This document provides an update to the 2012 Surviving Sepsis Campaign guidelines with 93 statements on the early management and resuscitation of patients with sepsis and septic shock. It includes definitions of sepsis and septic shock, and provides recommendations on initial resuscitation, antimicrobial therapy, source control, fluid therapy, vasoactive medications, corticosteroids, blood products, immunoglobulins, anticoagulants, mechanical ventilation, sedation/analgesia, glucose control, renal replacement therapy, VTE prophylaxis, stress ulcer prophylaxis, and nutrition.

1. Dr Khaled Zeineldin, MD
Lecturer Critical Care Medicine Department,
Cairo University

2.  Objective:
 To provide an update to Survivng Sepsis Campaign 2012
 Conclusion:
 Provided 93 statements on early management and
resuscitation of patients with sepsis and septic shock
 32 were strong recommendations
 39 were weak recommendations
 18 were best practice statement
 No recommendation was provided for 4 questions

3. Definitions
 Sepsis:
 A life threatening organ dysfunction caused by a
dysregulated host response to infection
 Septic Shock:
 Sepsis with circulatory and cellular/metabolic
dysfunction associated with a higher risk of mortality

4. Initial Resuscitation
 Sepsis and septic shock are medical emergencies, and
recommend that treatment and resus begin immediately
(BPS)
 Resuscitation to start by at least 30ml/Kg of IV crystalloids
given within the first 3 hours (strong recommendation)
 Following initial resus, additional fluids be guided by
frequent assessment of haemodynamic status (BPS)
 Further haemodynamic assessment to determine the type of
shock if clinical examination does not lead to clear diagnosis
(BPS)

5. Initial Resuscitation
 Dynamic over static variables to be used to predict fluid
responsiveness (weak recommendation)
 Initial target mean arterial pressure of 65mmHg in
patients with septic shock requiring vasopressors
(strong recommendation)
 Guiding resuscitation to normalize lactate in patients
with elevated lactate levels as a marker of tissue of
hypoperfusion (weak recommendation)

6. Screening for Sepsis AND
Performance Improvement
 Hospitals and hospital systems should have a
performance improvement program for sepsis,
including sepsis screening for acutely ill, high risk
patients (BPS)

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

8. Antimicrobial Therapy
 Administration of IV antimicrobials be initiated as soon as
possible after recognition and within one hour fro both
sepsis and septic shock (strong recommendation)
 Empiric broad spectrum therapy with one or more
antimicrobials to cover all likely pathogens (including
bacterial and potentially fungal or viral)(strong
recommendation)
 Empiric antimicrobial therapy be narrowed once pathogen
identifies and sensitivities established and/or adequate
clinical improvement noted (BPS)

9. Antimicrobial Therapy
 Recommend against systemic antimicrobial prophylaxis in
patients with severe inflammatory states of noninfectious
origin (severe pancreatitis, burn injury) (BPS)
 Dosing strategies of antimicrobials be optimized based on
accepted pharmacokinetic/pharmacodynamic principles
and specific drug properties (BPS)
 Empiric combination therapy (using atleast two antibiotics
of different antimicrobial classes) aimed at the most likely
bacterial pathogen (weak recommendation)

10. Antimicrobial Therapy
 Combination therapy not be routinely used for ongoing
treatment of most serious infections, including bacteremia
and sepsis without shock (weak recommendation)
 Recommend against combination therapy for the routine
treatment of neutropenic sepsis/ bacteremia (strong
recommendation)
 If combination therapy is initially used fro septic shock,
recommend de-escalation with discontinuation of
combination therapy within the first few days in response
to clinical improvement (BPS)

11. Antimicrobial Therapy
 Antimicrobial treatment duration of 7-10 days is adequate
for most serious infections (weak recommendation)
 Longer courses are appropriate in patienst who have a slow
clinical response, undrainable foci of infection, bacteremia
with S.aureus, some fungal and viral infections,
immunological deficiencies (weak recommendation)
 Shorter courses are appropriate in some patients with rapid
clinical resolution following effective source control of
intrabdominal or urinary sepsis (weak recommendation)

