Surviving Sepsis CampaignInternational Guidelines for Management of Severe Sepsis and Septic Shock: 2016

Intensive Care Medicinedoi: 10.1007/s00134-017-4683-6Published online: 18 Jan 2017

STOPSEPSIS

MANAGEMENT OF SEVERE SEPSISManagement of Severe Sepsis

Initial Resuscitation Diagnosis Antibiotic

Therapy

Source Control Fluid Therapy Vasopressors

Corticosteroids Blood Product Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Initial Resuscitation

Initial Resuscitation Sepsis and septic shock are medical

emergencies, and we recommend that treatment and resuscitation begin immediately (best practice statements, BPS).

In the resuscitation from sepsis-induced hypoperfusion, at least 30 mL/kg of IV crystalloid fluid be given within the first 3 h (strong recommendation, low quality of evidence).

Initial Resuscitation Following initial fluid resuscitation, additional

fluids be guided by frequent reassessment of hemodynamic status (BPS).Remarks Reassessment should include a thorough clinical examination and evaluation of available physiologic variables (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, and others, as available) as well as other noninvasive or invasive monitoring, as available.

Initial Resuscitation An initial target MAP of 65 mmHg in patients with septic shock requiring vasopressors (strong recommendation, moderate quality of evidence).Guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (weak recommendation, low quality of evidence).

Application of Fluid Resuscitation in Adult Septic Shock

Considerations post 30ml/kg crystalloid infusion1. Continue to balance fluid resuscitaon and vasopressor dose with attention to maintain tissue perfusion and minimize interstitial edema2. Implement some combinaon of the list below to aid in further resuscitaon choices that may include addional fluid or inotrope therapy

• blood pressure/heart rate response, • urine output,• cardiothoracic ultrasound,• CVP, ScvO2,• pulse pressure variaon• lactate clearance/normalizaon or• dynamic measurement such as response of flow to fluid bolus or passive leg raising

3. Consider albumin fluid resuscitaon, when large volumes of crystalloid are required to maintain intravascular volume.

Sepsis-induced hypotension or lactate > 4 mmol/L(Based on SSC bundle and CMS threshold)

No high flow oxygen andNo ESRD on dialysis or CHF

Pneumonia or ALI with high flow oxygen requirements

ESRD on hemodialysisor CHF

Rapid infusionof 30 ml/kgCrystalloid*

Not intubated/mechanically ventilated

Intubated/mechanically ventilated Total of 30 ml/kg crystalloid*

with frequent reassessment of oxygenation

If no

IfYes

Considerintubaon/mechanicalvenlaon to facilitate

30 ml/kg crystalloid *

Rapid infusionof 30 ml/kgcrystalloid *

Total of 30 ml/kg withfrequent reassessment of

oxygenaon

Diagnosis

DiagnosisAppropriate routine microbiologic cultures

(including blood) be obtained before starting antimicrobial therapy in patients with suspected sepsis or septic shock if doing so results in no substantial delay in the start of antimicrobials (BPS).Remarks Appropriate routine microbiologic cultures always include at least two sets of blood cultures (aerobic and anaerobic).

Antimicrobial Therapy

Antimicrobial Therapy Administration of IV anti-microbials be

initiated as soon as possible after recognition and within 1 h for both sepsis and septic shock (strong recommendation, moderate quality of evidence; grade applies to both conditions).

Antimicrobial Therapy Empiric broad-spectrum therapy with one or

more antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens (including bacterial and potentially fungal or viral coverage) (strong recommendation, moderate quality of evidence).

Empiric antimicrobial therapy be narrowed once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted (BPS).

Antimicrobial Therapy Antimicrobial treatment duration of 7–10

days is adequate for most serious infections associated with sepsis and septic shock (weak recommendation, low quality of evidence).

Antimicrobial Therapy Measurement of procalcitonin levels can be

used to support shortening the duration of antimicrobial therapy in sepsis patients (weak recommendation, low quality of evidence).

Procalcitonin levels can be used to support the discontinuation of empiric antibiotics in patients who initially appeared to have sepsis, but subsequently have limited clinical evidence of infection (weak recommendation, low quality of evidence).

Source Control

Source Control A specific anatomic diagnosis of infection

requiring emergent source control be identified or excluded as rapidly as possible in patients with sepsis or septic shock, and that any required source control intervention be implemented as soon as medically and logistically practical after the diagnosis is made (BPS).

Source Control Prompt removal of intravascular access

devices that are a possible source of sepsis or septic shock after other vascular access has been established (BPS).

Fluid Therapy

Fluid TherapyCrystalloids as the fluid of choice for initial

resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock (strong recommendation, moderate quality of evidence).

Against using hydroxyethyl starches (HESs) for intravascular volume replacement in patients with sepsis or septic shock (strong recommendation, high quality of evidence).

