADE 1B)
• Providers should consider the diagnosis of sepsis in pregnant
patients with otherwise unexplained end-organ damage in the
presence of an infectious process, regardless of the presence of
fever (GRADE 1B)

SURVIVING SEPSIS
GUIDELINES-2021
Guidelines and recommendations
Surviving Sepsis Campaign: International Guidelines for Management of
Sepsis and Septic Shock 2021, published in Critical Care Medicine

• American College of Obstetricians and Gynecologists
• Society for Maternal-Fetal Medicine,
• Royal Australian and New Zealand College of Obstetricians and
Gynaecologists
• Society of Obstetric Medicine of Australia and New Zealand
• Royal College of Obstetricians and Gynaecologists
• Royal College of Physicians of Ireland Institute of Obstetricians
and Gynaecologists
• World Health Organization. Guidelines

PREGNANCY-SPECIFIC SEPSIS
BUNDLES
• Pregnancy-specific sepsis bundles have been extrapolated from those
developed for the general population
• Takes into consideration physiological variables of pregnancy.
• The key elements emphasised
• Clinicians to have a low index of suspicion to aid early recognition,
• Perform essential investigations and monitoring (cultures, blood lactate and
hourly urine output)
• Commence essential treatment (oxygen, intravenous fluids and antibiotics) –
‘the sepsis six’.
• In addition to promoting initiation of the bundle, the importance of critical
care outreach involvement is emphasised
• Engagement with relevant multidisciplinary specialities

SCREENING AND EARLY TREATMENT
• A performance improvement program for sepsis, including sepsis screening
for acutely ill, high-risk patients and standard operating procedures for
treatment
• Sepsis screening tools are designed to promote early identification
of sepsis
• Sequential Organ Failure Assessment (SOFA) criteria
• Systemic inflammatory response syndrome (SIRS) criteria
• Quick Sequential Organ Failure Score (qSOFA)
• National Early Warning Score (NEWS)
• Modified Early Warning Score (MEWS)

OBSTETRICALLY MODIFIED SOFA
SCORE
System parameter Score 0 Score 1 Score 2
Respiration
(PaO2/FiO2 )
≥400 300 to 400 <300
Coagulation
Platelets (x 10 /l)
≥150 100–150 <100
Liver
Bilirubin (µmol/l)
≤20 20–32 >32
Cardiovascular Mean
arterial pressure
(mmHg)
≥70 <70 Vasopressor required
Central nervous
system
Alert Rousable by voice Rousable by pain
Renal Creatinine
(µmol/l)
≤90 91–120 >120

LIMITATIONS OF SCREENING TOOLS
• Overlap with normal physiology
• Disproportionately high number of false alarms
• Poor positive predictive value (PPV)
RECOMMENDATION 2 - AGAINST USING QSOFA
COMPARED WITH SIRS, NEWS, OR MEWS AS A
SINGLE SCREENING TOOL FOR SEPSIS OR SEPTIC
SHOCK
SURVIVING SEPSIS GUIDELINES-
2021

OBSTETRICALLY MODIFIED QSOFA SCORE
Parameter Score 0 Score 1
Systolic blood
pressure (mmHg)
≥90 <90mmH
g
Respiratory rate <25 /min >25/min
Altered mental status Alert Not Alert

EARLY RECOGNITION OF PREGNANCY-
RELATED SEPSIS
• Saving Mother’s Lives- 2007
• Confidential Enquiries into Maternal and Child Health in the United Kingdom
• Strongly advocated adoption of an early warning system to identify critically ill
parturients
• Tools for early Warning
• United Kingdom
• Modified Early Obstetric Warning System
• National Partnership for Maternal Safety in the United States
• Maternal Early Warning Criteria
McClure JH et al. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006-8: a review. Br J
Anaesth. 2011

WHY IS EARLY RECOGNITION OF
SEPSIS DIFFICULT IN PREGNANCY?
• Early recognition of sepsis is often difficult
• Significant overlap between normal maternal physiological parameters and early
signs of systemic inflammatory response syndrome.
• Early warning Signs in Pregnancy- Pregnancy adjusted vital signs
• Abnormal Parameters during Pregnancy
Two standard deviations from the mean:
• Temperature >38.10C (100.6○F)
• Respiratory rate >25/min,
• Heart rate >107/min,
• Mean PaCO2>32 mm Hg,
• WBC> 18,000

MODIFIED EARLY OBSTETRIC
WARNING SYSTEM

SCREENING AND DIAGNOSIS OF SEPSIS IN
PREGNANACY: TWO STEP APPROACH
1. Current screening systems perform poorly in pregnancy.
2. Two-step approach for the diagnosis of sepsis during pregnancy
and postpartum. Is recommended
• The first screening step is limited to vital signs adjusted for
pregnancy and the most recent white blood cell WBC count
(within 24 hours).
• The second diagnostic step uses evaluation for end organ
injury with laboratory values adjusted for pregnancy where
needed.
3. The utility of lactic acid during labor is debated, but women with
elevated values require careful individual consideration.

