SEPSIS NEW DEFINITION AND ITS MANAGEMENT 2017 GUIDELINE BY SURVIVING SEPSIS CAMPAIGN

1. A TO Z(U) IN SEPSIS
MANAGEMENT
Dr. Ashish Ranjan
Senior Resident
Deptt of pulmonary medicine
ESICPGIMSR,New Delhi

2. REFERENCE ARTICLE

3. OPERATIONALIZATION OF CLINICAL CRITERIA

4. QUICK SOFA( Q SOFA) SEYMOR ET AL
Early Screening for Performance
Improvement
Parameters Criteria
Respiratory rate ≥22/min
Altered mentation GCS <13
Systolic blood pressure ≤100mmHg

5. CRITERIA FOR NEW DEFINITIONS
• SOFA score ≥ 2 points consequent to the
infection.
• Baseline SOFA score is assumed to be zero
• SOFA score ≥ 2 overall mortality risk 10%

6. A-INITIAL
RESUCITATI
ON
B-SCREENING FOR
SEPSIS AND
PERFORMANCE
IMPROVEMENT
C-
DIAGNOSI
S

7. INITIAL RESUSCITATION
Sepsis and septic shock are medical emergencies, and we
recommend that treatment and resuscitation begin
immediately (best practice statements, BPS).
In the resuscitation from sepsis-induced hypoperfusion, at
least 30 mL/kg of IV crystalloid fluid be given within the
first 3 h (strong recommendation, low quality of evidence).

8. INITIAL RESUSCITATION
Following initial fluid resuscitation, additional fluids
be guided by frequent reassessment of
hemodynamic status (BPS).
Remarks Reassessment should include a thorough
clinical examination and evaluation of available physiologic
variables (heart rate, blood pressure, arterial oxygen
saturation, respiratory rate, temperature, urine output, and
others, as available) as well as other noninvasive or
invasive monitoring, as available.

9. INITIAL RESUSCITATION
An initial target MAP of 65 mmHg in patients with
septic shock requiring vasopressors (strong
recommendation, moderate quality of evidence).
Guiding resuscitation to normalize lactate in patients
with elevated lactate levels as a marker of tissue
hypoperfusion (weak recommendation, low quality of
evidence).

10. Application of Fluid Resuscitation in Adult Septic Shock
Considerations post 30ml/kg crystalloid infusion
1. Continue to balance fluid resuscitaon and vasopressor dose with attention to maintain tissue perfusion and minimize interstitial edema
2. Implement some combinaon of the list below to aid in further resuscitaon choices that may include addional fluid or inotrope therapy
• blood pressure/heart rate response,
• urine output,
• cardiothoracic ultrasound,
• CVP, ScvO2,
• pulse pressure variaon
• lactate clearance/normalizaon or
• dynamic measurement such as response of flow to fluid bolus or passive leg raising
3. Consider albumin fluid resuscitaon, when large volumes of crystalloid are required to maintain intravascular volume.
Sepsis-induced hypotension or lactate > 4 mmol/L
(Based on SSC bundle and CMS threshold)
No high flow oxygen and
No ESRD on dialysis or CHF
Pneumonia or ALI with high
flow oxygen requirements
ESRD on hemodialysis
or CHF
Rapid infusion
of 30 ml/kg
Crystalloid*
Not intubated/
mechanically ventilated
Intubated/
mechanically ventilated Total of 30 ml/kg crystalloid*
with frequent reassessment
of oxygenation
If no
If
Yes
Consider
intubaon/mechanical
venlaon to facilitate
30 ml/kg crystalloid *
Rapid infusion
of 30 ml/kg
crystalloid *
Total of 30 ml/kg with
frequent reassessment of
oxygenaon

11. SEPSIS SCREENING AND
PERFORMANCE IMPROVEMENT
 Hospitals and hospital systems have a performance
improvement program for sepsis, including sepsis
screening for acutely ill, high-risk patients (BPS)
 Notably, sepsis screening has been associated
with decreased mortality in several studies .
 The implementation of a core set of
Recommendations (“bundle”) has been a
cornerstone of sepsis performance improvement
programs aimed at improving management

12. TO BE COMPLETED WITHIN 3 HOURS OF TIME OF
PRESENTATION
 1. Measure lactate level
 2. Obtain blood cultures prior to administration of
antibiotics
 3. Administer broad spectrum antibiotics
 4. Administer 30ml/kg crystalloid for hypotension or
lactate ≥4mmol/L
 Time of presentation” is defined as the time of triage in
the emergency department or, if presenting from another
care venue, from the earliest chart annotation consistent
with all elements of severe sepsis or septic shock
ascertained through chart review.

