This document provides guidelines for the management of severe sepsis and septic shock according to the Surviving Sepsis Campaign. It outlines diagnostic criteria for sepsis, septic shock, and organ dysfunction. It also details bundles of care that should be completed within 3 and 6 hours of diagnosis, including measuring lactate levels, administering antibiotics and fluids, and applying vasopressors if needed. The guidelines provide recommendations on initial resuscitation, antibiotic therapy, source control, infection prevention, fluid therapy, vasopressors, corticosteroids, mechanical ventilation, and other supportive care measures for managing sepsis.

1. Surviving Sepsis Campaign
International Guidelines for Management
of Severe Sepsis & Septic Shock
Dr Rimita Dey & Dr Raja Basu
Department of Critical Care Medicine
Peerless Hospital & B K Roy Research Center
Kolkata
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2. Systemic Inflammatory Response Syndrome(SIRS)
To SEPTIC SHOCK

3. Diagnostic Criteria for Sepsis
Infection(documented or suspected)
& some of the following :
General Variables
Fever > 100.9 F Hypothermia < 96.8 F
Heart rate >90 Respiratory rate > 20
Altered Mental status Hyperglycemia >140
(absence of Diabetes)
Significant edema
or positive Fluid Balance ( >20 ml/kg over 24 hrs)

4. Inflammatory variables
Leucocytosis (WCC > 12000)
Leucopenia ( WCC < 4000)
Normal WCC with > 10 % immature forms
Plasma CRP > two SD above the normal
Plasma Procalcitonin > two SD above the normal
Hemodynamic Variables
Arterial Hypotension
( SBP < 90, MAP < 70, OR
an SBP decrease > 40 in adults OR
SBP Less than two SD below normal for age)
WCC- White Cell Count, CRP- C Reactive Protein, SD- Standard Deviation,
SBP- Systolic Blood Pressure, MAP- Mean Arterial Pressure

5. Organ Dysfunction Variables (Severe Sepsis Criteria)
Arterial Hypoxemia (PaO2 /FiO2 <300)
Acute Oliguria (UO< 0.5 ml/kg/hr for at least
2 hours despite fluid resuscitation)
Creatinine increase > 0.5 mg/dl
Coagulation abnormalities (INR> 1.5 or aPTT >60s)
Ileus (absent bowel sounds)
Thrombocytopenia ( < I lakh)
Hyperbilirubinemia ( > 4 mg/dl)
Tissue Perfusion Variables
HyperLactaemia ( > 1 mmol/L)
Decreased Capillary Refilling Time or Mottling

6. SURVIVING SEPSIS CARE BUNDLES
TO BE COMPLETED WITHIN 3 HOURS
1.Measure Lactate Levels
2.Obtain Blood Cultures prior to administration
of Antibiotics.
3.Administer broad spectrum Antibiotics
4.Administer 30ml/kg Crystalloid for low BP or
lactate level – 4

7. TO BE COMPLETED WITHIN 6 HOURS
5. Apply Vasopressors (for hypotension that does
not respond to the initial fluid resuscitation) to
maintain a MAP > 65.
6. In the event of persistent hypotension despite
volume resuscitation (septic Shock) Or
initial lactate being > 4
- Measure CVP & CVP saturation(ScvO2)
7. Remeasure Lactate levels if the initial lactate
was elevated.
MAP = Diastolic BP + (Systolic BP – Diastolic BP)
3

8. SURVIVING SEPSIS CARE BUNDLES

9. Initial Resuscitation
• Begin Resuscitation immediately in patients
with low BP or elevated serum lactate > 4;
DONOT delay pending ITU admission.
• Resuscitation Goals:
CVP 8-12 mm Hg
MAP > 65mm Hg
Urine output > 0.5ml/Kg/Hr
Central Venous O2 saturation >70%, or
mixed venous >65%.

10. If venous o2 saturation target is not achieved :
• Consider further fluids
• Transfuse Packed RBCs to achieve a
haematocrit of > 30%
And/ or
• Dobutamine infusion max 20 mic/kg/min
A higher target CVP of 12-15 mm Hg is
recommended in the presence of mechanical
ventilation or pre-existing decreased ventricular
compliance.

11. Diagnosis
Obtain appropriate Blood cultures before
starting antibiotics provided this does not
significantly delay antimicrobial administration
• obtain two or more blood cultures(BCs).
• one or more BCs should be percutaneous.
• one BC from each vascular access device in place
>48hrs.
• Culture other sites as clinically indicated (CSF, Ascitic
Fluid).
Perform imaging studies promptly in order to
Confirm & sample any source of infection; if safe
to do so.