Sepsis Evaluation
Flow Chart
NOTE:
A MAP < 65 mm Hg
(persistent after
30ml/kg fluid load) in
setting of infection
directly defines
SEPTIC SHOCK
Action: Start source-
directed antibiotics,
broad spectrum
antibiotics if source
unclear; increase fluids
to 30 ml/kg within 3
hours; collect blood
cultures if not already
obtained, maintain close
surveillance, e.g. RRT,
and repeat lactate.
Escalate care as needed.
Action: As above for Sepsis, admit to ICU. If
hypotension persists after 30 ml/kg fluid load,
assess hemodynamic status and consider
vasopressor use.
Action: At a minimum, maintain close
surveillance; consider additional fluids to reduce
lactic acid level; repeat lactate. (See Discussion
of the Role of Lactic Acid in the Peripartum
Period In the toolkit for more detail.)
Suspected Infection
Step 1: Initial Sepsis Screen
• Oral temp < 36°C (96.8°F) or > 38°C (100.4°F)
• Heart rate > 110 beats per minute
• Respiratory rate > 24 breaths per min
• WBCs > 15,000/mm3 or < 4,000/mm3 or > 10% bands
Positive if any 2 of 4 criteria met
MAP < 65 mm Hg
(with confirmation)
defines
SEPTIC SHOCK
Elevated
lactate ONLY
in Labor
≥ 1 Criterion
POSITIVE
defines SEPSIS
Action: This group
remains at high risk
for sepsis and requires
close supervision and
reevaluation.
Routine Vital Signs / WBC Screening
CMQCC Maternal Sepsis Evaluation Flow Chart
Step 2: Confirmation of Sepsis Evaluation
• Respiratory: New need for mechanical ventilation or PaO2/FiO2 < 300
• Coagulation: Platelets < 100 x 109/L or INR > 1.5 or PTT > 60 secs
• Liver: Bilirubin > 2 mg/dL
• Cardiovascular: SBP < 85 mm Hg or MAP < 65 mm Hg or > 40 mm Hg
decrease in SBP (after fluids)
• Renal: Creatinine ³ 1.2 mg/dL or doubling of creatinine or urine
output < 0.5 ml/kg/hr x 2 hrs
• Mental Status: Agitated, confused, or unresponsive
• Lactic Acid: > 2 mmol/L in absence of labor
Confirmed if 1 or more criteria met
All Criteria
NEGATIVE
Action: If suspected infection, start
source-directed antibiotics and
1-2 L of IV fluids; increase
monitoring and surveillance.
Move to confirmation evaluation.
DIAGNOSIS OF
MATERNAL SEPSIS:
A TWO-STEP
APPROACH

INITIAL SEPSIS SCREEN (STEP 1)

CONFIRMATION OF SEPSIS: STEP 2
Tests to Evaluate End Organ Injury
Laboratory values
 CBC (including % immature neutrophils [bands], Platelets)
 Coagulation status (PT, INR, PTT)
 Comprehensive Metabolic Panel (specifically include bilirubin, creatinine)
 Venous Lactic Acid
Bedside assessment
 Urine output (place Foley catheter with urometer)
 Pulse oximetry
 Mental status assessment

STEP 2: CRITERIA FOR END ORGAN INJURY
Measure of End
Organ Injury
Criteria
Positive if one (1) or more criteria are met
Respiratory
function*
 Acute respiratory failure as evidenced by acute need for invasive or non-invasive
mechanical ventilation, OR
 PaO2/FiO2 < 300
Coagulation status  Platelets < 100 x 109/L, OR
 International Normalized Ratio (INR) > 1.5, OR
 Partial Thromboplastin Time (PTT) > 60 seconds
Liver function  Bilirubin > 2 mg/dL
Cardiovascular
function
 Persistent hypotension after fluid administration:
o SBP < 85 mm Hg, OR
o MAP < 65 mm Hg, OR
o > 40 mm Hg decrease in SBP
Renal function  Creatinine > 1.2mg/dL, OR
 Doubling of serum creatinine, OR
 Urine output less 0.5 mL/kg/hour (for 2 hours)
Mental status
assessment
 Agitation, confusion, or unresponsiveness
Lactic acid  > 2 mmol/L in absence of labor
(Lactic acid not used for diagnosis in labor, but remains important for treatment.)

CONFIRMATION OF SEPSIS EVALUATION: STEP 2

PERFORMANCE OF TWO-STEP SYSTEM FOR
DIAGNOSIS OF MATERNAL SEPSIS
OB Vital Signs
Screen
Sepsis (End Organ Injury)
Source
Populatio
n
Screened
Screen
Positive
Total with End Organ
injury
Among
Screen
Positive
(Sens)
Not Among
Screen
Positive
(Spec)
Combine
d
Systems*
14,752
199
(1.3%)
33
(16.6% of screen positives)
(0.22% of all screened)
32 (97%) 1 (3%)
(1) Initial screen positive rate is 1.3%
(2) Overall performance of the Two-Step System
Sensitivity of 97%
Specificity of 99%
* Data from Dignity Health and Sutter Health

ROLE OF SERUM LACTATE
• Serum lactate is an important and valuable biomarker to identify patients
with suspected sepsis
• A 1 mmoL/L increase in serum lactate was associated with a 2.34
increased odds of admission to the ICU in women with suspected sepsis
either during pregnancy or the postpartum period.
• Lactate >2 mmoL/L should trigger escalation of care and a critical care
consult.
• If serum lactate is >4 mmoL/L despite adequate fluid resuscitation
(solution 20 mL/kg of crystalloid solution) and vasopressor therapy,
• Central venous line be placed
• Central venous pressure of > 8 mm Hg
• Central venous oxygen saturation of >70%

Management of Sepsis
SURVIVING SEPSIS GUIDELINES- 2021
Sepsis Bundles

ASSESSMENT AND TREATMENT OF
MATERNAL SEPSIS: CARE BUNDLES
KEY PRINCIPLES
1. Act quickly upon recognition of sepsis and septic shock.
2. Minimize time to treatment: Sepsis is a medical emergency.
3. Monitor closely for response to or lack of response interventions.
4. Communicate sepsis status during bedside care and handoff.

TREATMENT OF SEPSIS AND SEPTIC
SHOCK
• Mainstay treatment of sepsis
• Surviving Sepsis Guidelines -Early goal directed therapy for septic
shock
• Fluid resuscitation
• Ascertaining of culture data (blood, urine, tissue, sputum, and amniotic fluid)
• Antibiotic therapy
• Source control

MATERNAL SEPSIS
SCREEN POSITIVE WITH END ORGAN
INJURY
FIRST STEPS
• Source-directed antibiotics if not already started
• If source unclear, give broad spectrum antibiotics
• Increase fluids to 30 mL/kg within 3 hours if not already done
• Repeat lactate
• Blood cultures, if not already drawn
• Call for RRT to escalate care, as needed

MONITORING RECOMMENDATIONS
FOLLOWING A POSITIVE STEP 1 INITIAL
SEPSIS SCREEN
Monitoring Time Frame Additional Considerations
Fetal Monitoring Continuous Antepartum/intrapartum
Pulse Oximetry Continuous Until vital signs are normalized
Blood Pressure
(MAP)
Q 30 minutes
from
‘Time Zero’
Until lactate less than 2.0 mmol/L, then Q2
h for non-laboring patients (Jones AE)
Temperature Q 30 minutes
from
‘Time Zero’
Until lactate less than 2.0 mmol/L, then Q2
h for non-laboring patients*
Urine Output Q 1 hour from
‘Time Zero’
Foley catheter with urometer
Mental Status Continuous Note: agitation, confusion or
unresponsiveness
’. Once the patient triggers a positive Initial Sepsis Screen, ‘Time Zero’ will start.

