Guidelines For Management Sepsis 2008

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  • 1.Intensive Care Med (2008) 34:1760 DOI 10.1007/s00134-007-0934-2SPE C I A L A R T I C L E R. Phillip Dellinger Mitchell M. LevySurviving Sepsis Campaign: Jean M. Carlet International guidelines for management Julian Bion Margaret M. Parker of severe sepsis and septic shock: 2008 Roman Jaeschke Konrad Reinhart Derek C. Angus Christian Brun-Buisson Richard Beale Thierry Calandra Jean-Francois Dhainaut Herwig Gerlach Maurene Harvey John J. Marini John Marshall Marco Ranieri Graham Ramsay Jonathan Sevransky B. Taylor Thompson Sean Townsend Jeffrey S. Vender Janice L. Zimmerman Jean-Louis Vincent Medicine**. Participation and endorsementD. C. Angus Received: 3 August 2007by the German Sepsis Society and the Latin University of Pittsburgh, Accepted: 25 October 2007 Published online: 4 December 2007American Sepsis Institute. Pittsburgh PA, USA Society of Critical Care Medicine 2007 C. Brun-BuissonR. P. Dellinger (u)Hopital Henri Mondor, The article will also be published in Critical Cooper University Hospital, Care Medicine.Crteil, FranceOne Cooper Plaza, 393 Dorrance, * Sponsor of 2004 guidelines; ** Sponsor Camden 08103, NJ, USAR. Beale of 2008 guidelines but did not participate e-mail: Dellinger-Phil@CooperHealth.eduGuys and St Thomas Hospital Trust, formally in revision process; *** Members London, UK of the 2007 SSC Guidelines Committee are M. M. Levy S. Townsend listed in Appendix I.; **** Please see Ap- Rhode Island Hospital, T. Calandra pendix J for author disclosure information.Providence RI, USA Centre Hospitalier Universitaire Vaudois,J. M. Carlet Lausanne, Switzerland for the International Surviving Sepsis Hospital Saint-Joseph, Campaign Guidelines Committee***, ****J.-F. DhainautParis, France French Agency for Evaluation of Research Sponsoring Organizations: American Asso- J. Bionand Higher Education, ciation of Critical-Care Nurses*, American Birmingham University, Paris, France College of Chest Physicians*, American Birmingham, UK College of Emergency Physicians*, Cana- H. Gerlach dian Critical Care Society, European Soci- M. M. Parker Vivantes-Klinikum Neukoelln, ety of Clinical Microbiology and InfectiousSUNY at Stony Brook, Berlin, Germany Diseases*, European Society of Intensive Stony Brook NY, USA Care Medicine*, European Respiratory Society*, International Sepsis Forum*, R. JaeschkeM. Harvey Japanese Association for Acute Medicine, McMaster University, Consultants in Critical Care, Inc., Japanese Society of Intensive Care Medi- Hamilton, Ontario, CanadaGlenbrook NV, USA cine, Society of Critical Care Medicine*, Society of Hospital Medicine**, Surgical K. ReinhartJ. J. Marini Infection Society*, World Federation ofFriedrich-Schiller-University of Jena, University of Minnesota, Societies of Intensive and Critical Care Jena, GermanySt. Paul MN, USA

2. 18J. Marshallof evidence. In areas without completeacute respiratory distress syndrome St. Michaels Hospital,agreement, a formal process of re-(ARDS); application of at least Toronto, Ontario, Canadasolution was developed and applied. a minimal amount of positive end- M. Ranieri Recommendations are grouped intoexpiratory pressure in acute lung Universit di Torino,those directly targeting severe sepsis, injury (1C); head of bed elevation Torino, Italyrecommendations targeting general in mechanically ventilated patients G. Ramsaycare of the critically ill patient that unless contraindicated (1B); avoid- West Hertfordshire Health Trust, are considered high priority in severeing routine use of pulmonary artery Hemel Hempstead, UKsepsis, and pediatric considerations. catheters in ALI/ARDS (1A); to de-Results: Key recommendations, crease days of mechanical ventilation J. Sevransky listed by category, include: earlyand ICU length of stay, a conserva- The Johns Hopkins University School of Medicine, goal-directed resuscitation of thetive uid strategy for patients with Baltimore MD, USAseptic patient during the rst 6 hrsestablished ALI/ARDS who are notafter recognition (1C); blood culturesin shock (1C); protocols for weaning B. T. Thompson prior to antibiotic therapy (1C); imag- and sedation/analgesia (1B); using Massachusetts General Hospital,ing studies performed promptly to either intermittent bolus sedation or Boston MA, USAconrm potential source of infectioncontinuous infusion sedation with J. S. Vender (1C); administration of broad-daily interruptions or lightening (1B); Evanston Northwestern Healthcare,spectrum antibiotic therapy withinavoidance of neuromuscular blockers, Evanston IL, USA 1 hr of diagnosis of septic shock (1B)if at all possible (1B); institution J. L. Zimmermanand severe sepsis without septic shockof glycemic control (1B) targeting The Methodist Hospital,(1D); reassessment of antibiotic ther-a blood glucose < 150 mg/dL after Houston TX, USAapy with microbiology and clinicalinitial stabilization ( 2C ); equivalencydata to narrow coverage, when ap- of continuous veno-veno hemoltra- J.