2012 Surviving Sepsis Campaign Guidelines SYED

7/26/2019 2012 Surviving Sepsis Campaign Guidelines SYED

1/76

2012 Surviving Sepsis

Campaign Guidelines


2/76

AgendaUnderstand the scope of the sepsis epidemic1

Become familiar with the Surviving SepsisCampaign and the SCCM defined sepsis

bundles2

Recognize how time-criticaltherapies can save lives inthe emergency departments and ICUs

3


3/76

Comparable GlobalEpidemiology

95 cases per 100,000

2 week surveillance

206 French ICUs 95 cases per 100,000

3 month survey

23 Australian/New

Zealand ICUs

51 cases per 100,000

England, Wales andNorthern Ireland.


4/76

Severe Sepsis: Comparison With

Other Major Diseases

0

50

100

150

200

250

300

AIDS* Colon Breast

Cancer

CHF Severe

Sepsis

Cases/100,0

00

Incidence of Severe Sepsis Mortality of Severe Sepsis

0

50,000

100,000

150,000

200,000

250,000

AIDS* Severe

SepsisAMIBreast

Cancer

Deaths/Year

National Center for Health Statistics, 2001.

American Cancer Society, 2001. *American Heart Association. 2000.Angus DC

et al. Crit Care Med.2001


5/76

Sepsis Epidemiology: Effect of the Aging Population

0

5

10

15

20

25

30

35

40

45

0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

Without Comorbidity

With Comorbidity

Overal


6/76

Economics of Sepsis Severe Sepsis

$22,000 per case

US annual cost $16.7Billion

Nosocomial Sepsis

increased LOS - ICU 8 days, Hosp 24 days $40,890 per case

Angus CCM, 2001

Pittet JAMA, 1994


7/76

Time Sensitive Interventions

AMI

StrokeTime is Brain

The sooner that treatment begins, the better are ones

chances of survival without disability.

TraumaThe Golden Hour

Requires immediate response and medical care on the scene.

Patients typically transferred to a qualified trauma center for care.

Door to PCI

Focus on the timely return of blood flow to the affected

areas of the heart.


8/76

Severe Sepsis vs. Current Care Priorities

Care PrioritiesU.S.

Incidence# of Deaths Mortality Rate

AMI (1) 900,000 225,000 25%

Stroke (2) 700,000 163,500 23%

Trauma (3)

(Motor Vehicle)

2.9 million(injuries)

42,643 1.5%

Severe Sepsis (4) 751,000 215,000 29%

Source: (1) Ryan TJ, et al. ACC/AHA Guidelines for management of patients with AMI. JACC. 1996; 28: 1328-1428. (2) American HeartAssociation. Heart Disease and Stroke Statistics2005 Update. Available at: www.americanheart.org. (3) National Highway TrafficSafety Administration. Traffic Safety Facts 2003: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Report ingSystem and the General Estimates System. Available at http://www.nhtsa.dot.gov/. (4) Angus DC et al. Crit Care Med2001;29(7): 1303-1310.
http://www.nhtsa.dot.gov/http://www.nhtsa.dot.gov/


9/76

Surviving Sepsis Campaign

Launched in Autumn 2002 as a collaborativeeffort of European Society of Intensive Care

Medicine, the International Sepsis Forum, andthe Society of Critical Care Medicine

Goal: reduce sepsis mortality by 25% in the next5 years

Guidelines revealed at SCCM in Feb 2004,REVISED 2008

Critical Care MedicineMarch 2004 32(3):858-87.

Website: survivingsepsis.org


10/76

What is sepsis?

Sepsis, Septic Shock,

SIRS (systemic inflammatory responsesyndrome),

SSI (signs and symptoms of infection),

Septicaemia, Bacteraemia,Toxic Shock Syndrome,

Bloodstream infection etc, etc.


11/76

Infection

Inflammatory response to

microorganisms, or

Invasion of normally steriletissues

Systemic Inflammatory

Response Syndrome (SIRS)

Systemic response to a

variety of processes

Sepsis

Infection plus

2 SIRS criteria

Severe Sepsis

Sepsis

Organ dysfunction

Septic shock Sepsis

Hypotension despite fluid

resuscitation

Bone RC et al. Chest.1992;101:1644-55.