13. TO BE COMPLETED WITHIN 6 HOURS OF TIME
OF PRESENTATION
 5. Apply vasopressors (for hypotension that does
not respond to initial fluid resuscitation) to maintain
a mean arterial pressure (MAP) ≥65mmHg
 6. In the event of persistent hypotension after initial
fluid administration (MAP < 65 mm Hg) or if initial
lactate was ≥4 mmol/L, re-assess volume status
and tissue perfusion and document findings
according to Table 1.
 7. Re-measure lactate if initial lactate elevated.

14. TABLE 1
DOCUMENT REASSESSMENT OF VOLUME STATUS AND
TISSUE PERFUSION WITH:
EITHER
• Repeat focused exam (after initial fluid resuscitation) including
vital signs, cardiopulmonary, capillary refill, pulse, and skin
findings.
OR TWO OF THE FOLLOWING:
 Measure CVP
 Measure ScvO2
 Bedside cardiovascular ultrasound
 Dynamic assessment of fluid responsiveness with passive leg
raise or fluid challenge
 Of note, the 6-hour bundle has been updated; the 3-hour SSC
bundle is not affected.

15. DIAGNOSIS
Appropriate routine microbiologic cultures (including
blood) be obtained before starting antimicrobial
therapy in patients with suspected sepsis or septic
shock if doing so results in no substantial delay in
the start of antimicrobials (BPS).
Remarks Appropriate routine microbiologic cultures
always include at least two sets of blood cultures (aerobic
and anaerobic).

16. D-
ANTIBIOTICS
G-
VASOACTIVE
AMINES
F-FLUID
THERAPY
E-
SOURCE
CONTRO
L

17. ANTIMICROBIAL THERAPY
Administration of IV anti-microbials be initiated as
soon as possible after recognition and within 1 h
for both sepsis and septic shock (strong
recommendation, moderate quality of evidence;
grade applies to both conditions).

18. ANTIMICROBIAL THERAPY
Empiric broad-spectrum therapy with one or more
antimicrobials for patients presenting with sepsis or
septic shock to cover all likely pathogens (including
bacterial and potentially fungal or viral coverage) (strong
recommendation, moderate quality of evidence).
Empiric antimicrobial therapy be narrowed once pathogen
identification and sensitivities are established and/or
adequate clinical improvement is noted (BPS).

19. ANTIMICROBIAL THERAPY
 Antimicrobial treatment duration of 7–10 days is
adequate for most serious infections associated with
sepsis and septic shock (weak recommendation, low
quality of evidence).
 We suggest that longer courses are appropriate in
patients who have a
1. slow clinical response,
2. Undrainable foci of infection,
3. Bacteremia with S aureus,
4. Some fungal and viral infections,
5. Immunologic deficiencies,including neutropenia.

20.  No sustained systemic antimicrobial prophylaxis in
patients with severe inflammatory states of
noninfectious origin (e.g., severe pancreatitis, burn
injury) (BPS).
 Dosing - based on pharmacokinetics and
pharmacodynamics
 Empiric combination.
 Combination therapy not be routinely used for
ongoing treatment of most other serious
infections,including bacteraemia and sepsis without
shock.

21.  No combination therapy for the routine treatment of
neutropenic sepsis/bacteremia (strong R /
moderate E).
 If combination therapy is initially used for septic
shock,de-escalate with discontinuation of
combination therapy within the first few days in
response to clinical improvement and/or evidence
of infection resolution.
 This applies to both targeted (for culture-positive
infections) and empiric (for culture-negative
infections) combination therapy (BPS).

22. ANTIMICROBIAL THERAPY
Measurement of procalcitonin levels can be used to
support shortening the duration of antimicrobial therapy
in sepsis patients (weak recommendation, low quality of
evidence).
Procalcitonin levels can be used to support the
discontinuation of empiric antibiotics in patients who
initially appeared to have sepsis, but subsequently have
limited clinical evidence of infection (weak
recommendation, low quality of evidence).

24. SOURCE CONTROL
A specific anatomic diagnosis of infection requiring
emergent source control be identified or excluded as
rapidly as possible in patients with sepsis or septic shock,
and that any required source control intervention be
implemented as soon as medically and logistically
practical after the diagnosis is made (BPS).
Prompt removal of intravascular access devices that are a
possible source of sepsis or septic shock after other
vascular access has been established (BPS).

