Survivng Sepsis 2012 Summary

8/16/2019 Survivng Sepsis 2012 Summary

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Surviving SepsisCampaign

International Guidelines for Management of Severe Sepsis

and Septic Shock: 2012


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•

Strength of recommendation and quality of evidencehave een assessed using G!"#$ criteria% presented inrackets after each guideline&

• 'or added clarity:• Indicates a strong recommendation or ()e recommend&*• Indicates a )eak recommendation or ()e suggest&*• +G means the evidence is ungraded&• ,-lease refer to the guidelines for further details on the

grading of recommendations&


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GRADING QUALITY OF EVIDENCE,2012


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Initial !esuscitation and

Infection Issues


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Initial !esuscitation•

-rotocoli.ed% quantitative resuscitation of patients )ith sepsisinduced tissue hypoperfusion /de ned in this document ashypotension persisting after initial uid challenge or loodlactate concentration 3 mmol456 /grade 1C6&

• Goals during the rst 7 hrs of resuscitation:• a6 Central venous pressure /C8-6 9 12 mm ;g• 6 Mean arterial pressure /M"-6 7< mm ;g• c6 +rine output 0&< m54kg4hr d6 Central venous /superior vena cava6

or mi=ed venous o=ygen saturation >0? or 7


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"ntimicro ial herapy•

"dministration of eAective intravenous antimicro ials )ithin therst hour of recognition of septic shock /grade 1F6 and severesepsis )ithout septic shock /grade 1C6 as the goal of therapy&

• a6 Initial empiric antiEinfective therapy of one or more drugs thathave activity against all likely pathogens / acterial and4or fungalor viral6 and that penetrate in adequate concentrations intotissues presumed to e the source of sepsis /grade 1F6&

• 6 "ntimicro ial regimen should e reassessed daily for potentialdeEescalation /grade 1F6&

• @ +se of lo) procalcitonin levels or similar iomarkers to assist the clinicianin the discontinuation of empiric anti iotics in patients )ho initiallyappeared septic% ut have no su sequent evidence of infection /grade 2C6&


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"ntimicro ial herapy•

@ a6 Com ination empirical therapy for neutropenic patients )ithsevere sepsis /grade 2F6 and for patients )ith diHcultEtoEtreat%multidrugEresistant acterial pathogens such as "cineto acterand -seudomonas spp& /grade 2F6&

• 'or patients )ith severe infections associated )ith respiratoryfailure and septic shock% com ination therapy )ith an e=tendedspectrum etaElactam and either an aminoglycoside or a

uoroquinolone is for -& aeruginosa acteremia /grade 2F6&• " com ination of etaElactam and macrolide for patients )ith

septic shock from acteremic Streptococcus pneumoniaeinfections /grade 2F6& @


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Source Control•

" speci c anatomical diagnosis of infection requiring consideration foremergent source control e sought and diagnosed or e=cluded as rapidlyas possi le% and intervention e undertaken for source control )ithin the

rst 12 hr after the diagnosis is made% if feasi le /grade 1C6&• @ Jhen infected peripancreatic necrosis is identi ed as a potential

source of infection% de nitive intervention is est delayed until adequatedemarcation of via le and nonvia le tissues has occurred /grade 2F6&

Jhen source control in a severely septic patient is required% the eAectiveintervention associated )ith the least physiologic insult should e used/eg% percutaneous rather than surgical drainage of an a scess6 /+G6& Ifintravascular access devices are a possi le source of severe sepsis orseptic shock% they should e removed promptly after other vascularaccess has een esta lished /+G6&


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Infection -revention•

@ a6 Selective oral decontamination and selectivedigestive decontamination should e introduced andinvestigated as a method to reduce the incidence ofventilatorEassociated pneumonia this infection controlmeasure can then e instituted in health care settingsand regions )here this methodology is found to eeAective /grade 2F6&

• @ 6 Kral chlorhe=idine gluconate e used as a form oforopharyngeal decontamination to reduce the risk ofventilatorEassociated pneumonia in IC+ patients )ithsevere sepsis /grade 2F6&


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;emodynamic Support

and "dLunctive herapy


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'luid herapy of Severe Sepsis• Crystalloids as the initial uid of choice in the resuscitation of severe sepsis and

septic shock /grade 1F6&• "gainst the use of hydro=yethyl starches for uid resuscitation of severe sepsis

and septic shock /grade 1F6&• @ "l umin in the uid resuscitation of severe sepsis and septic shock )hen

patients require su stantial amounts of crystalloids /grade 2C6&• Initial uid challenge in patients )ith sepsisEinduced tissue hypoperfusion )ith

suspicion of hypovolemia to achieve a minimum of D0 m54kg of crystalloids /aportion of this may e al umin equivalent6& More rapid administration andgreater amounts of uid may e needed in some patients /grade 1C6&