ACCP/SCCM Consensus Def ini t ions


12/76

A systemic response to a nonspecific insult

Infection, trauma, surgery, massive transfusion, etc

Defined as 2 of the following:

Temperature >38.3 or 90 min-1

Respiratory rate >20 min-1

White cells 12

Acutely altered mental state

Hyperglycaemia (BM>7.7) in absence of DM

SIRSSEVERE SEPSIS

What is SIRS?


13/76

Pneumonia 50%

Urinary Tract infection

Meningitis

Endocarditis

Device related

Central line

Cannula

Abdominal 25%Pain

DiarrhoeaDistension

Urgent laparotomy

Soft tissue/ musculoskeletal

Cellulitis

Septic arthritisFasciitis

Wound infection

What counts as an infection?


14/76

SIRS due to an infection

what is Sepsis?


15/76

Sepsis with organ dysfunction, hypoperfusion or hypotension

CNS: Acutely altered mental status

CVS: Syst < 90 or mean < 65 mmHg

Resp: SpO2>90% only with new/ more O2

Renal: Creatinine >177 mol/l

or UO 34 mol/l

Bone marrow: Platelets 2 mmol/l

Coagulopathy: INR>1.5 or aPTT>60secs

What is Severe Sepsis?


16/76

Tissue perfusion is not adequate for the

tissuesmetabolic requirements

What is shock?

Septic Shock

Shock secondary to systemic

inflammatory response to a

new infection

Types of Shock

Cardiogenic

Neurogenic

Hypovolaemic

Anaphylacticand


17/76

Tissue perfusion is not adequate for the

tissuesmetabolic requirements

For sepsis, shock is one of:

SBP < 90 mmHg

MBP < 65 mmHg after IV

fluidsDrop of < 40 mmHg

Lactate > 4 mmol/l

What is shock?


18/76

The Sepsis Continuum

A clinical responsearising from anonspecific insult, with2 of the following:

T >38oC or 90 beats/min

RR >20/min

WBC >12,000/mm3or 10% bands

SIRS = systemic inflammatoryresponse syndrome

SIRS with a

presumed

or confirmed

infectiousprocess

Chest 1992;101:1644.

SepsisSIRSSevereSepsis

Septic

Shock

Sepsis with

organ failure

Refractory

hypotension


19/76

Are any 2of the following SIRS criteria present and new to your patient?

Obs: Temperature >38.3 or 20 min-1

Heart rate >90 bpm Acutely altered mental state

Bloods: White cells 12x109/l Glucose>7.7mmol/l

(if patient is not diabetic)

If yes,

patient has SIRS

Severe Sepsis Screen ing Too l


20/76

Is this likely to be due to an infection?For example

Cough/ sputum/ chest pain Dysuria

Abdo pain/ diarrhoea/ distension Headache with neck stiffness

Line infection Cellulitis/wound infection/septic arthritis

Endocarditis

If yes,

patient has SEPSIS

Start SEPSIS BUNDLE


21/76

Severe Sepsis: Ensure Senior Doctor/ITU to

attend NOW!

Check for SEVERE SEPSIS

BP Syst < 90 / Mean < 65 mmHg

(after initial fluid challenge)

Lactate > 4 mmol/l

Urine output < 0.5 ml/kg/hr for 2 hrs

INR > 1.5

aPTT > 60 s

Bilirubin > 34 mol/l

O2 Needed to keep SpO2 > 90%

Platelets < 100 x 109/l

Creatinine > 177 mol/l or UO < 0.5 ml/kg/hr


22/76


23/76


24/76

What is a Bundle?

Specifically selectedcare elements

From evidence basedguidelines

Implemented togetherprovide improved

outcomes compared toindividual elementsalone


25/76


26/76

Initial Resuscitation

Protocolized, quantitative resuscitation of

patients with sepsis- induced tissue

hypoperfusion (defined in this document as

hypotension persisting after initial fluidchallenge or blood lactate concentration 4

mmol/L).


27/76

Initial Resuscitation

Goals during the first 6 hrs of resuscitation:

Central venous pressure812 mm Hg

Mean arterial pressure(MAP) 65 mm Hg

Urine output 0.5 mL/kg/hr

Central venous (superior vena cava) or mixed venous

oxygen saturation 70% or 65%, respectively (grade 1C).