25. FLUID THERAPY
Crystalloids as the fluid of choice for initial resuscitation
and subsequent intravascular volume replacement in
patients with sepsis and septic shock (strong
recommendation, moderate quality of evidence).
Against using hydroxyethyl starches (HESs) for
intravascular volume replacement in patients with sepsis
or septic shock (strong recommendation, high quality of
evidence).

26. FLUID THERAPY
Using albumin in addition to crystalloids for initial
resuscitation and subsequent intravascular volume
replacement in patients with sepsis and septic
shock when patients require substantial amounts of
crystalloids (weak recommendation, low quality of
evidence).

27. VASOPRESSORS
Norepinephrine as the first choice vasopressor (strong
recommendation, moderate quality of evidence).
Adding either vasopressin (up to 0.03 U/min) (weak
recommendation, moderate quality of evidence) or
epinephrine (weak recommendation, low quality of
evidence) to norepinephrine with the intent of raising
MAP to target, or adding vasopressin (up to 0.03 U/min)
(weak recommendation, moderate quality of evidence) to
decrease norepinephrine dosage.

28. VASOPRESSORS
Using dopamine as an alternative vasopressor agent to
norepinephrine only in highly selected patients (e.g.,
patients with low risk of tachyarrhythmias and absolute or
relative bradycardia) (weak recommendation, low quality
of evidence).
Against using low-dose dopamine for renal protection
(strong recommendation, high quality of evidence).

29. VASOPRESSORS
Using dobutamine in patients who show evidence of
persistent hypoperfusion despite adequate fluid
loading and the use of vasopressor agents (weak
recommendation, low quality of evidence).

30. VASOPRESSORS
All patients requiring vasopressors have an arterial
catheter placed as soon as practical if resources
are available (weak recommendation, very low
quality of evidence).

31. Vasopressor Use for Adult Sepc Shock
(with guidance for steroid administraon)
Iniate norepinephrine (NE) and trate up to 35-90 μg/min
to achieve MAP target 65 mm Hg
MAP target
achieved
Contnue norepinephrine alone or
add vasopressin 0.03 units/min
with anticipaton of decreasing
norepinephrine dose
MAP target not achieved
and judged
poorly responsive to NE
Add vasopressin up to
0.03 units/min to achieve
MAP target*
MAP target
achieved
MAP target
not achieved
Add epinephrine up to
20-50 μg/min to achieve MAP
target**
MAP target
achieved
MAP target
not achieved
Add phenylephrine up to
200-300 μg/min to
achieve MAP target***
* Consider IV steroid administraon
** Administer IV steroids
*** SSC guidelines are silent on phenylephrine
Notes:
• Consider dopamine as niche vasopressor in the presence
of sinus bradycardia.
• Consider phenylephrine when serious tachyarrhythmias
occur with norepinephrine or epinephrine.
• Evidence based medicine does not allow the firm
establishment of upper dose ranges of norepinephrine,
epinephrine and phenylephrine and the dose ranges
expressed in this figure are based on the authors
interpretaon of the literature that does exist and personal
preference/experience. Maximum doses in any individual
paent should be considered based on physiologic response
and side effects.

32. H-
CORTICOSTE
ROIDS
L-
ANTICOAGULATI
ON
J-
IMMUNOG
LOBULINS
N-SEDATION
AND
ANALGESIA
I-BLOOD
PRODUC
TS
K-BLOOD
PURIFICATION
M-
MECHANIC
AL
VENTILATI
ON

33. CORTICOSTEROIDS
Against using IV hydrocortisone to treat septic shock
patients if adequate fluid resuscitation and vasopressor
therapy are able to restore hemodynamic stability. If this
is not achievable, we suggest IV hydrocortisone at a
dose of 200 mg per day (weak recommendation, low
quality of evidence).

34. BLOOD PRODUCT ADMINISTRATION
RBC transfusion occur only when hemoglobin
concentration decreases to <7.0 g/dL in adults in
the absence of extenuating circumstances, such as
myocardial ischemia, severe hypoxemia, or acute
hemorrhage (strong recommendation, high quality
of evidence).
NO FFP AND ERYTHROPOIETIN

35. BLOOD PRODUCT ADMINISTRATION
Prophylactic platelet transfusion
when counts are <10,000/mm3 in the absence of
apparent bleeding and
when counts are <20,000/mm3 if the patient has a
significant risk of bleeding.
Higher platelet counts (≥50,000/mm3) are advised for
active bleeding, surgery, or invasive procedures (weak
recommendation, very low quality of evidence).