12. Antibiotic Therapy
• Begin IV Antibiotics as early as possible, & always within the
first hour of recognizing severe sepsis and septic shock.(Grade 1B)
• Broad-spectrum : one or more agents active against likely
bacterial/ fungal pathogens & with good penetration into the
presumed source. (Grade 1B)
• Duration of therapy typically limited to 7-10 days; longer if
response is slow, undrainable foci of infection, or
immunogenic deficiencies & neutropenic patients, or
Bacteremia with S.Aureus. (Grade 2C)
• Use of low Procalcitonin level or similar biomarkers to assist
discontinuation of empiric antibiotics in patients who initially
appeared septic, but have no subsequent evidence of
infection. (Grade 2C)
• Antiviral initiated as early as possible in severe sepsis of viral
origin.

13. • Reassess antimicrobial regimen daily to optimize
efficacy, prevent resistance, avoid toxicity &
minimize costs.
– Consider combination therapy in Pseudomonas & Acenetobacter
infection
– Treat with an extended spectrum Beta-lactum & either an
aminoglycoside or a fluroquinolone for Pseudomonas bacteremia.
– A combination of Beta-lactum & Macrolide for patients with
Streptococcus Pneumoniae infections
– Consider combination empiric therapy in neutropenic patients
– Combination therapy no more than 3-5 days &
de-escalation following susceptibilities.
• Antimicrobials should NOT be used in patients with
severe inflammatory states determined to be of
noninfectious cause.

14. Source Identification & control
• A specific anatomic site of infection should be
established as rapidly as possible & within the first 6
hours of presentation.
• Formally evaluate patient for a focus of infection
amenable to source control measures (e.g. abscess
drainage, tissue debridement)
• Implement source control as soon as possible
following successful initial resuscitation.
– Exception : infected pancreatic necrosis, where surgical
intervention is best delayed.
• Remove Intravascular access devices if potentially
infected.

15. Infection Prevention
• Selective oral decontamination and selective
digestive decontamination should be
introduced and investigated as a method to
reduce the incidence of ventilator-associated
pneumonia.
• Oral chlorhexidine gluconate be used as a
form of oropharyngeal decontamination to
reduce the risk of ventilator-associated
pneumonia in ICU patients. (Grade 2B)

16. Fluid Therapy

17. Crystalloids Solutions

18. Vasopressors

19. • Dopamine as an alternative to NA is
recommended only for patients with low risk of
tachyarrhythmia & absolute or relative
bradycardia.
• Phenylephrine is NOT recommended for septic
shock except in (Grade 1C)
– NA associated serious arrhythmias
– C.Output is known to be high but BP is low
– As salvage therapy when combined vasopressor-inotrope
drugs & low dose vasopressin have all failed to achieve MAP.
• Do NOT use low dose dopamine for Renal
Protection.(Grade 1A)
• All patients requiring Vasopressors should have
an arterial catheter placed as soon as practical.

20. Ionotropic Therapy
• A trial of Dobutamine infusion of up to
20microgm/kg/min may be administered
alone or added to vasopressor in presence of
–Myocardial dysfunction suggested by
elevated cardiac filling pressures & low
cardiac output, or
–Ongoing signs of hypo perfusion, despite
achieving intravascular volume & adequate
MAP. (Grade 1C)

21. Corticosteroids
• Do NOT use IV Hydrocortisone to treat adult septic
shock if adequate fluid resuscitation & vasopressor
therapy is able to restore hemodynamic stability.
Incase this is not achieved IV Hydrocortisone alone
@ 200mg IV OD may be used.(Grade 2C)
• ACTH stimulation test is NOT to be used to identify
adults with septic shock receiving Hydrocortisone.
• When Hydrocortisone is given, use continuous flow.
• Steroid therapy may be weaned when vasopressors
are no longer required.
• Do NOT use corticosteroids to treat sepsis in the
absence of shock.

22. Blood Product Administration
• Transfuse Red Blood Cells when Hb decreases to < 7
& target a Hb of 7-9 in adults.(Grade 1B)
• Higher Hb level may be required in presence of
myocardial ischemia, severe hypoxemia, or acute
hemorrhage.
• Erythropoietin not recommended as a treatment of
sepsis related severe anemia.(Grade 1B)
• FFP should only be used to correct clotting
abnormalities in the presence of bleeding or
planned invasive procedures. (Grade 2D)
• Antithrombin should not be used for the treatment
of severe sepsis. (Grade 1B)

24. Mechanical ventilation in Sepsis
induced ARDS
• Target a Tidal volume of 6ml/kg of predicted body
wt.(vs. 12ml/kg). (Grade 1A)
• Plateau pressure should be measured in pts with
ARDS & Target an initial upper limit pressure <30
cm H2o in a passively inflated lung.
• PEEP should be applied to avoid alveolar collapse
at end expiration (atelectrauma). (Grade 1B)
• Higher rather than lower levels of PEEP should be
used in sepsis associated ARDS. (Grade 2C)

25. • Recruitment maneuvers should be used in sepsis
patients with severe refractory hypoxemia.
• Prone positioning should be considered in ARDS
pts requiring potentially injurious levels of FiO2 or
plateau pressures.
• Ventilated pts should be positioned at 30-45’
head elevation to limit aspiration risk & VAP.(Grade
1B)
• NIV should be in only that minority of ARDS
patients with mild to moderate hypoxemic
respiratory failure. The pts need to be
haemodynamically stable, comfortable easily
arousable, able to protect /clear their airway &
expected to recover rapidly.