In patients with elevated lactate levels targetingresuscitation to normalize lactate (grade 2C).

Screening for Sepsis and


28/76

Screening for Sepsis and

Performance Improvement

Routine screening of potentially infected

seriously ill patients for severe sepsis to

allow earlier implementation of therapy

(grade 1C).

Hospitalbased performance improvement

efforts in severe sepsis (UG).


29/76

Diagnosis

Culturesas clinically appropriate before

antimicrobial therapyif no significant delay

(> 45 mins) in the start of antimicrobial(s)

(grade 1C).


30/76

Diagnosis

At least 2 sets of blood cultures (both aerobic

and anaerobic bottles) be obtained before

antimicrobial therapy with at least 1 drawn

percutaneouslyand 1 drawn through eachvascular access device, unless the device was

recently (


31/76

Diagnosis

Use of the 1,3 beta-D-glucan assay (grade 2B),

mannan and anti-mannan antibody assays (2C), if

available and invasive candidiasis is in differential

diagnosis of cause of infection.

Imaging studies performed promptly to confirm a

potential source of infection (UG).


32/76

Antimicrobial Therapy

Administration of effective intravenous antimicrobials within the firsthour of recognition of septic shock (grade 1B) and severe sepsiswithout septic shock (grade 1C) as the goal of therapy.

Initial empiric anti-infective therapy of one or more drugs that haveactivity against all likely pathogens (bacterial and/or fungal or viral) andthat penetrate in adequate concentrations into tissues presumed to bethe source of sepsis (grade 1B).

Antimicrobial regimen should be reassessed daily for potentialdeescalation(grade 1B).

Use of low procalcitonin levels or similar biomarkers to assist theclinician in the discontinuation of empiric antibiotics in patients whoinitially appeared septic, but have no subsequent evidence of infection(grade 2C).


33/76


Combination empirical therapy for neutropenicpatients with severe sepsis (grade 2B) and forpatients with difficult-to-treat, multidrug resistantbacterial pathogens such as Acinetobacterand

Pseudomonas spp. (grade 2B).

For patients with severe infections associated withrespiratory failure and septic shock, combination

therapy with an extended spectrum beta-lactam andeither an aminoglycoside or a fluoroquinolone is forP. aeruginosa bacteremia (grade 2B).


34/76


A combination of beta-lactam and macrolide forpatients with septic shock from bacteremicStreptococcus pneumoniae infections (grade 2B).

Empiric combination therapy should not beadministered for more than 35 days.

De-escalation to the most appropriate singletherapyshould be performed as soon as thesusceptibility profile is known (grade 2B).


35/76


Duration of therapy typically 710 days; longer courses may

be appropriate in patients who have a slow clinical response,

undrainable foci of infection, bacteremia with S. aureus;

some fungal and viral infections or immunologic

deficiencies, including neutropenia (grade 2C).

Antiviral therapy initiated as early as possible in patients with

severe sepsis or septic shock of viral origin (grade 2C).

Antimicrobial agents should not be used in patients with

severe inflammatory states determined to be of

noninfectious cause(UG).


36/76

Source Control

A specific anatomical diagnosis of infection requiring

consideration for emergent source control be sought and

diagnosed or excluded as rapidly as possible, and

intervention be undertaken for source control within

the first 12 hr after the diagnosis is made, if feasible(grade 1C).

When infected peripancreatic necrosis is identified as a

potential source of infection, definitive intervention isbest delayed until adequate demarcation of viable and

nonviable tissues has occurred (grade 2B).


37/76

Source Control

When source control in a severely septic patient is

required, the effective intervention associated with the

least physiologic insult should be used (eg,

percutaneous rather than surgical drainage of an

abscess) (UG).

If i.v access devices are a possible source of severe

sepsis or septic shock, they should be removed promptly

after other vascular access has been established (UG).


38/76

Infection Prevention

Selective oral decontamination and selectivedigestive decontamination should beintroduced and investigated as a method toreduce the incidence of ventilator-associatedpneumonia;

This infection control measure can then beinstituted in health care settings and regions

where this methodology is found to be effective(grade 2B).


