International Guidelines for Management of Severe Sepsis and Septic Shock

2012

Presented by Dr.Nabina LalaIMO(Medicine)

CMCH

INTRODUCTION•Major cause of morbidity and mortality worldwide.

•MortalitySepsis: 15% - 30%Severe sepsis & Septic Shock :40%-60%

Mortality is highest among the elderly

Risk factors•Extemesof age(<10yrs and > 70 yrs)

•DM,CLD,alcoholism,malignancy

•Immunosupression(immunosupressive therapy,corticosteroid,IV drug abusers,organ and bone marrow transplant recipients,complement deficiencies)

•Major surgery ,trauma ,burns

•Invasive procedures(catheters,intravascular device,prosthetic device,hemodialysis and peritoneal dialysis catheters,or endotracheal tubes)

•Previous antibiotic treatment

•Prolonged hospitalization

•Malnutrition,child birth,abortion.

Definitions

Widespread inflammatory response to a variety of severe clinical insults is known to as SIRS.

Clinically recognized by the presence of 2 or more of the following:

-Temperature >38C or < 36C -Heart Rate >90 -Respiratory Rate > 20 or PaCO2 <32-WBC > 12,000, < 4000 or > 10% immature forms

Sepsis is defined as the presence of infection together with systemic manifestations of infection.

Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypo perfusion.

Sepsis-induced hypotension is defined as a systolic blood pressure(SBP) < 90 mm Hg or mean arterial pressure (MAP) < 70 mmHg or a absence of other causes of hypotension.

Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation

MANAGEMENT

• Initial Resuscitation and Infection Issues

• Hemodynamic Support & AdjunctiveTherapy

• Supportive Therapy of Severe Sepsis

Initial Resuscitation and Infection Issues

A. Initial Resuscitation

1.During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced hypoperfusion should include all of the following as a part of a treatment protocol:

a) CVP 8–12 mm Hgb) MAP ≥ 65 mm Hgc) Urine output ≥ 0.5 mL ・ kg ・ hrd) Superior vena cava oxygenation saturation (Scvo2) or mixed venous oxygen saturation (Svo2) 70% or 65%,respectively.

2. We suggest targeting resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

B. Screening for Sepsis and Performance Improvement

•Routine screening of seriously ill patients for severe sepsis to increase the early identification of sepsis allow implementation of early sepsis therapy.

•Performance improvement efforts to improve patient outcomes and decrease sepsis-related mortality.

The SSC guidelines and bundles can be used as the basis of a sepsis performance improvement program.

Application of the SSC sepsis bundles led to sustained, continuous quality improvement in sepsis care and was associated with reduced mortality.

C. Diagnosis• Cultures before antibiotic therapy

-Without causing significant delay

• At least 2 blood cultures (both aerobic and anaerobic) -percutaneous-drawn through each lumen of each vascular

access device(if >48 hrs)

• Imaging studies in attempts to confirm a potential source of infection

Other Cultures if indicated- Urine, CSF,sputum etc.

Vol of blood sample > 10ml

1,3 β-d-glucan assay , mannan and anti-mannan antibody assays

-If invasive candidiasis suspected

D. Antimicrobial Therapy

1.The administration of effective intravenous antimicrobials within the first hour of recognition of septic shock and severe sepsis without septic shock should be the goal of therapy.

2a. Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis .

2b. Antimicrobial regimen should be reassessed daily for potential de escalation .

4a.Combination empiric therapy (>=2 )

-Neutropenic patients with severe sepsis

-Difficult-to-treat,multidrug-resistant bacterial pathogens such as Acinetobacter and Pseudomonas. -For patients with severe infectionsassociated with respiratory failure and septic shock.

-

Extended spectrum beta-lactam + AGS/FQs for P. aeruginosa bacteremia

Beta-lactam and macrolide for bacteremic Streptococcus pneumoniae infections

Not for more than 3–5 days

-

De-escalation to the most appropriate single therapy as per susceptibility.

Duration of therapy 7–10 days.

Longer courses if

-slow clinical response -undrainable foci of infection

-bacteremia with S. aureus some fungal and viral infections

-immunologic deficiencies

E. Source Control

•Specific anatomical diagnosis of infection

•Intervention for source control within the first 12 hr of diagnosis.

•Source control with least physiological insult in severe sepsis.

Intravascular access suspected to be source of severe sepsis or septic shock – remove promptly after other vascular access has been established.

Surgical intervention done when minimally invasive approaches are inadequate / when diagnostic uncertainty persists despite imaging.