26. • Use a weaning protocol & a spontaneous breathing trial (SBT)
regularly to evaluate the potential for discontinuing mechanical
ventilation. (Grade 1A)
• SBT options include a low level of pressure support with CPAP 5 or a
T-piece.
• Before SBT pts should be
– Arousable
– Haemodynamically stable
– Have no new potentially serious conditions
– Have low ventilatory & end-expiratory pressure requirement
– Require FiO2 that can be safely delivered with a face mask or nasal cannula.
• Do Not use a pulmonary catheter for the routine monitoring of pts
with ARDS . (Grade IA)
• Use a conservative rather than liberal fluid strategy for ARDS pts
without any evidence of tissue hypo perfusion.
• Do NOT use beta 2-agonists for the treatment of sepsis induced ARDS
unless there is specific indication such as bronchospasm.

27. Sedation, Analgesia & Neuromuscular
Blocking Agents(NBMAs)
• Continuous or intermittent sedation should be minimized
in mechanically ventilated sepsis pts targeting specific
titration endpoints. (Grade 1B)
• NBMAs should be avoided if possible in septic pts without
ARDS.(due to risk of prolonged NM blockade following
discontinuation)
• If NMBAs are needed, either intermittent bolus as required
or continuous infusion with Train of Four monitoring of the
depth of blockade is advised. (Grade 1C)
• A short course of NMBA of NOT greater than 48hrs for pts
with early sepsis induced ARDS & a PaO2/ FiO2 < 150 is
advised.

28. Glucose Control
• In patients with severe sepsis start insulin dosing
when 2 consecutive blood sugar reading are > 180.
• A protocolized approach should target an upper level
of < 180 rather than a upper target blood glucose
level of < 110. (Grade 1A)
• Blood glucose monitoring every 1-2 hrs until glucose
values & insulin infusion rates are stable & thereafter
every 4hrs. (Grade 1C)
• Use IV insulin in pts with severe sepsis.
• Interpret with caution low glucose levels obtained
with point of care testing as these techniques may
overestimate arterial blood or plasma glucose values

29. Renal Replacement Therapy
& Bicarbonate
• CRRT & Intermittent HD are equivalent in Severe
Sepsis and ARF. (Grade 2B)
• Use continuous therapies to facilitate
management of fluid balance in hemodynamically
unstable septic pts.
• Do NOT use Sodium Bicarbonate for the purpose
of improving hemodynamics or reducing
vasopressor requirements when treating hypo
perfusion induced lactic acidemia with a pH>7.15
(Grade 2B)

30. DVT Prophylaxis
• Pts with severe sepsis should receive daily
phamacoprophylaxis against VTE. (Grade 1B)
• Use once daily S/C LMWH (vs BD dosing of UFH & vs TDS
dosing of UFH). (Grade 1B)
• If CrCl <30 use Dalteparin. (Grade 1A)
• Whenever possible treat with a combination of
pharmacological therapy & intermittent pneumatic
compression.
• Where heparin is C/I (low platelets, severe
coagulopathy, active bleeding or recent ICH) mechanical
prophylactic treatment (compression stocking or
devices) should be used.

31. Stress Ulcer Prophylaxis
• Use H2 Blocker or Proton Pump Inhibitor in pts
who have bleeding risk factors. (Grade 1B)
• When stress ulcer prophylaxis is needed use PPI
rather than H2 RA.
• Pts without risk factors should not receive
prophylaxis

32. Nutrition
• Give oral or enteral feeding, as tolerated rather than
either complete fasting or only IV glucose within the first
48 hrs of diagnosing severe sepsis.
• Avoid mandatory full caloric feeding in the first week
instead suggest low dose feeding (e.g. upto 500 calories
per day) then advancing only as tolerated.
• Use IV glucose & Enteral Nutrition rather than TPN alone
or Parenteral nutrition in conjugation with enteral
feeding during the first 7 days of diagnosis.
• Use nutrition with no specific immunomodulating
supplementation (rather than nutrition providing specific
immunomodulating supplementation) in severe sepsis.

33. Setting Goals of Care
• Discuss prognosis & goals of care with
patients & their families.
• Incorporate goals of care into the treatment &
end-of-life planning, utilizing the palliative
care principles, where possible.
• Address goals of care as early as feasable, but
no later than within 72 hrs of admission.

34. THANK YOU