39/76

Infection Prevention

Oral chlorhexidine gluconate be used as a form of

oropharyngeal decontamination to reduce the risk of

ventilator-associated pneumonia in ICU patients with

severe sepsis (grade 2B).


40/76

Fluids

Why?

To reduce organ dysfunction and

multi-organ failure

By optimising tissue oxygen delivery

By increasing organ perfusion


41/76

DO2 = Oxygen delivery to the tissue

CaO2= Amount of O2 in arterial blood

Fluid therapy improves cardiac output by increasing

venous return to the heart

CaO2= ([Hb] x SaO2x 1.34) + (PaO2x 0.0225)

DO2= CaO2x CO

Optimising oxygen delivery


42/76

Fluid Therapy of Severe Sepsis

Crystalloidsas the initial fluid of choice inthe resuscitation of severe sepsis and septicshock (grade 1B).

Against the use of HESfor fluid resuscitationof severe sepsis and septic shock (grade 1B).

Albuminin the fluid resuscitation of severesepsis and septic shock when patients requiresubstantial amounts of crystalloids (grade 2C).


43/76

Fluid Therapy of Severe Sepsis

Initial fluid challenge in patients with sepsis-induced tissuehypoperfusion with suspicion of hypovolemia to achieve aminimum of 30 mL/kg of crystalloids(a portion of this may bealbumin equivalent).

More rapid administration and greater amounts of fluid may beneeded in some patients (grade 1C).

Fluid challenge technique be applied wherein fluid

administration is continued as long as there is hemodynamicimprovement either based on dynamic(eg, change in pulsepressure, stroke volume variation) or static(eg, arterialpressure, heart rate) variables (UG).


44/76

Vasopressors

Vasopressor therapy initially to target a meanarterial pressure (MAP) of 65 mm Hg (grade 1C).

Norepinephrineas the first choice vasopressor(grade 1B).

Epinephrine(added to and potentiallysubstituted for norepinephrine) when anadditional agent is needed to maintain adequateblood pressure (grade 2B).

Vasopressin0.03 units/minute can be added tonorepinephrine (NE) with intent of either raisingMAP or decreasing NE dosage (UG).


45/76

Vasopressors

Low dose vasopressin is not recommended as single initial

vasopressor for treatment of sepsis-induced hypotension

.vasopressin doses higher than 0.030.04 units/minute

should be reserved for salvage therapy (failure to achieve

adequate MAP with other vasopressor agents) (UG).

Dopamineas an alternative vasopressor agent to

norepinephrine only in highly selected patients (eg, patients

with low risk of tachyarrhythmias and absolute or relativebradycardia) (grade 2C).


46/76

Vasopressors

Phenylephrineis not recommended in thetreatment of septic shock exceptin circumstanceswhere

(a) NEis associated with serious arrhythmias,(b) cardiac output is known to be highand bloodpressure persistently low or

(c) as salvage therapy when combined

inotrope/vasopressor drugs and low dosevasopressin have failed to achieve MAP target(grade 1C).


47/76

Vasopressors

Low-dose dopamine should not be used for

renal protection(grade 1A).

All patients requiring vasopressors have an

arterial catheterplaced as soon as practical if

resources are available (UG).


48/76

Inotropic Therapy

A trial of dobutamine infusion up to 20mcg/kg/min be administered or added tovasopressor (if in use) in the presence of:-

(a) myocardial dysfunction as suggested byelevated cardiac filling pressures and lowcardiac output,

(b) ongoing signs of hypoperfusion, despiteachieving adequate intravascular volume andadequate MAP (grade 1C).


49/76

Inotropic Therapy

Not using a strategy to increase cardiac index to

predetermined supranormal levels (grade 1B).

C i id


50/76

Corticosteroids

Not using intravenous hydrocortisone to treatadult septic shock patients if adequate fluidresuscitationand vasopressortherapy are able torestore hemodynamic stability.

In case this is not achievable, i.v hydrocortisonealone at a dose of 200 mg per day (grade 2C).

Not using the ACTH stimulation test to identifyadults with septic shock who should receivehydrocortisone (grade 2B).


