New Surviving Sepsis Guidelines

New surviving sepsis guidelines were just been released, incorporating new evidence and new sepsis definition.

It is a 38 page document(excluding references) .

Here is a concise summary of the new guidelines.

 

FOR RECOMMENDATIONS

  1. Treatment and resuscitation should begin immediately.
  2. 30 mL/kg of IV crystalloid fluid should be given within the first 3 hours.
  3. Following initial fluid resuscitation, additional fluids be guided by frequent reassessment of hemodynamic status.
  4. Further hemodynamic assessment to determine the type of shock using dynamic over static variables.
  5. Fluid administration is continued as long as hemodynamic factors continue to improve.
  6. Balanced crystalloids or saline as the fluid of choice, Albumin when patients require substantial amounts of crystalloids.
  7. Conservative fluid strategy for patients with established sepsis-induced ARDS who do not have evidence of tissue hypoperfusion.
  8. Initial target mean arterial pressure (MAP) of 65 mm Hg in patients with septic shock requiring vasopressors.
  9. Normalize lactate in patients with elevated lactate levels with resuscitation.
  10. Institutional implementation of performance improvement program for sepsis.
  11. Appropriate routine microbiologic cultures (including blood) be obtained before starting antimicrobial therapy.
  12. Administration of IV antimicrobials be initiated as soon as possible after recognition and ideally within one hour.
  13. Empiric broad-spectrum therapy to cover all likely pathogens for patients with sepsis (including bacterial and potentially fungal or viral coverage).
  14. De-escalation of antimicrobials once pathogen is identified.
  15. Dosing strategies of antimicrobials to be optimized based on pharmacodynamics.
  16. Empiric combination therapy (using at least two antibiotics of different antimicrobial classes) aimed at the most likely bacterial pathogen(s) for the initial management of septic shock.
  17. Duration of 7 to 10 days is adequate for most serious infections associated with sepsis and septic shock.
  18. Longer courses in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S aureus, some fungal and viral infections, or immunologic deficiencies, including neutropenia.
  19. Shorter courses are appropriate in patients with rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis and those with anatomically uncomplicated pyelonephritis.
  20. Procalcitonin levels can be used to support shortening the duration of antimicrobial therapy.
  21. Any required source control intervention be implemented as soon as medically and logistically practical after the diagnosis is made and prompt removal of intravascular access.
  22. Norepinephrine as the first-choice vasopressor, add vasopressin followed by epinephrine if necessary.
  23. Dopamine if bradycardia, Dobutamine if persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents.
  24. All patients requiring vasopressors have an arterial catheter placed as soon as practical.
  25. IV hydrocortisone at a dose of 200 mg per day if fluids and vasopressors do not restore hemodynamic stability.
  26. Prophylactic platelet transfusion when count are < 10,000/mm3 (10 × 109/L) in the absence of apparent bleeding and when counts are < 20,000/mm3 (20 × 109/L) if the patient has a significant risk of bleeding. Higher platelet counts (≥ 50,000/mm3 [50 × 109/L]) are advised for active bleeding, surgery, or invasive procedures.
  27. A target tidal volume of 6 mL/kg predicted body weight (PBW) compared with 12 mL/kg, an upper limit goal for plateau pressures of 30 cm H2O , higher PEEP over lower PEEP and use of recruitment maneuvers in adult patients with sepsis-induced ARDS.
  28. Prone over supine position in adult patients with sepsis-induced ARDS and a Pao2/Fio2 ratio < 150.
  29. Neuromuscular blocking agents (NMBAs) for ≤ 48 hours in adult patients with sepsis induced ARDS and a Pao2/Fio2 ratio < 150 mm Hg.
  30. Head of the bed elevated between 30 and 45 degrees, along with spontaneous breathing trials in mechanically ventilated patients with sepsis.
  31. Sedation be minimized in mechanically ventilated sepsis patients, targeting specific titration end points.
  32. Protocolized approach to blood glucose management to target an upper blood glucose level ≤ 180 mg/dL with measuring glucose every 1 to 2 hours until glucose values and insulin infusion rates are stable.
  33. Use of arterial blood rather than capillary blood for point-of-care testing using glucose meters.
  34. Either continuous RRT (CRRT) or intermittent RRT be used in patients with sepsis and acute kidney injury but CRRT for to facilitate management of fluid balance in hemodynamically unstable septic shock patients.
  35. Unfractionated heparin [UFH] or low-molecular-weight heparin [LMWH]) for venous thromboembolism (VTE) prophylaxis in the absence of contraindications, and LMWH rather than UFH if no contraindications, using combination pharmacologic VTE prophylaxis and mechanical prophylaxis, whenever possible.
  36. GI prophylaxis(proton pump inhibitors (PPIs) or histamine-2 receptor antagonists) for patients with septic shock/sepsis who have risk factors (mechanical ventilation for > 48 hours, coagulopathy, preexisting liver disease, need for RRT, and higher organ failure scores) for gastrointestinal (GI) bleeding.
  37. Early initiation of enteral feeding.
  38. Measure gastric residuals in patients with feeding intolerance or who are considered to be at high risk of aspiration (surgery, hemodynamic instability).
  39. Use of prokinetic agents in critically ill patients with sepsis or septic shock and feeding intolerance.
  40. Post-pyloric feeding tubes in critically ill patients with sepsis or septic shock with feeding intolerance or who are considered to be at high risk of aspiration.
  41. Goals of care and prognosis be discussed with patients and families within 72 hours of ICU admission.

 

AGAINST RECOMMENDATIONS

 

  1. Sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of noninfectious origin.
  2. Combination therapy not to be routinely used for ongoing treatment of most other serious infections(other than septic shock), including bacteremia and sepsis without shock.
  3. Combination therapy not to be used for the routine treatment of neutropenic sepsis/bacteremia.
  4. Using hydroxyethyl starches (HESs).
  5. Low-dose dopamine for renal protection.
  6. Against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability.
  7. Against RBC transfusion unless 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.
  8. Against the use of erythropoietin for treatment of anemia.
  9. Against using high-frequency oscillatory ventilation (HFOV) in adult patients with sepsis-induced ARDS.
  10. Against the use of β-2 agonists for the treatment of patients with sepsis-induced ARDS without Bronchospasm.
  11. 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.
  12. 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.
  13. Against the administration of early parenteral nutrition or against the administration of parenteral nutrition over the first 7 days if enteral feeding is not feasible.
  14. Against routinely monitoring gastric residual volumes (GRVs).
  15. Against the use of IV selenium, arginine, omega-3 fatty acids, IV immunoglobulins, antithrombin or glutamine.

 

NO RECOMMENDATIONS

  1. Use of blood purification techniques.
  2. Thrombomodulin or heparin for the treatment of sepsis or septic shock.
  3. Use of noninvasive ventilation (NIV) for patients with sepsis-induced ARDS.
  4. Use of carnitine for sepsis and septic shock.