EARLY ICU INTERVENTION
• Assessing Severity
• ICU scoring systems to assess severity
• APACHE II (Acute Physiology and Chronic Health Evaluation II)
• SAPS II (Simplified Acute Physiology Score II)
• Not designed for use in obstetric patients and hence it is difficult to
assess illness severity or predict outcomes

A composite score of ≥6 would predict ICU admission

INDICATIONS FOR TRANSFER TO THE
INTENSIVE CARE UNIT
• Cardiovascular - Hypotension or raised serum lactate persisting
despite fluid resuscitation, suggesting the need for inotrope support
• Respiratory - Pulmonary oedema Mechanical ventilation Airway
protection
• Renal- Renal dialysis
• Neurological - Significantly decreased conscious level
• Miscellaneous - Multi-organ failure Uncorrected acidosis
Hypothermia

ADMISSION TO INTENSIVE CARE
FOR A D U LTS W ITH SEPSIS OR SEPTIC SH OC K W H O
REQUIRE ICU ADMISSION, WE SUGGEST ADMITTING THE
PATIEN TS TO TH E IC U W ITH IN 6 H OU R S.
W E A K R E C O M M E N D AT I O N , L O W - Q U A L I T Y E V I D E N C E
2021

What is the initial
management of sepsis?

Resuscitation
Haemodynamic Management

Role of fluid therapy in the
management of sepsis

INITIAL RESUSCITATION
• Sepsis and septic shock are medical emergencies, and we
recommend that treatment and resuscitation begin immediately.
• Best practice statement.
• For patients with sepsis induced hypoperfusion or septic shock we
suggest that at least 30mL/kg of IV crystalloid fluid should be given
within the first 3 hours of resuscitation.
• Weak recommendation, low-quality evidence.
2021

HEMODYNAMIC MANAGEMENT
FLUID MANAGEMENT
• For adults with sepsis or septic shock, we recommend using crystalloids as first-line
fluid for resuscitation.
• Strong recommendation, moderate quality of evidence.
• For adults with sepsis or septic shock, we suggest using balanced crystalloids
instead of normal saline for resuscitation.
• Weak recommendation, low quality of evidence.
• For adults with sepsis or septic shock, we suggest using albumin in patients who
received large volumes of crystalloids over using crystalloids alone.
• Weak recommendation, moderate quality of evidence.
• For adults with sepsis or septic shock, we recommend against using starches for
resuscitation.
• Strong recommendation, high quality of evidence.
• For adults with sepsis and septic shock, we suggest against using gelatin for
resuscitation.
• Weak recommendation, moderate quality.
2021

SEPSIS COMPOUNDED BY MATERNAL
PHYSIOLOGY
• Sepsis also has compounds maternal physiology
• Sepsis is a disease with a cardiovascular consequences high cardiac output
and low systemic vascular resistance.
• Physiologic maternal hyperdynamic state along with loss of afterload
• Hypoalbuminemia and loss of intravascular oncotic pressure
• More intravascular resuscitation, which could result interstitial edema
(pulmonary edema, skin swelling, etc

FLUID RESUSCITATION IN
PREGNANACY
• The SSC recommends initial intravenous fluid resuscitation at a rate of
30 ml/kg.
• This recommendation is modified to 20 ml/kg by the RCOG
• Due to an increased risk of pulmonary oedema in pregnancy caused by decreased
colloid oncotic pressure.
• This should be initiated without delay for the management of septic
shock, when there is a blood lactate of >4 mmol/l and/or to achieve a
mean arterial pressure >65 mmHg.
• Early administration of 1-2 L of crystalloid solutions in sepsis complicated
by hypotension or suspected organ hypoperfusion (GRADE 1C)
• After initial fluid resuscitation, further fluid therapy should be guided by
dynamic measures of preload.

MONITORING AND INTRAVENOUS
ACCESS
• Use invasive monitoring of arterial blood pressure over noninvasive
monitoring, as soon as practical and if resources are available.
• Weak recommendation, very low quality of evidence.
• Start vasopressors peripherally to restore MAP rather than
delaying initiation until a central venous access is secured.
• Remark: When using vasopressors peripherally, they should be
administered only for a short period of time and in a vein in or
proximal to the antecubital fossa.
2021

TITRATING FLUID IN RESOURCE-
CONSTRAINED INSTITUTIONS
• To avoid over- and under-resuscitation, fluid administration beyond
the initial resuscitation should be guided by careful assessment of
intravascular volume status and organ perfusion.
• Heart rate, central venous pressure (CVP) and systolic blood
pressure alone are poor indicators of fluid status.
• Dynamic measures have demonstrated better diagnostic accuracy
at predicting fluid responsiveness compared with static techniques.
2021

DYNAMIC MEASURES
• Passive leg raising combined with cardiac output (CO)
measurement,
• Fluid challenges against stroke volume (SV), systolic pressure or
pulse pressure
• Increases of SV in response to changes in intrathoracic pressure

MONITORING FOR ADEQUACY OF FLUID
THERAPY
• Pulse-pressure variation
• Obtained by analysing the waveform of an arterial line
• Not be affected by pregnancy.
• Reliable only in sedated individuals receiving positive-pressure, controlled
mechanical ventilation
• Normal sinus rhythm
• Pulse pressure varies by more than 13% with the respiratory cycle,
the patient is considered to be volume responsive

THERAPY
• Passive Leg Raising
• Raise both legs to 300 to 45⁰,
• Causes an autotransfusion of close to 300 mL of blood
• After 2-3 minutes of passive leg raising
• Fluid responders will have an increase in cardiac output (until utilizing invasive
cardiac output monitors)
• Non-responders treated with vasopressors

THERAPY
• Fluid Challenge
• Passive leg raising may not be useful during the third trimester because of
uterine compression of the inferior vena cava
• Fluid challenge
• Increase in cardiac output may be identified by administering a
small bolus of fluid (250-500 mL)
• If cardiac output increases, further fluid administration is likely
indicated.