-L. Vincent Erasme University Hospital,propriate (1C); a usual 710 days oftion or intermittent hemodialysis Brussels, Belgiumantibiotic therapy guided by clinical (2B); prophylaxis for deep veinresponse (1D); source control withthrombosis (1A); use of stress ulcer Abstract Objective: To provide attention to the balance of risks and prophylaxis to prevent upper GI an update to the original Survivingbenets of the chosen method (1C);bleeding using H2 blockers (1A) or Sepsis Campaign clinical manage- administration of either crystalloid or proton pump inhibitors (1B); and ment guidelines, Surviving Sepsis colloid uid resuscitation (1B); uid consideration of limitation of support Campaign guidelines for management challenge to restore mean circulating where appropriate (1D). Recommen- of severe sepsis and septic shock,lling pressure (1C); reduction in rate dations specic to pediatric severe published in 2004. Design: Modied of uid administration with risingsepsis include: greater use of physical Delphi method with a consensus ling pressures and no improvementexamination therapeutic end points conference of 55 international ex- in tissue perfusion (1D); vasopressor (2C); dopamine as the rst drug of perts, several subsequent meetings preference for norepinephrine orchoice for hypotension (2C); steroids of subgroups and key individuals,dopamine to maintain an initial targetonly in children with suspected or teleconferences, and electronic-basedof mean arterial pressure 65 mm Hgproven adrenal insufciency (2C); discussion among subgroups and (1C); dobutamine inotropic therapya recommendation against the use of among the entire committee. This when cardiac output remains low recombinant activated protein C in process was conducted independentlydespite uid resuscitation and com- children (1B). Conclusion: There of any industry funding. Methods:bined inotropic/vasopressor therapy was strong agreement among a large We used the GRADE system to(1C); stress-dose steroid therapy cohort of international experts regard- guide assessment of quality of evi-given only in septic shock after blooding many level 1 recommendations dence from high (A) to very low (D)pressure is identied to be poorlyfor the best current care of patients and to determine the strength of responsive to uid and vasopressorwith severe sepsis. Evidenced-based recommendations. A strong rec- therapy (2C); recombinant activated recommendations regarding the acute ommendation [1] indicates that anprotein C in patients with severe management of sepsis and septic interventions desirable effects clearly sepsis and clinical assessment of highshock are the rst step toward im- outweigh its undesirable effects (risk,risk for death (2B except 2C for post-proved outcomes for this important burden, cost), or clearly do not. Weak operative patients). In the absence ofgroup of critically ill patients. recommendations [2] indicate thattissue hypoperfusion, coronary artery the tradeoff between desirable and disease, or acute hemorrhage, targetKeywords Sepsis Severe sepsis undesirable effects is less clear. The a hemoglobin of 79 g/dL (1B); a lowSeptic shock Sepsis syndrome grade of strong or weak is consideredtidal volume (1B) and limitation of Infection GRADE Guidelines of greater clinical importance thaninspiratory plateau pressure strategy Evidence-based medicine Surviving a difference in letter level of quality(1C) for acute lung injury (ALI)/ Sepsis Campaign Sepsis bundles 3. 19Introductionwhen he or she is provided with a patients unique set of clinical variables. Most of these recommendations are ap- Severe sepsis (acute organ dysfunction secondary to in- propriate for the severe sepsis patient in both the intensive fection) and septic shock (severe sepsis plus hypotension care unit (ICU) and non-ICU settings. In fact the commit- not reversed with uid resuscitation) are major healthcaretee believes that, currently, the greatest outcome improve- problems, affecting millions of individuals around thement can be made through education and process change world each year, killing one in four (and often more),for those caring for severe sepsis patients in the non-ICU and increasing in incidence [15]. Similar to polytrauma, setting and across the spectrum of acute care. It should also acute myocardial infarction, or stroke, the speed and be noted that resource limitations in some institutions and appropriateness of therapy administered in the initialcountries may prevent physicians from accomplishing par- hours after severe sepsis develops are likely to inuence ticular recommendations. outcome. In 2004, an international group of experts in the diagnosis and management of infection and sepsis, repre- senting 11 organizations, published the rst internationallyMethods accepted guidelines that the bedside clinician could use to improve outcomes in severe sepsis and septic shock [6, 7].Sepsis is dened as infection plus systemic manifestations These guidelines represented Phase II of the Surviv