36. MECHANICAL VENTILATION
 Tidal volume-6ml/kg
 Plateau pressure<30 cm of H2O
 PEEP- Higher
 Recruitment maneuvers
 Prone over supine(PaO2/FiO2<150)
 No to HFOV
 NIV- No recommendation
 Neuromuscular blocking agents-<48 hours
+

37.  No Beta 2 agonists for the treatment of patients
with sepsis-induced ARDS without bronchospasm
 No to routine use of the pulmonary artery catheter
 Lower tidal volumes even in adult patients with
sepsis-induced respiratory failure without ARDS
 Head of the bed elevated between 30 and 45
degrees
 Daily SBTfor weaning using a weaning protocol
 N. SEDATION AND ANALGESIA
 Continuous or intermittent sedation be minimized in
mechanically ventilated sepsis patients

38. O-GLUCOSE
CONTROL
Q-
BICARBONAT
E
S-STRESS
ULCER
PROPHYLA
XIS
R-VTE
PROPHYLA
XISP-RRT
T-
NUTRITION
GOALS
OF
CARE

39. GLUCOSE CONTROL
A protocolized approach to blood glucose
management in ICU patients with severe sepsis
commencing insulin dosing when 2 consecutive
blood glucose levels are >180 mg/dL. This
protocolized approach should target an upper
blood glucose ≤180 mg/dL rather than an upper
target blood glucose ≤ 110 mg/dL (strong
recommendation, high quality of evidence).

40. GLUCOSE CONTROL
Blood glucose values be monitored every 1–2 hrs until
glucose values and insulin infusion rates are stable
and then every 4 hrs thereafter in patients receiving
insulin infusions (BPS).
Arterial blood better than capillary blood

41. RENAL REPLACEMENT THERAPY
 Continuous or Intermittent RRT in AKI
 Continuous therapy in haemodynamically unstable
patient
 No to RRT only for increased creatinine or oliguria
in the absence of definitive indications

42. Q.BICARBONATE THERAPY
R.VTE PROPHYLAXIS
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).
LMWH OR UFH BUT LMWH better
Combination pharmacological and mechanical better
Mechanical if pharmacological contraindicated

43. STRESS ULCER PROPHYLAXIS
 Stress ulcer prophylaxis using H2 blocker or proton
pump inhibitor in patients with GI bleeding risk
factors
 Coagulopathy
 Mechanical ventilation for at least 48 hrs
 Hypotension
o PPIs > H2RA*
o Patients without risk factors do not receive
prophylaxis

44. NUTRITION*
o Oral or enteral feeding, as tolerated, rather than
complete fasting or only i/v glucose within the first
48 hours after diagnosis of severe sepsis/septic
shock
o Low dose feeding > full caloric feeding in the first
week (upto 500 Calories/day, advancing as
tolerated)
o Use i/v glucose + enteral nutrition rather than TPN
alone or parenteral nutrition + enteral feeding in the
first 7 days
 Nutrition without specific immunomodulating
supplementation

45. SETTING GOALS OF CARE
 Discuss goals of care and prognosis with patients
and families
 Goals of care to be incorporated into treatment and
end-of-life care planning

46. TAKE HOME MESSAGE
RESUCITATION
☑ Crystalloid ≥ 30 ml/kg within 3
hrs
☐ Target MAP ≥ 65 mmHg
☐ Normalize lactate
☒ EGDT, CVP, ScvO2
ANTIMICROBIALS
☑ Empiric broad-spectrum ABx
within 1 hr
☐ Procalcitonin to support the
discontinuation of ABx
DETECTION OF SOURCE OF
INFECTION
☐ as soon as possible
FLUIDS
☐ Crystalloids ± albumin
☒ HESs
VASOPRESSORS
☑ Norepinephrine ± vasopressin or
epinephrine
☐ Dopamine for bradycardia only
STEROIDS
☐ Hydrocortisone 200 mg/day for
refractory shock
BLOOD TRANSFUSION
☑ pRBC: Hb < 7
☐ platelet: 10K, 20K, 50K
GLUCOSE CONTROL < 180
mg/dl

47. THANK YOU