This is guide to sepsis and Septic Shock management in adult patient derived from Surviving sepsis guidelines till date.

1. Sepsis and Septic Shock
management guidelines 2019
Insp. Dr. Sunder Chapagain
Nepal APF Hospital
Kathmandu

2. Definition (3rd International Consensus
Definitions for Sepsis and Septic Shock)
“life threatening organ dysfunction caused by a dysregulated host
response to infection”
• Infection: the invasion of normally sterile tissue by organisms
resulting in infectious pathology
• Organ Dysfunction: Increase of 2 or more points in SOFA Score
(Sepsis-related/Sequential Organ Failure Assessment)

7. 2018 update to SSC bundle of care

9. 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.

10. 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.

11. 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

12. 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)

13. • 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 shouldnot be administered for >3-5
days  de-escalation to appropriate single therapy.
• Duration of therapy: 7-10 days (longer for slower response)

14. Antibiotic review: Sepsis from
pulmonary source
Infection Example antibiotic regimens
CAP β-lactam1 + azithromycin
β-lactam1 + respiratory FQ2
HCAP antipseudomonal β-lactam3
+ aminoglycoside4 or antipseudomonal FQ5
+ vancomycin or linezolid
1 ceftriaxone, cefotaxime, ampicillin/sulbactam
2 levofloxacin, moxifloxacin
3 piperacillin/tazobactam, cefepime, meropenem, imipenem, doripenem
4 gentamicin, tobramycin, amikacin
5 levofloxacin, ciprofloxacin
Clin Infect Dis 2007;44:S27-72
Am J Respir Crit Care Med 2005;171:388-416

15. Antibiotic review: Sepsis from catheter-
related bloodstream infection (CRBSI)
Infection Example antibiotic regimens
CRBSI vancomycin or daptomycin1
+ antipseudomonal β-lactam2,3
+/- aminoglycoside4
Fungemia
risk factors
+ fluconazole or echinocandin5
1 if high rates of vancomycin MIC ≥ 2 µg/mL
2 piperacillin/tazobactam, cefepime
3 meropenem, imipenem, doripenem
4 gentamicin, tobramycin, amikacin
5 caspofungin, micafungin, anidulafungin
Clin Infect Dis 2009;49:1-45

16. Antibiotic review: Sepsis from
urinary source
Infection Example antibiotic regimens
Urosepsis 3rd generation cephalosporin1
+/- aminoglycoside2 or FQ3
Urological interventions or
MDR risk factors
antipseudomonal β-lactam4,5
1 ceftriaxone, cefotaxime
2 gentamicin, tobramycin, amikacin
3 levofloxacin, ciprofloxacin
4 piperacillin/tazobactam, cefepime
5 meropenem, imipenem, doripenem
Int J Urol 2013; Epub ahead of print.

17. Antibiotic review: Sepsis from
unknown source
Infection Example antibiotic regimens
Unknown antipseudomonal β-lactam1,2
+ aminoglycoside or antipseudomonal FQ3
+ vancomycin
Fungemia
risk factors
+ fluconazole or echinocandin4
1 piperacillin/tazobactam, cefepime
2 meropenem, imipenem, doripenem
3 levofloxacin, ciprofloxacin
4 caspofungin, micafungin, anidulafungin
Clin Infect Dis 2009;48:503-35

18. 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

19. 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

21. 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 (Salvage Therapy)
• Low dose vasopressin not recommended
• Dopamine: alternative to Norad only in selected patients
• Patients with low risk of tachycardia or absolute relative bradycardia

22. • 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

24. 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

25. Other Supportive Therapy
1. Infection Prevention:
• Limited patient contact
• Hand washing
• Prevent Ventilator associated pneumonia
• Propped Up position
• Chlorhexidine mouth wash
2. 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.

26. • 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
• No use of Selenium or Immunoglobulins

27. 3. 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

28. • Weaning Protocol:
• Arousable
• Hemodynamically stable (without or minimal vasopressors)
• No new potentially serious conditions
• Low ventilatory and end-expiratory pressures requirements
• Low FIO2 requirement (≤ 40%)

29. 4. Glucose Control
• 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.
5. Bicarbonate:
• NOT to be used if pH ≥ 7.15
• Used after calculating deficit
• Shouldn't be corrected rapidly

30. 6. DVT Prophylaxis:
• Daily LMWH (Inj. Enoxaparin 40 mg SC OD)
• If CrCl < 30 ml/min, use Dalteparin or another form of LMWH that has low
degree of renal metabolism.
• Graduated compression stockings or intermittent compression devices
7. Stress Ulcer Prophylaxis:
• H2 Histamine blocker
• Proton Pump Inhibitors

31. 8. Nutrition:
• Oral or enteral feeding as tolerated within the first 48 hours of diagnosis
• Low dose feeding(upto 500 calories/day) in 1st week, advancing only as
tolerated.
• Use IV glucose and enteral nutrition rather than TPN alone in first 7 days
Address goal of care as early as possible, but no later than 72 hours of
admission in ICU

32. References
• Surviving Sepsis Campaign-3 (SSC-3) and 2016
• SSC hour 1 bundle (2018) (survivingsepsis.org)

33. Thank You