THERAPY
• Point-of-care ultrasound
• Used to identify fluid responsiveness by
measuring the diameter of the inferior vena
cava with respiration
• Inferior vena cava diameter 2-2.5 cm with
minimal variability with the respiratory cycle
suggests that the patient is already fully fluid
loaded
• This technique is most commonly used in
patients receiving mechanical ventilation
• Has not been validated in pregnancy

FLUID BALANCE
• For adults with sepsis or septic shock, guide resuscitation to
decrease serum lactate in patients with elevated lactate level, over
not using serum lactate.
• Remarks: During acute resuscitation, serum lactate level should be interpreted
considering the clinical context and other causes of elevated lactate.
• For adults with septic shock, use capillary refill time to guide
resuscitation as an adjunct to other measures of perfusion.
2021

NO ADVANCED MONITORING – CRT IS
AS GOOD
• Alternative measures of organ perfusion when no advanced
hemodynamic monitoring is available
• Temperature of the extremities,
• Skin mottling
• Capillary refill time (CRT)
• Validated and shown to be reproducible signs of tissue perfusion
• CRT during resuscitation has physiologic plausibility and is easily
performed, noninvasive, and no cost.
• Should be augmented by careful, frequent, and comprehensive
patient evaluation to predict or recognize fluid overload early,
particularly

WHEN ARE VASOPRESSORS AND
INOTROPES INDICATED IN SEPSIS?
• Vasopressors to increase blood pressure
• The purpose of vasopressors is to constrict the pathologically
dilated systemic circulation and maintain adequate perfusion.
• Hypotensive patients who are not fluid responsive
• Who are not candidates for further fluid resuscitation (eg, women who are in
pulmonary edema).
• Current guidelines recommend norepinephrine as the first-line agent with a
target MAP

VASOACTIVE AGENTS
• For adults with septic shock, recommended to use norepinephrine as the
first-line agent over other vasopressors.
• Strong recommendation
• For adults with septic shock on norepinephrine with inadequate MAP
levels, add vasopressin instead of escalating the dose of norepinephrine.
• Weak recommendation, moderate-quality evidence.
• For adults with septic shock and inadequate MAP levels despite
norepinephrine and vasopressin, add epinephrine.
• Weak recommendation, low-quality evidence
• For adults with septic shock, we suggest against using terlipressin.
2021

RECOMMEND THE USE OF NOREPINEPHRINE AS THE
FIR ST- LIN E VA SOPR ESSOR D U R IN G PR EGN A N C Y A N D TH E
POSTPA R TU M PER IOD IN SEPSIS W ITH PER SISTEN T
H YPOTEN SION A N D /OR H YPOPER FU SION D ESPITE FLU ID
R ESU SC ITATION ( GR A D E 1C ) .
• Norepinephrine nevertheless appears to be safe for the fetus,
especially at low doses
• The evidence regarding the use of other vasopressors (eg,
vasopressin) is more limited,
• Theoretical interaction of vasopressin with oxytocin receptors

F O R AD U LT S W I T H S E P T I C S H O C K O N VAS O P R E S S O R S , AN
I N I T I AL TAR G E T M E AN AR T E R I A L P R E S S U R E ( M AP ) O F 6 5 M M
H G O V E R H I G H E R M AP TAR G E T S .
S T R O N G R E C O M M E N D AT I O N , M O D E R AT E - Q U A L I T Y E V I D E N C E .
• Threshold has not been studied in pregnant women
• MAP of 65−70mm Hg, versus a target of 80−85mm Hg No difference in
mortality
• “permissive hypotension” (MAP 60–65mm Hg)
• A target MAP of 65 mm Hg is generally recommended in nonpregnant
individuals.
• Lower blood pressures may be acceptable during pregnancy, provided no signs
of hypoperfusion
• Altered mental status
• Oliguria
• Elevated serum lactate,
• Cold extremities
• Evidence of fetal compromise
2021

INOTROPES
• For adults with septic shock and cardiac dysfunction with persistent
hypoperfusion despite adequate volume status and arterial blood
pressure, we suggest either adding dobutamine to norepinephrine
or using epinephrine alone.
• For adults with septic shock and cardiac dysfunction with persistent
hypoperfusion despite adequate volume status and arterial blood
pressure, we suggest against using levosimendan.
2021

GOALS OF MANAGEMENT
• Surrogate end points to ensure fetal well-being
• Optimization of maternal oxygenation
• Optimisation of acid-base status .

VENTILATION
OXYGEN TARGETS
• Conservative oxygen targets
• PaO2 55 to 70 mmHg; SpO2 88 to 92%
• Mixed venous oxygen saturation (SvO2) of 65% or a ScvO2 of 70%
2021

OXYGEN TARGETS IN PREGNANCY
• Oxygen should be administered to achieve a saturation ≥94%
• In the third trimester of healthy pregnancy, the SvO2 is
approximately 80%,
• Currently there is limited evidence to guide the optimum SvO2 in
the critically ill pregnant patient.