51/76

Corticosteroids

In treated patients hydrocortisone taperedwhen

vasopressors are no longer required (grade 2D).

Corticosteroids not be administered for the treatment of

sepsis in the absence of shock (grade 1D).

When hydrocortisone is given, use continuous flow

(grade 2D).

l d d d i i i


52/76

Blood Product Administration

Once tissue hypoperfusion has resolved and in

the absence myocardial ischemia, severe

hypoxemia, acute hemorrhage, or IHD

guideline recommends red blood cell

transfusion occur only when Hb concentration

decreases to


53/76


Not using erythropoietin as a specific treatment of anemiaassociated with severe sepsis (grade 1B).

Fresh frozen plasma not be usedto correct laboratoryclotting abnormalities in the absence of bleeding or plannedinvasive procedures (grade 2D).

Not using antithrombin for the treatment of severe sepsisand septic shock (grade 1B).


54/76


In patients with severe sepsis, administer platelets

prophylactically when counts are 50,000/mm3 [50 x 109/L]) are advised

for active bleeding, surgery, or invasive procedures (grade 2D).

I l b li


55/76

Immunoglobulins

Not using intravenous immunoglobulins

in adult patients with severe sepsis or septic

shock (grade 2B).

S l i


56/76

Selenium

Not using intravenous selenium for the

treatment of severe sepsis (grade 2C).

History of Recommendations Regarding Use of


57/76

y g g

Recombinant Activated Protein C (rhAPC)

A history of the evolution of SSC

recommendations as to rhAPC (no longer

available) is provided.

Mechanical Ventilation of Sepsis-Induced Acute


58/76

p

Respiratory Distress Syndrome (ARDS)

Target a tidal volume of 6 mL/kg predicted body weight in patientswith sepsis-induced ARDS (grade 1A vs. 12 mL/kg).

Plateau pressures be measured in patients with ARDS and initial

upper limit goal for plateau pressures in a passively inflated lung be


59/76



Recruitment maneuvers be used in sepsis patientswith severe refractory hypoxemia (grade 2C).

Prone positioning be used in sepsis-induced ARDSpatients with a P:F ratio < 100 mm Hg in facilities that

have experience with such practices (grade 2B). That mechanically ventilated sepsis patients be

maintained with the head of the bed elevated to 3045 degreesto limit aspiration risk and to prevent the

development of ventilator-associated pneumonia(grade 1B).

M h i l V il i f S i I d d A


60/76



Noninvasive mask ventilation (NIV) be used in

that minority of sepsis-induced ARDS patients in

whom the benefits of NIV have been carefullyconsidered and are thought to outweigh the

risks (grade 2B).

M h i l V til ti f S i I d d A t


61/76



A weaning protocol be in place and that mechanically ventilatedpatients with severe sepsis undergo spontaneous breathing trialsregularly to evaluate the ability to discontinue mechanical ventilationwhen they satisfy the following criteria:

a) arousable; b) hemodynamically stable (without vasopressor agents);

c) no new potentially serious conditions;

d) low ventilatory and end-expiratory pressure requirements;

e) low Fio2 requirements which can be met safely delivered with a

face mask or nasal cannula.

If the spontaneous breathing trial is successful, consideration shouldbe given for extubation (grade 1A).

M h i l V til ti f S i I d d A t


62/76



Againstthe routine use of the pulmonary arterycatheter for patients with sepsis-induced ARDS(grade 1A).

A conservative rather than liberal fluid strategyfor patients with established sepsis-induced ARDSwho do not have evidence of tissuehypoperfusion (grade 1C).

In the absence of specific indications such asbronchospasm, not using beta 2-agonistsfortreatment of sepsis-induced ARDS (grade 1B).

Sedation, Analgesia, and


63/76

, g ,Neuromuscular Blockade in Sepsis

Continuous or intermittent sedation beminimizedin mechanically ventilated sepsispatients, targeting specific titration endpoints

(grade 1B). Neuromuscular blocking agents (NMBAs) be

avoided if possible in the septic patientwithout ARDS due to the risk of prolonged

neuromuscular blockade followingdiscontinuation.