F. Infection Prevention

•Selective oral decontamination with Oral chlorhexidine gluconate has been shown to reduce VAP

•Selective digestive decontamination

HAEMODYNAMIC SUPPORT & ADJUNCTIVE THERAPY

•FLUID THERAPY

•VASOPRESSORS

•INOTROPIC SUPPORT

•CORTICOSTEROIDS

FLUID THERAPY

•Crystalloids •Against the use of hydroxyethyl starches.Albumin for fluid resuscitation when patients require substantial amounts of crystalloids

•Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion & suspected of hypovoluemia @ 30 mL/kg of crystalloids.`

VASOPRESSORS

•Target a mean arterial pressure (MAP) of 65 mm Hg

•Norepinephrine as the first choice Epinephrine added when an additional agent is needed to maintain adequate B.P.

•Vasopressin 0.03 U/min added to NE for raising MAP or decreasing NE dosage .

•Low dose vasopressin not recommended as the single initial vasopressor for sepsis-induced hypotension

•Vasopressin doses > 0.03-0.04 U/min reserved for salvage therapy

•Dopamine as an alternative vasopressor agent to NE only in highly selected patients

with low risk of tachyarrhythmias absolute or relative bradycardia

•Phenylephrine not recommended except when

–NE associated with serious arrhythmias

–cardiac output high and BP persistently low

–as salvage therapy when combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP

–Low dose dopamine should not be used for renal protection

INOTROPIC THERAPY

•Trial of dobutamine infusion up to 20 mcg/kg/min be administered or added to vasopressor if

–myocardial dysfunction suggested by elevated cardiac filling pressures and low cardiac output

–ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP.

CORTICOSTEROID

Not indicated if adequate fluid resuscitation and vasopressor therapy able to restore hemodynamic stability.

In case not achievable, iv hydrocortisone at a dose of 200 mg per day.

Corticosteroids not be administered for treatment of sepsis in the absence of shock

OTHER SUPPORTIVE THERAPY

OTHER SUPPORTIVE THERAPY

•Blood products administration

•Immunoglobulins*

•Selenium*

•Mechanical ventilation of sepsis induced ARDS

•Sedation, anaelgesia & neuromuscular blockade

•Glucose control

•Renal replacement therapy

•Bicarbonate therapy

•DVT prophylaxis

•Stress ulcer prophylaxis

•Nutrition*

•Setting goals of care

BLOOD PRODUCT ADMINISTRATION

•RBC transfusion only when Hb <7.0 g/dl

•EPO not be used as specific treatment of anemia associated with severe sepsis. FFP not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures.

•Not using antithrombin for the treatment of severe sepsis and septic shock.

Platelet transfusion

<10,000/mm3 in the absence of apparent bleeding.

< 20,000/mm3 if the patient has a significant risk of bleeding.

Higher platelet counts (≥50,000/mm3) advised for active bleeding, surgery, or invasive procedures.

GLUCOSE CONTROL

•A protocolised approach to blood glucose management in ICU patients with severe sepsis commencing insulin dosing when -2 consecutive blood glucose levels are >180 mg/dL.

•Blood glucose values be monitored every 1 to 2 hrs until glucose values and insulin infusion rates are stable and then every 4 hrs thereafter.

RENAL REPLACEMENT THERAPY

•Continuous renal replacement therapies and intermittent hemodialysis are equivalent in patients with severe sepsis and acute renal failure.

•Use continuous therapies to facilitate management of fluid balance in hemodynamically unstable septic patients.

DVT PROPHYLAXIS

•VTE prophylaxis required using daily subcutaneous LMWH.

•If creatinine clearance <30 mL/min, use dalteparin.

•Patients with severe sepsis should be treated with a combination of pharmacologic therapy and intermittent pneumatic compression devices whenever possible.

•Septic patients who have a contraindication for heparin use (eg, thrombocytopenia, severe coagulopathy, active bleeding, recentintracerebral hemorrhage) not to receive pharmacoprophylaxis but receive mechanical prophylactic treatment, suchas graduated compression stockings or intermittent compression devices , unless contraindicated.

STRESS ULCER PROPHYLAXIS

•Stress ulcer prophylaxis using H2 blocker or proton pump inhibitor be given to patients with severe sepsis/septic shock whohave bleeding risk factors .

•When stress ulcer prophylaxis is used, proton pump inhibitors rather than H2RA.

•Patients without risk factors do not receive prophylaxis

NUTRITION

•Administer oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of onlyintravenous glucose within the first 48 hours after a diagnosis of severe sepsis/septic shock.

• Avoid mandatory full caloric feeding in the first week but rather suggest low dose feeding (eg, up to 500 calories per day),advancing only as tolerated.

Use i/v glucose + enteral nutrition rather than TPN alone or parenteral nutrition in the first 7 days after a diagnosis of severe sepsis/septic shock.

Nutrition without specific immunomodulating supplementation.

SETTING GOALS OF CARE

•Discuss goals of care and prognosis with patients and families.

•Incorporate goals of care into treatment and end-of-life care planning, utilizing palliative care principles where appropriate .

•Address goals of care as early as feasible, but no later than within 72 hours of ICU admission.

The Third International Consensus Definitions for Sepsis and Septic Shock

(Sepsis-3)