HIGH-FLOW NASAL OXYGEN THERAPY
• For adults with sepsis-induced hypoxemic respiratory failure, we
suggest the use of high flow nasal oxygen over noninvasive
ventilation.
• Non-invasive Ventilation
• There is insufficient evidence to make a recommendation on the
use of noninvasive ventilation in comparison to invasive ventilation
for adults with sepsis-induced hypoxemic respiratory failure
2021

STRATEGIES FOR MECHANICAL
VENTILATION IN PREGNANCY
• Modifications to standard ventilatory approaches
• Hyperventilation- Avoided
• Adversely affects uterine blood flow.
• Permissive hypercapnia-
• Not been evaluated in pregnancy.
• Chest wall compliance is reduced
• Higher inflation pressures may be required to achieve adequate tidal volumes.
• Maternal hypoxia
• Maternal hyperoxia – effects on the fetus are unclear
• Ventilation in the prone position is unfeasible
• Left uterine displacement and/or left lateral decubitus position must be considered
• Role of expedited delivery improves outcomes not clear

ARDS IN PREGNANCY
• Mortality
• Antepartum- 23%
• Postpartum - 50%

TREATMENT OF ARDS IN OBSTETRIC
PATIENTS
• Key differences in obstetric physiology warrant slight adjustments
to standard ventilatory approaches
• Maintaining a SaO2 of 95%, instead of 88% as compared to the general
population for fetal oxygenation and well-being
• Limiting maternal hypercapnia to PaCO2 to <45mmHg as a gradient of 10
mm Hg is required for fetal clearance of PaCO2
• Rapid increase in minute ventilation during pregnancy
• Standard ventilation of 6 mL/kg based on ideal body weight may potentially
underestimate ventilatory demands in the parturient.
• If oxygenation goals are not met, respiratory rate can be increased before
increasing the tidal volume.

PROTECTIVE VENTILATION IN ACUTE
RESPIRATORY DISTRESS SYNDROME
(ARDS)
• .For adults with sepsis-induced ARDS, we recommend using a low tidal
volume ventilation strategy (6mL/kg), over a high tidal volume strategy (>
10mL/kg).
• Strong recommendation, high quality of evidence
• For adults with sepsis-induced severe ARDS, we recommend using an
upper limit goal for plateau pressures of 30cm H2O, over higher plateau
pressures
• Strong recommendation, moderate quality of evidence
• For adults with moderate to severe sepsis-induced ARDS, we suggest
using higher PEEP over lower PEEP.
• Weak recommendation, moderate quality of evidence
2021

RECRUITMENT MANEUVERS
• For adults with sepsis-induced moderate-severe ARDS, we
suggest using traditional recruitment maneuvers.
• When using recruitment maneuvers, we recommend against using
incremental PEEP titration/strategy.
2021

PRONE VENTILATION
• For adults with sepsis-induced moderate-severe ARDS, we
recommend using prone ventilation for more than 12 hours daily.
• Strong recommendation, moderate quality of evidence
2021

NEUROMUSCULAR BLOCKING AGENTS
• For adults with sepsis induced moderate-severe ARDS, we
suggest using intermittent NMBA boluses, over NMBA continuous
infusion.
2021

EXTRACORPOREAL MEMBRANE
OXYGENATION
• For adults with sepsis-induced severe ARDS, we suggest using
venovenous (VV) ECMO when conventional mechanical ventilation
fails in experienced centers with the infrastructure in place to
support its use.
• Weak recommendation, low quality of evidence
2021

ECMO USE IN PREGNANCY
• Overall maternal and fetal survival rate was 80% and 70%

Infection Control
Antimicrobials and Source
Control

MANAGEMENT OF SEPSIS IN
PREGNANCY
• Organ dysfunction in a previously healthy woman should raise
suspicion for sepsis.
• If the history or physical examination supports sepsis as a possible
diagnosis, cultures (blood, sputum, urine, and others as clinically
indicated) and serum lactate levels should be obtained and
antibiotics initiated within 1 hour of diagnosis
• Initiation of broad-spectrum antibiotic therapy within 1 hour after
suspicion of severe sepsis (the Golden Hour)

COMMONLY ORGANISMS
• Most commonly recovered organisms
• E. coli
• Staphylococcus aureus
• Group A Streptococcus

TIME TO ANTIBIOTICS
• For adults with possible septic shock or a high likelihood for sepsis,
we recommend administering antimicrobials immediately, ideally
within one hour of recognition.
• Strong recommendation, low quality of evidence (septic shock) Strong
recommendation, very low quality of evidence (sepsis without shock)
• For adults with possible sepsis without shock, we suggest a time-
limited course of rapid investigation and if concern for infection
persists, the administration of antimicrobials within 3 hours from
the time when sepsis was first recognized.
2021

WHY LOW THRESHOLD FOR EMPIRICAL
ANTIBIOTICS?
• Chorioamnionitis is associated with an increased neonatal
morbidity and mortality,
• There is a low threshold to commence empirical broad-spectrum
intravenous antibiotics, particularly during preterm labour at
<34wks

2021

ANTIMICROBIALS IN RESOURCE-
LIMITED SETTINGS
• Access and availability of a wide range of antimicrobials in such
settings may however vary
• Availability and turnaround time for laboratory testing, rapid
infectious diagnostic, imaging, etc. varies widely by regions and
settings
2021

BIOMARKERS TO START ANTIBIOTICS
• For adults with suspected sepsis or septic shock, we suggest
against using procalcitonin plus clinical evaluation to decide when
to start antimicrobials, as compared to clinical evaluation alone.
• Weak recommendation, very low quality of evidence
2021

CHOICE OF EMPIRIC ANTIBIOTIC
• Empiric antibiotic choices will be driven
• Presumed source
• Likely microorganisms
• Local patterns of antibiotic resistance but should be broad spectrum
• Initial coverage should include
• Anaerobic and aerobic Gram positive and Gram-negative bacteria.
• Recommendations are expected to change as antibiotic resistance
spreads

SOURCE CONTROL
• Obtain cultures (blood, urine, respiratory, and others as indicated)
and serum lactate levels in pregnant or postpartum women in
whom sepsis is suspected or identified. Early source control should
be completed as soon as possible (GRADE 1C).