Fluid TherapyUsing albumin in addition to crystalloids for

initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock when patients require substantial amounts of crystalloids (weak recommendation, low quality of evidence).

Vasoactive Medications

Vasopressors Norepinephrine as the first choice

vasopressor (strong recommendation, moderate quality of evidence).

Adding either vasopressin (up to 0.03 U/min) (weak recommendation, moderate quality of evidence) or epinephrine (weak recommendation, low quality of evidence) to norepinephrine with the intent of raising MAP to target, or adding vasopressin (up to 0.03 U/min) (weak recommendation, moderate quality of evidence) to decrease norepinephrine dosage.

Vasopressors Using dopamine as an alternative

vasopressor agent to norepinephrine only in highly selected patients (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (weak recommendation, low quality of evidence).

Against using low-dose dopamine for renal protection (strong recommendation, high quality of evidence).

Vasopressors Using dobutamine in patients who show

evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents (weak recommendation, low quality of evidence).

Vasopressors All patients requiring vasopressors have an

arterial catheter placed as soon as practical if resources are available (weak recommendation, very low quality of evidence).

Vasopressor Use for Adult Sepc Shock (with guidance for steroid administraon)

Iniate norepinephrine (NE) and trate up to 35-90 μg/minto achieve MAP target 65 mm Hg

MAP targetachieved

Connue norepinephrine alone oradd vasopressin 0.03 units/min

with ancipaon of decreasingnorepinephrine dose

MAP target not achievedand judged

poorly responsive to NE

Add vasopressin up to0.03 units/min to achieve

MAP target*

MAP targetachieved

MAP targetnot achieved

Add epinephrine up to20-50 μg/min to achieve MAP

target**

MAP targetachieved

MAP targetnot achieved

Add phenylephrine up to 200-300 μg/min to

achieve MAP target***

* Consider IV steroid administraon** Administer IV steroids*** SSC guidelines are silent on phenylephrine

Notes:• Consider dopamine as niche vasopressor in the presence

of sinus bradycardia.• Consider phenylephrine when serious tachyarrhythmias

occur with norepinephrine or epinephrine.• Evidence based medicine does not allow the firm

establishment of upper dose ranges of norepinephrine, epinephrine and phenylephrine and the dose ranges expressed in this figure are based on the authors interpretaon of the literature that does exist and personal preference/experience. Maximum doses in any individual paent should be considered based on physiologic response and side effects.

Corticosteroids

Corticosteroids Against using IV hydrocortisone to treat

septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg per day (weak recommendation, low quality of evidence).

Blood Products

Blood Product Administration RBC transfusion occur only when

hemoglobin concentration decreases to <7.0 g/dL in adults in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, or acute hemorrhage (strong recommendation, high quality of evidence).

Blood Product Administration Prophylactic platelet transfusion

when counts are <10,000/mm3 in the absence of apparent bleeding and when counts are <20,000/mm3 if the patient has a significant risk of bleeding. Higher platelet counts (≥50,000/mm3) are advised for active bleeding, surgery, or invasive procedures (weak recommendation, very low quality of evidence).

Glucose Control

Glucose Control A protocolized approach to blood glucose

management in ICU patients with severe sepsis commencing insulin dosing when 2 consecutive blood glucose levels are >180 mg/dL. This protocolized approach should target an upper blood glucose ≤180 mg/dL rather than an upper target blood glucose ≤ 110 mg/dL (strong recommendation, high quality of evidence).

Glucose Control Blood glucose values be monitored every

1–2 hrs until glucose values and insulin infusion rates are stable and then every 4 hrs thereafter in patients receiving insulin infusions (BPS).

Bicarbonate Therapy

Bicarbonate Therapy Against the use of sodium bicarbonate

therapy to improve hemodynamics or to reduce vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH ≥ 7.15 (weak recommendation, moderate quality of evidence).

西暦 2017 年 1 月17 日

輸液☐ Crystalloids ± albumin☒ HESs

昇圧剤☑ Norepinephrine ± vasopressin or

epinephrine☐ Dopamine for bradycardia only

類固醇 ☐ Hydrocortisone 200 mg/day for refractory shock

輸血☑ pRBC: Hb < 7☐ platelet: 10K, 20K, 50K

血糖制御 < 180 mg/dl重炭酸塩 pH < 7.15

Intensive Care Medicinedoi: 10.1007/s00134-017-4683-6

症、襲来敗血症

SSC Guidelines 2016

蘇生補完計画☑ Crystalloid ≥ 30 ml/kg within 3

hrs☐ Target MAP ≥ 65 mmHg☐ Normalize lactate☒ EGDT, CVP, ScvO2抗生物質☑ Empiric broad-spectrum ABx

within 1 hr☐ Procalcitonin to support the

discontinuation of ABx感染源制御☐ as soon as possible