• 'luid challenge technique e applied )herein uid administration is continuedas long as there is hemodynamic improvement either ased on dynamic /eg%change in pulse pressure% stroke volume variation6 or static /eg% arterialpressure% heart rate6 varia les /+G6&


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8asopressors• 8asopressor therapy initially to target a mean arterial pressure /M"-6 of 7<

mm ;g /grade 1C6&• Norepinephrine as the rst choice vasopressor /grade 1F6&• @ $pinephrine /added to and potentially su stituted for norepinephrine6 )hen

an additional agent is needed to maintain adequate lood pressure /grade2F6& 8asopressin 0&0D units4minute can e added to norepinephrine /N$6 )ithintent of either raising M"- or decreasing N$ dosage /+G6& 5o) dosevasopressin is not recommended as the single initial vasopressor for treatmentof sepsisEinduced hypotension and vasopressin doses higher than 0&0DE0&03units4minute should e reserved for salvage therapy /failure to achieveadequate M"- )ith other vasopressor agents6 /+G6&

• @ #opamine as an alternative vasopressor agent to norepinephrine only inhighly selected patients /eg% patients )ith lo) risk of tachyarrhythmias anda solute or relative radycardia6 /grade 2C6&


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•

-henylephrine is not recommended in the treatmentof septic shock e=cept in circumstances )here /a6norepinephrine is associated )ith serious arrhythmias%/ 6 cardiac output is kno)n to e high and loodpressure persistently lo) or /c6 as salvage therapy )hencom ined inotrope4vasopressor drugs and lo) dosevasopressin have failed to achieve M"- target /grade1C6&

• 5o) dose dopamine should not e used for renalprotection /grade 1"6& "ll patients requiringvasopressors have an arterial catheter placed as soon

as practical if resources are availa le /+G6&


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INK !K-IC ;$!"-O•

" trial of do utamine infusion up to 20micrograms4kg4min e administered or added tovasopressor /if in use6 in the presence of /a6 myocardialdysfunction as suggested y elevated cardiac llingpressures and lo) cardiac output% or / 6 ongoing signsof hypoperfusion% despite achieving adequateintravascular volume and adequate M"- /grade 1C6&

• Not using a strategy to increase cardiac inde= topredetermined supranormal levels /grade 1F6&


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Corticosteroids• @ Not using intravenous hydrocortisone to treat adult septic shock

patients if adequate uid resuscitation and vasopressor therapy area le to restore hemodynamic sta ility /see goals for Initial!esuscitation6& In case this is not achieva le% )e suggest intravenoushydrocortisone alone at a dose of 200 mg per day /grade 2C6&

• @ Not using the "C ; stimulation test to identify adults )ith septicshock )ho should receive hydrocortisone /grade 2F6&

• @ In treated patients hydrocortisone tapered )hen vasopressors are nolonger required /grade 2#6&

• Corticosteroids not e administered for the treatment of sepsis inthe a sence of shock /grade 1#6& @ Jhen hydrocortisone is given% usecontinuous o) /grade 2#6


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Kther Supportive herapy

of Severe Sepsis


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Flood -roduct "dministration• Knce tissue hypoperfusion has resolved and in the a sence of

e=tenuating circumstances% such as myocardial ischemia% severehypo=emia% acute hemorrhage% or ischemic heart disease% )erecommend that red lood cell transfusion occur only )hen hemoglo inconcentration decreases to >g4d5 to target a hemoglo inconcentration of >&0 P&0 g4d5 in adults /grade 1F6&

• Not using erythropoietin as a speci c treatment of anemia associated

)ith severe sepsis /grade 1F6&• @ 'resh fro.en plasma not e used to correct la oratory clotting

a normalities in the a sence of leeding or planned invasive procedures/grade 2#6&

• Not using antithrom in for the treatment of severe sepsis and septicshock /grade 1F6&


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Flood -roduct "dministration•

@ In patients )ith severe sepsis% administer plateletsprophylactically )hen counts are 20%0004mmD /20 =10P456 if the patient has a signi cant risk of leeding&;igher platelet counts /


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Immunoglo ulins•

@ Not using intravenous immunoglo ulins in adultpatients )ith severe sepsis or septic shock /grade 2F6&


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Selenium•

@ Not using intravenous selenium for the treatment ofsevere sepsis /grade 2C6


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Mechanical 8entilation of SepsisEInduced "!#S• arget a tidal volume of 7 m54kg predicted ody )eight in patients )ith sepsisE

induced "!#S /grade 1" vs& 12 m54kg6&• -lateau pressures e measured in patients )ith "!#S and initial upper limit

goal for plateau pressures in a passively in ated lung e D0 cm ;2K /grade1F6&

• -ositive endEe=piratory pressure /-$$-6 e applied to avoid alveolar collapse atend e=piration /atelectotrauma6 /grade 1F6&