Assessment and Treatment: Cultures
• For chorioamnionitis/intraamniotic infection and endometritis, lower genital
tract cultures are rarely performed because they may reflect primarily
contaminating organisms
• Patients initially diagnosed with chorioamnionitis/ endometritis generally have
negative blood cultures or a positive culture is reported after a recovered
patient has been discharged
• If patient show signs of end-organ injury or septic shock, blood cultures
should be obtained if not already done

Assessment and Treatment: Cultures (cont)
• Blood cultures should be collected prior to antibiotic administration in patients
with suspected sepsis and septic shock
• Two sets of cultures for anaerobes and aerobes should be collected
• If the same organism is identified in both sets of blood cultures, the likelihood
that the organism is causing sepsis is increased
Note: Blood cultures should be drawn within 3 hours following a diagnosis of
sepsis with organ dysfunction per CMS guidelines (CMS guidelines 5.5)
Dellinger, Mitchell, Rhodes, et al. Int Care Med 2013

CONTROVERSIES
• Guidelines extrapolated from the general population.
• Many patients for whom the sepsis bundle has been initiated may not
have an infectious aetiology.
• 175 intrapartum women with pyrexia >38°C, showed that no patients
developed sepsis or required admission to ICU.
• De-escalation of antibiotics could be considered if sterile site cultures are
negative at 48 hours and the patient is clinically well,
• Caveat- poor sensitivity/specificity of current microbiological culture
techniques and in the absence of a more sensitive tool, deescalation
should be determined with microbiological guidance.

OTHER CAUSES OF MATERNAL
PYREXIA
• Maternal Pyurexia in labour,
• Epidural analgesia
• Prolonged labour
• Ambient temperature.
• Maternal tachycardia
• Dehydration
• Work of labour
• Underlying cardiorespiratory and metabolic/endocrine pathology.

CHOICE OF ANTIBIOTICS DURING
GOLDEN HOUR
• Less Severe Disease
• Broad-spectrum b-lactam
• Critically Ill
• Invasive GAS/Escherichia coli
• b-lactam + gram-negative coverage + clindamycin ± flagyl
• If MRSA
• Teicoplanin or vancomycin

Source infection Recommended antibiotics
Community-acquired
pneumonia
Cefotaxime, ceftriaxone, ertapenem, or ampicillin plus azithromycin, clarithromycin,
or erythromycin
Hospital-acquired
pneumonia
Low-risk patients may be treated with piperacillin-tazobactam, meropenem,
imipenem, or cefepime.
Patients at high risk of mortality may need double coverage for Pseudomonas (beta
lactam plus an aminoglycoside or a quinolone) and MRSA coverage with
vancomycin or linezolid
Chorioamnionitis Ampicillin plus gentamicin.
Add anaerobic coverage with clindamycin or metronidazole if cesarean delivery
required.
Endomyometritis Ampicillin, gentamicin, and metronidazole (or clindamycin) Alternatively may use
cefotaxime or ceftriaxone plus metronidazoled
Urinary tract infections Gentamicin with ampicillin . Alternatively, may use monotherapy with a carbapenem
or piperacillin-tazobactam
Abdominal infections Ceftriaxone, cefotaxime, ceftazidime, or cefepime plus metronidazolef
Complicated cases may require monotherapy with a carbapenem or piperacillin-
tazobactam.
Skin and soft tissues
(necrotizing)
Vancomycin plus piperacillin-tazobactam
If Streptococcus Group A or Clostridium perfringens are present, use penicillin G

ANTIMICROBIAL CHOICE
• For adults with sepsis or septic shock at high risk of methicillin-
resistant Staphylococcus aureus (MRSA), empiric antimicrobials
with MRSA coverage over using antimicrobials is recommended
2021

• Patient-related risk factors for MRSA
• Prior history of MRSA infection or colonization,
• Recent IV antibiotics
• History of recurrent skin infections
• Chronic wounds,
• Resence of invasive devices
• Hemodialysis
• Recent hospital admissions and severity of illness
• Among patients with documented MRSA infections, delays of >
24−48 hours until antibiotic administration are associated with
increased mortality in some studies
2021

• For adults with sepsis or septic shock and high risk for multidrug
resistant (MDR) organisms, we suggest using two antimicrobials
with gram-negative coverage for empiric treatment over one gram-
negative agent.
• For adults with sepsis or septic shock and low risk for MDR
organisms, we suggest against using two gram-negative agents for
empiric treatment, compared with one gram-negative agent.
2021

FACTORS TO GUIDE THIS DECISION
RISK OF MDR PATHOGENS
• Proven infection or colonization with antibiotic-resistant organisms within
the preceding year
• Local prevalence of antibiotic-resistant organisms
• Hospital-acquired/healthcare−associated (versus community- acquired
infection)
• Broad-spectrum antibiotic use within the preceding 90 days
• Concurrent use selective digestive decontamination (SDD)
• Travel to a highly endemic country within the preceding 90 days (see
https://resistancemap.cddep.org/)
• Hospitalization abroad within the preceding 90 days

ANTIFUNGAL THERAPY
• For adults with sepsis or septic shock at high risk of fungal
infection, we suggest using empiric antifungal therapy over no
antifungal therapy.
• For adults with sepsis or septic shock at low risk of fungal infection,
we suggest against empiric use of antifungal therapy.
2021

ANTIFUNGAL AGENT FOR EMPIRIC
THERAPY
• Factors
• Host factors,
• Prior colonization and infection
• Prior exposure to prophylactic or therapeutic
antifungal therapy
• Comorbidities
• Toxicities and drug interactions of the therapeutic
options

ANTIVIRAL THERAPY
• No recommendation on the use of antiviral agents.
• Apart from specific clinical situations such as
epidemics/pandemics—are rarely the primary cause of sepsis
• Influenza has been one of the more common viral causes of sepsis
• No overall effect of neuraminidase inhibitors on mortality in patients
with influenza-related pneumonia, there may be an effect when
administered early in the course of the disease

PHARMACOKINETICS AND
PHARMACODYNAMICS
• For adults with sepsis or septic shock, we recommend optimizing
dosing strategies of antimicrobials based on accepted
pharmacokinetic/ pharmacodynamic (PK/PD) principles and
specific drug properties.
• Best practice statement
2021

SOURCE CONTROL
• For adults with sepsis or septic shock, we recommend rapidly
identifying or excluding a specific anatomical diagnosis of infection
that requires emergent source control and implementing any
required source control intervention as soon as medically and
logistically practical.

