Update of Surviving Sepsis

February 24, 2017

Short Attention Span Summary

Surviving this article
Surviving Sepsis has been updated since 2012.  Here is what you need to know for the ED and some for the ICU.  2016 deemphasizes protocolized initial resuscitation.

• Give 30mL/kg crystalloid (preferably balanced solutions) within 3 hours.
• Deemphasize invasive hemodynamic monitoring.
• Target a MAP of 65 and lactate clearance.
• Obtain appropriate cultures before antibiotics.
• Give broad spectrum antibiotics within one hour.
• Find and remove the source, including indwelling lines.
• Use norepinephrine as the initial vasopressor, then add vasopressin, then epinephrine, and ditch dopamine, especially low-dose “renal-protective.”
• Use hydrocortisone 200mg per day only if shock is refractory to fluid and vasopressors.
• Transfuse if hemoglobin < 7 g/dL, unless extenuating circumstances.
• Avoid epo.
• Don’t give FFP unless actively bleeding.
• Transfuse platelets if <10,000 or <20,000 and risk of bleeding, and aim for >50,000 if invasive procedures are needed.
• Use lung protective ventilation.  Manage the vent like a pro.
• Elevate head of bed 30-45 degrees.
• Minimize sedation.
• Use reasonable glucose targets, treating if consistently >180 mg/dL.
• Use continuous renal replacement therapy in unstable patients with AKI.
• Don’t use bicarb to make numbers look better.
• Use LMWH over UFH for VTE prophylaxis.
• Use either PPI or H2 blockers for ulcer prophylaxis only in sepsis or shock patients at risk for GI bleed.
• Start enteral feeds as soon as feasible.
• Set goals of care with family early, including palliation if appropriate.

Spoon Feed
Take a quick look at the high points above.  It’s worth reminding yourself about the basics of sepsis care.  Surviving Sepsis has taken the emphasis off protocolized initial resuscitation and placed it on common sense, rapid treatments.  You may also want to read a more critical take on 6 myths promoted by the new surviving sepsis guidelines.

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Abstract

Crit Care Med. 2017 Jan 17. doi: 10.1097/CCM.0000000000002255. [Epub ahead of print]

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.

Rhodes A1, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane D, Beale RJ, Bellinghan GJ, Bernard GR, Chiche JD, Coopersmith C, De Backer DP, French CJ, Fujishima S, Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad DR, Kleinpell RM, Koh Y, Lisboa TC, Machado FR, Marini JJ, Marshall JC, Mazuski JE, McIntyre LA, McLean AS, Mehta S, Moreno RP, Myburgh J, Navalesi P, Nishida O, Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA, Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson SQ, Singer M, Thompson BT, Townsend SR, Van der Poll T, Vincent JL, Wiersinga WJ, 
Zimmerman JL, Dellinger RP.

Author information:

11St. George’s Hospital London, England, United Kingdom.2New York University School of Medicine New York, NY.3McMaster University Hamilton, Ontario, Canada.4Brown University School of Medicine Providence, RI.5Instituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy.6Vall d’Hebron University Hospital Barcelona, Spain.7University of Manitoba Winnipeg, Manitoba, Canada.8Emory University Hospital Atlanta, GA.9Hadassah Hebrew University Medical Center Jerusalem, Israel.10Sunnybrook Health Sciences Centre Toronto, Ontario, Canada.11University of Pittsburgh Critical Care Medicine CRISMA Laboratory Pittsburgh, PA.12Hospital Raymond Poincare Garches, France.13Saint Thomas Hospital London, England, United Kingdom.14University College London Hospitals London, England, United Kingdom.15Vanderbilt University Medical Center Nashville, TN.16Service de Reanimation Medicale Paris, France.17CHIREC Hospitals Braine L’Alleud, Belgium.18Western Hospital Victoria, Australia.19Keio University School of Medicine, Tokyo, Japan.20Vivantes-Klinikum Neukölln, Berlin, Germany.21Karl Heusner Memorial Hospital Belize Healthcare Partners Belize City, Belize.22Cooper Health System Camden, NJ.23University of Mississippi Medical Center Jackson, MS.24Jupiter Hospital Thane, India.25Rush University Medical Center Chicago, IL.26ASAN Medical Center University of Ulsan College of Medicine Seoul, South Korea.27Hospital de Clinicas de Porto Alegre Porto Alegre, Brazil.28Federal University of Sao Paulo Sao Paulo, Brazil.29Regions Hospital St. Paul, MN.30Saint Michael’s Hospital Toronto, Ontario, Canada.31Washington University School of Medicine St. Louis, MO.32Ottawa Hospital Ottawa, Ontario, Canada.33Nepean Hospital, University of Sydney Penrith, New South Wales, Australia.34Mount Sinai Hospital Toronto, Ontario, Canada.35UCINC, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.36University of New South Wales, Sydney, New South Wales, Australia.37Università dellla Magna Graecia Catanzaro, Italy.38Fujita Health University School of Medicine, Toyoake, Aich, Japan.39Rigshospitalet Copenhagen, Denmark.40Università Sapienza, Rome, Italy.41Christiana Care Health Services Newark, DE.42University of Pittsburgh School of Medicine Pittsburgh, PA.43Stanford University School of Medicine Stanford, CA.44Kaust Medical Services Thuwal, Saudi Arabia.45University of Kansas Medical Center Kansas City, KS.46Wolfson Institute of Biomedical Research London, England, United Kingdom.47Massachusetts General Hospital Boston, MA.48California Pacific Medical Center San Francisco, CA.49University of Amsterdam Amsterdam, Netherlands.50Erasmé University Hospital Brussels, Belgium.51University of Amsterdam, Amsterdam, Netherlands.52Houston Methodist Hospital, Houston, TX.

Abstract

OBJECTIVE:

To provide an update to “Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012.”

DESIGN:

A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.

METHODS:

The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.

RESULTS:

The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.

CONCLUSIONS:

Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

PMID: 28098591 [PubMed – as supplied by publisher]