12. Antimicrobial Therapy
 Daily assessment for de-escalation of antimicrobial therapy
(BPS)
 Measurement of procalcitonin levels can be sued to
support shortening the duration of antimicrobial therapy
(weak recommendation)
 Procalcitonin levels can be used to support the
discontinuation of emperic antibiotics in patients who
initially appeared to have sepsis, but subsequently have
limited clinical evidence of infection (weak
recommendation)

13. Source Control
 A specific anatomic diagnosis of infection requiring
emergent source control be identified or excluded as
rapidly as possible , and that any required source
control intervention be implemented after the
diagnosis is made (BPS)
 Prompt removal of intravascular access devices that
are a possible source of sepsis after other vascular
access has been established (BPS)

14. Fluid Therapy
 Fluid challenge technique be applied where fluid
administration is continued as long as hemodynamic
factors continue to improve (BPS)
 Crystalloids as the fluid of choice for initial
resuscitation and subsequent intravascular volume
replacement (strong recommendation)
 Balanced crystalloids or saline for fluid resuscitation
(weak recommendation)

15. Fluid Therapy
 Using albumin in addition to crystalloids for initial
resuscitation and subsequent intravascular volume
replacement when patients require substantial amounts of
crystalloids (weak recommendation)
 Recommend against using hydroxyethyl starches for
intravascular volume replacement (strong
recommendation)
 Using crystalloids over gelatins when resuscitating patients
(weak recommendation)

16. Vasoactive Medications
 Norepinephrine as the first choice vasopressor (strong
recommendation)
 Adding either vasopressin (up to 0.03U/min) or
epinephrine to norepinephrine with the intent of raising
MAP to target(weak recommendation)
 Using dopamine as an alternative vasopressor agent to
norepinephrine only in highly selected patients (low risk of
tachyarrhythmia and absolute or relative
bradycardia)(weak recommendation)

17. Vasoactive Medications
 Recommend against low dose dopamine for renal
protection (strong recommendation)
 Using dobutamine in patients who show evidence of
persistent hypoperfusion despite adequate fluid
loading and the use of vasopressor agents (weak
recommendation)
 All patients requiring vasopressors have an arterial
catheter placed as soon as possible (weak
recommendation)

18. Corticosteroids
 Suggest 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 200mg/day (weak
recommendation)

19. Blood Products
 RBC transfusion occur only when hemoglobin concentration decreases
to <7 g/dL in absence of myocardial ischemia, severe hypoxemia or
acute hemorrhage (strong recommendation)
 Against use of erythropoietin for treatment of anemia (strong
recommendation)
 Against use of fresh frozen plasma to correct clotting abnormalities in
the absence of bleeding or planned invasive procedures (weak
recommendation)
 Suggest prophylactic platelete transfusion when counts are
<10,000/mm3 in the absence of apparent bleeding, and when counts
<20000/mm3 if patient has significant risk of bleeding, higher counts
>50000/mm3 for active bleeding, surgery or invasive procedures (weak
reecommendation)

20. Immunoglobulins
 Suggest against use of IV immunoglobulins in patients
with sepsis or septic shock (weak recommendation)
 No recommendations regarding the use of blood
purification techniques

21. Anticoagulants
 Recommend against use of antithrombin for the
treatment of sepsis and septic shock (strong
recommendation)
 No recommendation regarding the use of
thrombomodulin or heparin for the treatment of
sepsis or septic shock

22. Mechanical Ventilation
 Using target tidal volume of 6ml/kg PBW compared with 12
ml/kg in sepsis induced ARDS(strong recommendation)
 Using upper limit goal for plateau pressures of 30 cmH2O
over higher plateau pressures in sepsis induced ARDS
(strong recommendation)
 Using higher PEEP over lower PEEP in sepsis induced
ARDS (weak recommendation)
 Using recruitment maneuvers in sepsis induced ARDS
(weak recommendation)