SOURCE CONTROL
• Source control should be achieved as soon as possible following
initial resuscitation
• Source control within 6 to 12 hours is advantageous
• Without adequate source control, many severe presentations will
not stabilize or improve despite rapid resuscitation and provision of
appropriate antimicrobials. In view of this fact, prolonged efforts at
medical stabilization in lieu of source control for severely ill
patients, particularly those with septic shock, are generally not
advised

OPTIMAL SOURCE CONTROL METHODS
• The least invasive option that will effectively achieve source control
should be pursued
• Open surgical intervention should be considered when other
interventional approaches are inadequate or cannot be provided in a
timely fashion
• Surgical exploration may also be indicated when diagnostic uncertainty
persists despite radiologic evaluation, when the probability of success
with a percutaneous procedure is uncertain, or when the undesirable
effects of a failed procedure are high.
• Logistic factors unique to each institution, such as surgical or
interventional staff availability, may also play a role in the decision.

SOURCE CONTROL
• For adults with sepsis or septic shock, we recommend prompt
removal of intravascular access devices that are a possible source
of sepsis or septic shock after other vascular access has been
established.
2021

LIMITATIONS OF CULTURES
• One of the difficulties confirming a systemic microbial infection is
the poor specificity and time-consuming nature of traditional culture
and sensitivity methods.
• Despite being the gold standard,36 only 30–40% of blood cultures
will be positive in patients with severe sepsis and a minimum of
24 hours is required before the results are available
• New technologies are being developed with the potential for fast
identification of organism and antibiotic resistance patterns
• Ensures timely and optimised treatment
• Reduces the impact on antibiotic selection pressures

RECENT DEVELOPMENT IN
IDENTIFICATION OF ORGANISMS
• Multiplex polymerase chain reaction (PCR)
• Identifies multiple pathogen DNA sequences and their resistance genes,
from both positive blood cultures and whole blood samples
• .Matrix-assisted laser desorption/ionisation (MALDI) using a time-
of-flight (TOF) mass spectrometer
• identifies wide spectrum of organisms (bacteria and fungi) from clinical
isolates of positive cultures.
• Key advantages of MALDI-TOF and PCR-based methods are
accuracy and speed of analysis.
• Disadvantages- Expensive and may identify non-pathogenic
organisms

TARGETED PHASE
• In the directed/targeted phase, once causative agent(s) and
susceptibilities are known, sustained double gram-negative
coverage is not necessary except possibly for patients with highly
resistant organisms with no proven safe and efficacious
therapeutic option.

DURATION OF ANTIBIOTICS
• For adults with an initial diagnosis of sepsis or septic shock and
adequate source control, using shorter over longer duration of
antimicrobial therapy is suggested.
2021

DE-ESCALATION OF ANTIBIOTICS
• For adults with sepsis or septic shock, we suggest daily
assessment for de-escalation of antimicrobials over using fixed
durations of therapy without daily reassessment for de-escalation.
• Weak recommendation, very low quality of evidence
2021

BIOMARKERS TO DISCONTINUE
ANTIBIOTICS
• For adults with an initial diagnosis of sepsis or septic shock and
adequate source control where optimal duration of therapy is
unclear, we suggest using procalcitonin AND clinical evaluation to
decide when to discontinue antimicrobials over clinical evaluation
alone.

ADDITIONAL THERAPIES
• Corticosteroids
• For adults with septic shock and an ongoing requirement for
vasopressor therapy we suggest using IV corticosteroids.
• Weak recommendation; moderate quality of evidence.
• Remarks: The typical corticosteroid used in adults with septic shock is IV
hydrocortisone at a dose of 200mg/d given as 50mg intravenously every 6 hours
or as a continuous infusion. It is suggested that this is commenced at a dose of
norepinephrine or epinephrine ≥ 0.25 mcg/kg/min at least 4 hours after initiation

BLOOD PURIFICATION
• For adults with sepsis or septic shock, we suggest against using
polymyxin B hemoperfusion.
• Weak recommendation; low quality of evidence.
• There is insufficient evidence to make a recommendation on the
use of other blood purification techniques.

RED BLOOD CELL (RBC) TRANSFUSION
TARGETS
• For adults with sepsis or septic shock, we recommend using a
restrictive (over liberal) transfusion strategy.
• Strong recommendation; moderate quality of evidence.
• Remarks: A restrictive transfusion strategy typically includes a
hemoglobin concentration transfusion trigger of 70g/L; however,
RBC transfusion should not be guided by hemoglobin
concentration alone. Assessment of a patient’s overall clinical
status and consideration of extenuating circumstances such as
acute myocardial ischemia, severe hypoxemia or acute
hemorrhage is required.

IMMUNOGLOBULINS
• . For adults with sepsis or septic shock, we suggest against using
intravenous immunoglobulins

STRESS ULCER PROPHYLAXIS
• . For adults with sepsis or septic shock, and who have risk factors
for gastrointestinal (GI) bleeding, we suggest using stress ulcer
prophylaxis

VENOUS THROMBOEMBOLISM (VTE)
PROPHYLAXIS
• For adults with sepsis or septic shock, we recommend using
pharmacologic VTE prophylaxis unless a contraindication to such
therapy exists.
• For adults with sepsis or septic shock, we recommend using low
molecular weight heparin (LMWH) over unfractionated heparin (UFH) for
VTE prophylaxis
• For adults with sepsis or septic shock, we suggest against using
mechanical VTE prophylaxis in addition to pharmacological prophylaxis,
over pharmacologic prophylaxis alone.

RENAL REPLACEMENT THERAPY
• In adults with sepsis or septic shock and AKI who require renal
replacement therapy, we suggest using either continuous or
intermittent renal replacement therapy.
• In adults with sepsis or septic shock and AKI, with no definitive
indications for renal replacement therapy, we suggest against
using renal replacement therapy.
• Weak recommendation, moderate quality of evidence.

GLUCOSE CONTROL
• For adults with sepsis or septic shock, we recommend initiating
insulin therapy at a glucose level of ≥ 180mg/dL (10 mmol/L).
• Strong recommendation; moderate quality of evidence.
• Remark: Following initiation of an insulin therapy, a typical target
blood glucose range is 144−180mg/dL (8−10 mmol/L).

