The document summarizes updated guidelines from the 41th Society of Critical Care Medicine Meeting for treating sepsis. Key changes include recommending crystalloids like saline for initial fluid resuscitation; using norepinephrine as the first choice vasopressor; considering corticosteroids for refractory shock; using higher PEEP and recruitment maneuvers for ARDS; and considering procalcitonin to determine if antibiotics can be stopped. The Surviving Sepsis guidelines were previously criticized for being funded primarily by Eli Lilly without disclosure.

1. Surviving
Sepsis
Guidelines
Updated
Preview from the 41th Society of
Critical Care Medicine Meeting
Jun 16, 2012
http://pulmccm.org/2012/critical-care-review/surviving-sepsis-guidelines-updated-at-sccm-meeting/

2. SIRS Sepsis Severe Sepsis Septic Shock
SIRS with
Systemic Inflammatory Response Organ Dysfunction
Severe Sepsis and Hypotension
Sepsis plus
Syndrome Infection
•
• Elevated Creatinine (>2)Hypotension that does NOT
• Temp < 36 ° C or > 38.3 ° C respond to fluid (500 cc bolus)
• Elevated INR (DIC)
• HR > 90
• Altered Mental Status (GCS <12)
• RR > 20 or PCO2 < 32
• Elevated Lactate (>4)
• WBC < 4K or > 12K or bands > 10%
• Hypotension that responds to fluid
Bone et al. Chest 1992;101:1644

3. 2001;345:1368-77.

4. Guide to Recommendations’
Strengths and Supporting
Evidence
1 = strong recommendation
2 = weak recommendation or suggestion
A = good evidence from randomized trials
B = moderate strength evidence from small
randomized trial(s) or multiple good
observational trials
C = weak or absent evidence, mostly driven by
consensus opinion

5. New Fluid
Resuscitation
Recommendations
Using crystalloids like
normal saline as the initial
fluid resuscitation for
people with severe sepsis.
The initial fluid challenge
should be 1L or more of
crystalloid, and a minimum
of 30 mL/kg of crystalloid
(2.1 L in a 70 kg) in the first
4-6 hours. (Grade 1A)

6. New Fluid
Resuscitation
Recommendations
Incremental fluid boluses
should be continued as
long as patients continue
to improve hemo-
dynamically (in blood
pressure, delta pulse
pressure, or both)
(Grade 1C)

7. New Fluid
Resuscitation
Recommendations
Adding albumin to initial fluid
resuscitation with
crystalloid for severe
sepsis and septic shock
(Grade 2B)
Don’t using hetastarches/
hydroxyethyl starches
greater than 200 kDa in
molecular weight (Grade
1B)

8. New Recommendations for
Vasopressors, Inotropes
Using norepinephrine (Levophed) as
the first choice for vasopressor therapy
(Grade 1B). Vasopressin 0.03 units /
minute is an alternative to norepinephrine,
or may be added to it (Grade 2A)
When a second agent is needed,
epinephrine is weakly-recommended
vasopressor choice (Grade 2B)

9. New Recommendations for
Vasopressors, Inotropes
Dopamine was only recommended in highly
selected patients whose risk for arrhythmias
was felt to be very low and who had a low
heart rate and/or cardiac output (Grade 2C)
Dobutamine is strongly recommended (by
itself or in addition to a vasopressor) for
patients with cardiac dysfunction as evidenced
by high filling pressures and low cardiac
output, or clinical signs of hypoperfusion after
achievement of restoration of blood pressure
with effective volume resuscitation (Grade 1C)

10. Corticosteroid Recommendations
Don’t providing intravenous
corticosteroid therapy to patients for
whom fluid resuscitation and vasopressors
can restore an adequate blood pressure.
For those with vasopressor-refractory
septic shock, they recommend IV
hydrocortisone in a continuous infusion
totaling 200 mg/24 hrs (Grade 2C)

11. Mechanical Ventilation for ARDS
For patients with ARDS due to
severe sepsis:
Using higher levels of PEEP (Grade 2C)
Recruitment maneuvers for patients with
severe hypoxemia while receiving high PEEP
and FiO2 (Grade 2C)
Prone positioning for patients with
PaO2/FiO2 ratios < 100 despite such
maneuvers (Grade 2C)

12. Other New Surviving Sepsis
Guidelines
Using normalization of lactate levels
as an alternate goal in early goal-
directed therapy for severe sepsis,
if central venous oxygenation
monitoring is not available (Grade 2C)

13. Other New Surviving Sepsis
Guidelines
For patients at risk for fungal infection as a
source for severe sepsis, checking one
of the newer assays for invasive
candidiasis such as 1,3-beta-D-glucan,
mannan, or anti-mannan ELISA
antibody testing (Grade 2B/C)

14. Other New Surviving Sepsis
Guidelines
When no infection can be found during
empiric antibiotic therapy, consider
using a low procalcitonin level as a
supportive tool for the decision to
stop antibiotics (Grade 2C).

15. The Surviving Sepsis project was criticized in
the mid 2000s when it was revealed that Eli
Lilly (makers of since-discontinued Xigris)
provided a reported ~90% of the funding,
without disclosure by the committee.
Others (including the committee
itself) felt such criticism was
unfounded and unfair.