Dr.Sekar Loganathan ,Junior Resident ,Dept of Anaesthesia and Intensive care,PGIMER, Chandigarh, INDIA.

The need for new guidelines

• Sepsis still an economic burden on public health.

• Sepsis is the leading cause of death in non-coronary care intensive care units, with a mortality rate between 30-50%.

Why new definition?

• Definitions of sepsis and septic shock were last revised in 2001.

• Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management and epidemiology of sepsis, suggesting the need for re-examination.

Why new definition?

• To know what distinguishes sepsis from uncomplicated infection as simple infection.

• We need to differentiate a straightforward infection from one that can cause organ dysfunction or death.

• SIRS criteria doesn’t differentiate.

Overlap

• SIRS criteria have been used to diagnose sepsis for more than 20 years.

• The Validity of SIRS challenged.

• Poor concurrent Validity.

Previous definitions

• The care in sepsis is focused on prompt recognition and early treatment.

• “Shift of focus from inflammation to Organ Dysfunction ”

New definitions • Sepsis is defined as life-threatening organ

dysfunction caused by a dysregulated host response to infection.

• NB:– The SIRS criteria have been removed– It may present in simple, non-complicated infection, or in

response to non infectious-triggers (i.e. trauma, pancreatitis, post-cardiac arrest syndrome),

– Or may even be absent in critically ill patients with obvious evidence of a life-threatening infection.

New definitions • Septic shock is a subset of sepsis in which

underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.

– Clinical criteria identifying such condition include the need for vasopressors to obtain a MAP≥ 65mmHg and an increase in lactate concentration > 2 mmol/L, despite adequate fluid resuscitation.

Terms like Severe Sepsis/Septicemia has been removed

• Finally, all these new definitions are recommended for coding and research purposes. 

DEFINITON

2012 2016

SEPSIS-presence of infection + systemic manifestation of infection.

Severe sepsis- sepsis+ sepsis induced organ dysfunction or tissue hypoperfusion

Sepsis - life-threatening organ dysfunction caused by a dysregulated host response to infection.

Septic shock- subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality.

No severe sepsis category.

INITIAL RESUSCITATION2012 2016

ATLEAST 30 ml/kg in first 3 hrsCrystalloid fluid (no recommendation on 0.9% NS or balanced salt solutions).

Albumin if patients require substantial fluids

same

Proctocolised care including•CVP•Scvo2•Normalise lactate

Use dynamic resuscitation markers•Target MAP of 65mmhg•Reassess hemodynamic status to guide resuscitation•Normalise lactate

DIAGNOSIS 2012 2016

Use of the 1,3 beta D-glucan assay mannan and anti-mannan antibody assays if available and invasive candidiasis is in DD of cause of infection.

Imaging stiduies for cause of infection.

No specific recommendation for fungal etiological diagnosis and imaging studies.

ANTIBIOCTICS 2012

2016

One or more antibiotics active against persumed pathogen.

Combination theraphy (double coverage) for neutropenbic patients and for pseudomonas.

Initial broad spectrum antibiotics.

Against combination therapy.

May use procalcitonin to de-escalation of antibiotic

SOURCE CONTROL

2012 2016

Achieve within 12 hrs if feasible.

Achieve as soon as possible medically and logically feasible.

VASOACTIVE MEDICATIONS2012 2016

Choice of vasopressors:

Norepinephrine > epinephrine > Vasopressin

Norepinephrine > Vasopressin > Epinephrine

BLOOD PURIFICATION

• No recommendation regarding the use of blood purification techniques.

• Limitations of the available studies .• Evidence very low either in favour or against

this techniques.• Needs further research studies.

ANTICOAGULANTS

• Against the use of antithrombin for the treatment of sepsis and septic shock.

• Antithrombin- abundant anticoagulant in the blood, decreased plasma activity at onset of sepsis correlates with the DIC and lethal outcome.

• No beneficial effect on overall mortality.• Associated with the increased risk of bleeding.

• No recommendation regarding the use of thrombomodulin or heparin for the treatment of sepsis or septic shock.

• Shows beneficial effect on survival- systematic reviews.

• RCT ongoing on DIC- pending results.

VENTILATOR STRATEGIES 2012 2016No recommendation.

Weak recommendations for noninvasive ventilation in selected patients with sepsis induced ARDS.

Prone position ventilation in sepsis- induced ARDS with P/F < 100 mm hg.

Against high frequency oscillatory ventilation.

Unable to make recommendation on noninvasive ventilation.

Prone position ventilation in sepsis-iduced ARDS, P/F < 150mm hg

NMBA for < 48 hrs in adults with P/F < 150 mmhg

VENTILATION STRATEGIES

• Spontaneous breathing trials

• Weaning protocol in mechanically ventilated patients with sepsis induced respiratory failure.

SEDATION AND ANALGESIA

• Neuromuscular blocking agents – intermittent bolus or continuous infusion with TOF monitoring- 2012.

• 2016- no specific recommendation.

GLUCOSE CONTROL

• Arterial blood rather than capillary blood for POC testing if patient have arterial catheters.

• Recommends central labarotory testing of blood glucose over POC glucometers.

• Glucometers- erroneous higher values.

RENAL REPALCEMENT THERAPY

• Against the use of RRT in patients with sepsis and acute kidney injury for increase in creatinine or oliguria without other definitive indications for dialysis.

STESS ULCER PROPHYLAXIS 2012 2016PPI preferred rather than H2RB

Either PPI or histamine-2 receptor antagonists.

Small increase in risk of C.diificile infection with PPIs.

NUTRITION

• Against early parenteral nutrion.• Early enteral nutrition.• Against omega-3 fattyacids as an immuno

supplementation.• Against routine monitoring of gastric residual

volume .• Post-pyloric feeding tubes.

THANK YOU