• @ Strategies ased on higher rather than lo)er levels of -$$- e used forpatients )ith sepsisEinduced moderate or severe "!#S /grade 2C6&

• @ !ecruitment maneuvers e used in sepsis patients )ith severe refractoryhypo=emia /grade 2C6&

• @ -rone positioning e used in sepsisEinduced "!#S patients )ith a -ao24'io2ratio 100 mm ;g in facilities that have e=perience )ith such practices /grade2F6&


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Mechanical 8entilation of SepsisEInduced "!#S• hat mechanically ventilated sepsis patients e maintained )ith the head of the ed

elevated to D0E3< degrees to limit aspiration risk and to prevent the development ofventilatorassociated pneumonia /grade 1F6&

• @ hat noninvasive mask ventilation /NI86 e used in that minority of sepsisEinduced"!#S patients in )hom the ene ts of NI8 have een carefully considered and arethought to out)eigh the risks /grade 2F6&

• hat a )eaning protocol e in place and that mechanically ventilated patients )ithsevere sepsis undergo spontaneous reathing trials regularly to evaluate the a ility todiscontinue mechanical ventilation )hen they satisfy the follo)ing criteria:

• a6 arousa le• 6 hemodynamically sta le /)ithout vasopressor agents6• c6 no ne) potentially serious conditions• d6 lo) ventilatory and endEe=piratory pressure requirements and• e6 lo) 'io2 requirements )hich can e met safely delivered )ith a face mask or nasal cannula& If

the spontaneous reathing trial is successful% consideration should e given for e=tu ation /grade1"6&


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Glucose Control• " protocoli.ed approach to lood glucose management in IC+

patients )ith severe sepsis commencing insulin dosing )hen 2consecutive lood glucose levels are B190 mg4d5& hisprotocoli.ed approach should target an upper lood glucose

190 mg4d5 rather than an upper target lood glucose 110mg4d5 /grade 1"6&

• Flood glucose values e monitored every 1 2 hrs until glucosevalues and insulin infusion rates are sta le and then every 3 hrsthereafter /grade 1C6& Glucose levels o tained )ith pointEofEcaretesting of capillary lood e interpreted )ith caution% as suchmeasurements may not accurately estimate arterial lood orplasma glucose values /+G6&


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!enal !eplacement herapy•

@ Continuous renal replacement therapies andintermittent hemodialysis are equivalent in patients)ith severe sepsis and acute renal failure /grade 2F6&

• @ +se continuous therapies to facilitate management ofuid alance in hemodynamically unsta le septic

patients /grade 2#6&


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Ficar onate herapy•

@ Not using sodium icar onate therapy for the purposeof improving hemodynamics or reducing vasopressorrequirements in patients )ith hypoperfusionEinducedlactic acidemia )ith p; >&1< /grade 2F6&


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#eep 8ein hrom osis -rophyla=is• -atients )ith severe sepsis receive daily pharmacoprophyla=is against venous

throm oem olism /8 $6 /grade 1F6& his should e accomplished )ith dailysu cutaneous lo)molecular )eight heparin /5MJ;6 /grade 1F versus t)ice daily+';% grade 2C versus three times daily +';6& If creatinine clearance is D0m54min% use dalteparin /grade 1"6 or another form of 5MJ; that has a lo) degreeof renal meta olism /grade 2C6 or +'; /grade 1"6&

• @ -atients )ith severe sepsis e treated )ith a com ination of pharmacologictherapy and intermittent pneumatic compression devices )henever possi le/grade 2C6&

• @ Septic patients )ho have a contraindication for heparin use /eg%throm ocytopenia% severe coagulopathy% active leeding% recent intracere ralhemorrhage6 not receive pharmacoprophyla=is /grade 1F6% ut receivemechanical prophylactic treatment% such as graduated compression stockings orintermittent compression devices /grade 2C6% unless contraindicated& Jhen therisk decreases start pharmacoprophyla=is /grade 2C6&


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Nutrition• @ "dminister oral or enteral /if necessary6 feedings% as tolerated% rather than

either complete fasting or provision of only intravenous glucose )ithin therst 39 hours after a diagnosis of severe sepsis4septic shock /grade 2C6&

• @ "void mandatory full caloric feeding in the rst )eek ut rather suggestlo) dose feeding /eg% up to days after a diagnosis of severe sepsis4septic shock/grade 2F6&

• @ +se nutrition )ith no speci c immunomodulating supplementation ratherthan nutrition providing speci c immunomodulating supplementation inpatients )ith severe sepsis /grade 2C6&


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Setting Goals of Care• #iscuss goals of care and prognosis )ith patients and

families /grade 1F6&• Incorporate goals of care into treatment and endEofE

life care planning% utili.ing palliative care principles)here appropriate /grade 1F6& @ "ddress goals of careas early as feasi le% ut no later than )ithin >2 hours ofIC+ admission /grade 2C6&

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Survivng Sepsis 2012 Summary