BICARBONATE THERAPY
• For adults with septic shock and hypoperfusioninduced lactic
acidemia, we suggest against using sodium bicarbonate therapy to
improve hemodynamics or to reduce vasopressor requirements.
• For adults with septic shock, severe metabolic acidemia (pH ≤ 7.2)
and AKI (AKIN score 2 or 3), we suggest using sodium bicarbonate
therapy

NUTRITION
• For adult patients with sepsis or septic shock who can be fed
enterally, we suggest early (within 72 hours) initiation of enteral
nutrition.
• Weak recommendation; very low quality of evidence

FETAL MONITORING IN THE ICU
• Pre-viable fetus- monitoring not required
• Fetal heart rate (FHR) is a direct reflection of the adequacy of
uteroplacental perfusion
• New-onset late decelerations
• Absence of baseline variability
• Should prompt a thorough reevaluation of maternal cardiorespiratory status
• Exclude maternally administered sedative and analgesic drugs as the cause
for altered FHR tracing.

WHEN IS DELIVERY INDICATED IN
PREGNANT WOMEN WITH SEPSIS?
• The presence of sepsis alone is not an immediate indication for
delivery (except in cases of chorioamnionitis).
• Decision to deliver the fetus should be individualized
• Depend on gestational age as well as maternal and fetal conditions
• Resuscitation that improves maternal hemodynamics will result in improved
uteroplacental perfusion and therefore improved fetal condition.
• Delivery should be reserved for the usual obstetric indications after
stabilization of the woman;
• No evidence that delivery improves maternal outcomes.

Maternal and perinatal
outcomes associated with
sepsis

PARTURIENTS HAVE FAVORABLE
OUTCOMES!!!!
• Parturients have favorable outcomes when compared to non-
pregnant patient’s
• Overall much younger age
• Fewer comorbidities
• Focused site of infection
• Low resistance to antimicrobial therapies

HOW CAN DEATHS FROM SEPSIS BE
PREVENTED?
• Lessons learnt from studies of sepsis-related maternal mortality
• Key observations from the studies
• Majority had a delay in care and a delay in escalation of care.
• Most were afebrile, possibly delaying the recognition of the presence of
sepsis
• Even after diagnosis, 73% of women were started on antibiotics that
provided inadequate coverage
• Solution
• Early involvement of consultants with expertise in infectious disease may
expedite treatment of sepsis and help improve outcomes

KEY MANAGEMENT POINTS
• Treatment during pregnancy should follow the same basic
principles as in the nonpregnant population
• Early recognition
• Fluid therapy/ Vasopressors, such as norepinephrine when indicated
• Timely broad-spectrum antibiotics
• Source control.
• Delivery should be guided by obstetric indications

QUALITY IMPROVEMENT
• Infection prevention practices
• Increased crowding
• Prolonged labour
• Prolonged reupture of membrane
• Increased cesarian section
• Leaving facility early

• Context driven Customised quality improvement

2021
RECOMMENDATION
F O R H O S P I TAL S AN D H E ALT H S Y S T E M S , W E R E C O M M E N D
U S I N G A P E R F O R M AN C E I M P R O V E M E N T P R O G R AM F O R S E P S I S ,
I N C L U D I N G S E P S I S S C R E E N I N G F O R AC U T E LY I L L , H I G H - R I S K
PAT I E N T S AN D S TAN D A R D O P E R AT I N G P R O C E D U R E S F O R
T R E AT M E N T

Recommendation Evidence
Sepsis and septic shock be considered medical emergencies and that treatment
and resuscitation for sepsis begin immediately.
IB
Strong recommendation,
moderate-quality
evidence
Consider the diagnosis of sepsis in pregnant patients with otherwise
unexplained end-organ damage in the presence of an infectious process,
regardless of the presence of fever
IB
moderate-quality
evidence
Empiric broadspectrum antibiotics be administered as soon as possible, ideally
within 1 hour, in any pregnant woman in whom sepsis is suspected.
1B
moderate-quality
evidence
Obtaini cultures (blood, urine, respiratory, and others as indicated) and serum
lactate levels in pregnant or postpartum women in whom sepsis is suspected or
identified. Early source control should be completed as soon as possible
IC
low-quality evidence
Early administration of 1-2 L of crystalloid solutions in sepsis complicated by
hypotension or organ hypoperfusion
IC
Norepinephrine as the first-line vasopressor during pregnancy and the
postpartum period in sepsis with persistent hypotension and/or hypoperfusion
despite fluid resuscitation.
1C

SOMANZ guidelines for the investigation and management sepsis in pregnancy

I N I T I A L T R E AT M E N T O F S E P S I S D U R I N G P R E G N A N C Y
Suspect Sepsis
Within 1 hour of suspected
diagnosis:
Obtain
cultures and
serum
lactate
Administer
Broad
spectrum
antibiotics
Initiate fluid therapy (up to 30 ml/kg
of crystalloid initially) to maintain
MAP >65 mm Hg
(lower values may be acceptable in
pregnancy;
Individualise
Start norepinephrine through central
line if MAP <65 mm Hg and evidence
of hypoperfusion
Start low-dose steroid
(hydrocorƟsone 200 mg/day in a
continuous infusion) if no response to
norepinephrine
Achieve early source
control (use imaging
studies as indicated)
Consider electronic fetal
monitoring at 24 weeks of
pregnancy
Consider steroids for
fetal clung maturity
after 23 to 24 weeks of
pregnancy
Early enteral feeding
IniƟate DVT prophylaxis
Avoid hyperglycemia above 180
mg/d

KEY TAKE AWAYS
• The incidence of maternal sepsis and related mortality is on the rise despite
advances in medical care
• Recognition of antenatal risk factors
• Early detection with early warning criteria
• Referral to the ICU
• Prompt administration of broad-spectrum antibiotics
• Early critical care intervention, multidisciplinary focused care
• Mechanical ventilation adjusted to optimize pulmonary ventilation/perfusion
mismatch
• Fetal monitoring is continued in the ICU
• ECMO can be safely used for enhanced cardiorespiratory support during ARDS
in pregnancy

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