Sedation Analgesia and


64/76

Sedation, Analgesia, and

Neuromuscular Blockade in Sepsis

If NMBAs must be maintained, eitherintermittent bolus as required or continuousinfusion with train-of-four monitoring of the

depth of blockade should be used (grade 1C).

A short course of NMBA of not greater than48 hours for patients with early sepsis-induced ARDS and a Pao2/Fio2 < 150 mm Hg(grade 2C).

Glucose Control


65/76

Glucose Control

A protocolized approach to blood glucosemanagement in ICU patients with severesepsis commencing insulin dosing when 2

consecutive blood glucose levels are >180mg/dL.

This protocolized approach should target anupper blood glucose 180 mg/dL rather than

an upper target blood glucose 110 mg/dL(grade 1A).


66/76

Glucose Control

Blood glucose values be monitored every 12hrs until glucose values and insulin infusionrates are stable and then every 4 hrs

thereafter (grade 1C). Glucose levels obtained with point-of-care

testing of capillary blood be interpreted withcaution, as such measurements may not

accurately estimate arterial blood or plasmaglucose values (UG).

Renal Replacement Therapy


67/76

Renal Replacement Therapy

Continuous renal replacement therapies and

intermittent hemodialysis are equivalent in

patients with severe sepsis and acute renal

failure (grade 2B). Use continuous therapiesto facilitate

management of fluid balance in

hemodynamically unstable septic patients(grade 2D).

Bicarbonate Therapy


68/76

Bicarbonate Therapy

Not using sodium bicarbonate therapy for

the purpose of improving hemodynamics or

reducing vasopressor requirements in

patients with hypoperfusion-induced lacticacidemia with pH 7.15 (grade 2B).

Deep Vein Thrombosis Prophylaxis


69/76


Patients with severe sepsis receive dailypharmacoprophylaxis against venous thromboembolism(VTE) (grade 1B).

This should be accomplished with daily subcutaneous low-molecular weight heparin (LMWH) (grade 1B versus twicedaily UFH, grade 2C versus three times daily UFH).

If creatinine clearance is


70/76


Septic patients who have a contraindication forheparin use(eg, thrombocytopenia, severecoagulopathy, active bleeding, recent intracerebralhemorrhage) not receive pharmacoprophylaxis

(grade 1B), but receive mechanical prophylactictreatment, such as graduated compression stockingsor intermittent compression devices (grade 2C),unless contraindicated.

When the risk decreases start pharmacoprophylaxis(grade 2C).

Stress Ulcer Prophylaxis


71/76

Stress Ulcer Prophylaxis

Stress ulcer prophylaxis using H2 blocker or

proton pump inhibitor be given to patients

with severe sepsis/septic shock who have

bleeding risk factors (grade 1B). When stress ulcer prophylaxis is used, proton

pump inhibitors rather than H2RA(grade 2D)

Patients without risk factors do not receiveprophylaxis (grade 2B).

Nutrition


72/76

Nutrition

Administer oral or enteral (if necessary)feedings, as tolerated, rather than eithercomplete fasting or provision of onlyintravenous glucose within the first 48 hours

after a diagnosis of severe sepsis/septic shock(grade 2C).

Avoid mandatory full caloric feeding in the first

weekbut rather suggest low dose feeding (eg, upto 500 calories per day), advancing only astolerated (grade 2B).


73/76

Nutrition

Use intravenous glucose and enteral nutritionrather than total parenteral nutrition (TPN)alone or parenteral nutrition in conjunction withenteral feeding in the first 7 days after a diagnosis

of severe sepsis/septic shock (grade 2B).

Use nutrition with no specificimmunomodulating supplementationrather

than nutrition providing specificimmunomodulating supplementation in patientswith severe sepsis (grade 2C).

Setting Goals of Care


74/76

Setting Goals of Care

Discuss goals of care and prognosis withpatients and families(grade 1B).

Incorporate goals of care into treatment and

end-of-life care planning, utilizing palliativecare principles where appropriate (grade 1B).

Address goals of care as early as feasible, but

no later than within 72 hours of ICU admission(grade 2C).

ED Critical Care Bringing Upstairs


75/76

ED Critical Care Bringing Upstairs

Care, Downstairs


76/76

THANk YoU

Documents

2012 Surviving Sepsis Campaign Guidelines SYED