23. Mechanical Ventilation
 Using prone over supine position in sepsis induced ARDS
and PaO2/FiO2 ratio<150 (strong recommendation)
 Recommend against use high frequency oscillatory
ventilation in sepsis induced ARDS (strong
recommendation)
 No recommendation made regarding use of non invasive
ventilation in sepsis induced ARDS
 Using neuromuscular blocking agents for <48 hours in
sepsis induced ARDS and PaO2/FiO2 <150 mmHg (weak
recommendation)

24. Mechanical Ventilation
 Conservative fluid strategy in ARDS who donot have
evidence of tissue hypoperfusion (strong
recommendation)
 Against the use of PA catheter in ARDS (strong
recommendation)
 Against use of B2 agonists for treatment of sepsis induced
ARDS (strong recommendation)
 Lower tidal volumes over higher tidal volumes in ARDS
(weak recommendation)

25. Mechanical Ventilation
 Head of the bed to be elevated between 30-45 degrees to
limit aspiration and to prevent VAP (strong
recommendation)
 Using spontaneous breathing trials in mechanically
ventilated patients who are ready for weaning (strong
recommendation)
 Using a weaning protocol in mechanically ventilated
patients in sepsis induced respiratory failure who can
tolerate weaning (strong recommendation)

26. Sedation and Analgesia
 Continuous or intermittent sedation be minimized in
mechanically ventilated sepssi patients targeting
specific titration end points (BPS)

27. Glucose Control
 a protocolized approach to blood glucose management ,
insulin dosing when two consecutive blood glucose levels
>180mg/dl, target blood glucose levels<180mg/dl (strong
recommendation)
 Blood glucose monitoring every 1 to 2 hours until glucose
values and insulin infusion rates are stable then every 4
hours thereafter (BPS)
 Use arterial blood rather than capillary blood for blood
glucose testing(weak recommendation)

28. Renal Replacement Therapy
 Either continuous RRT or intermittent RRt be used in patients with
sepsis induced AKI (weak recommendation)
 Using CRRT to facilitate management of fluid balance in
haemodynamically unstable septic patients (weak recommendation)
 Against the use of RRT with sepsis induced AKI for increase creatinine
or oliguria without other definitive indication for dialysis (weak
recommendation)
 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)

29. Venous Thromboembolism
Prophylaxsis
 Pharmacologic prophylaxis against venous
thromboembolism in the absence of contraindication(
strong recommendation)
 Recommend LMWH rather than UFH for VTE prophylaxis
(strong recommendation)
 Combining pharmacologic VTE prophylaxis and
mechanical prophylaxis whenever possible (weak
recommendation)
 Mechanical prophylaxis when pharmacologic VTE is
contraindicated (weak recommendation)

30. Stress Ulcer Prophylaxis
 Stress ulcer prophylaxis should be given in sepsis and
risk factors for GI bleed (strong recommendation)
 Using either proton pump inhibitor or histamine 2
receptor antagonist fro stress ulcer prophylaxis (weak
recommendation)
 Recommend against stress ulcer prophylaxis in
patients without risk factor for GI bleed (BPS)

31. Nutrition
 Recommend against the administration of early parentral
nutrition alone or parentral in combination with enteral
feeding in critically ill patients with sepsis who can be fed
enterally (strong recommendation)
 Recommend against the administration of parenteral
nutrition alone or in combination with enetral feeds overt
the first 7 days in patients with sepsis for whom early
enteral feeding is not feasible (strong recommendation)
 Early initiation of enetral feeding rather than a complete
fast or only IV glucose in patients with sepsis and can be
fed enterally (weak recommendation)

32. Nutrition
 Early trophic/hypocaloric or early full enteral feeding in
patients with sepsis (weak recommendation)
 Against the use of omega 3 fatty acids as immune
supplements (strong recommendation)
 Against routine monitoring of gastric residual volumes
unless feeding intolerance or high risk of aspiration(weak
recommendation)
 Use of prokinetic agents in patients with sepsis and feeding
intolerance (weak recommendation)

33. Nutrition
 Placement of post pyloric feeding tubes in patients with
sepsis with feeding intolerance or high risk of aspiration
(weak recommendation)
 Against use of IV selenium (strong recommendation)
 Against use of arginine (weak recommendation)
 Against use of glutamine (strong recommendation)
 No recommendation about use of carnitine