Surviving Sepsis Campaign Guidelines 2008

OVERVIEW

INITIAL RESUSCITATION

  • resuscitate aggressively in first 6 hours
  • goals: CVP 8-12, MAP > 65, U/O >0.5mL/kg/hr, ScvO2 >70%
  • if SVO2 < 70% -> consider RBCs to haematocrit >30% and/or start dobutamine

INFECTION ISSUES

Diagnosis

  • culture but don’t delay antibiotics
  • get 2 or more blood cultures: at least one percutaneous; culture samples off all lines >48h old
  • culture other appropriate sites
  • imaging studies

Antibiotic Therapy

  • give within 1 hour in severe sepsis or shock
  • broad spectrum
  • reassess antibiotics daily
  • use combinations in Pseudomonas, the neutropenic and in the severely unwell with de-escalation after 3 days
  • typically limit treatment to 7-10 days

Source identification and control

  • identify source within 6 hours -> decide whether can be controlled
  • control with measure that is maximally effective and minimally invasive
  • remove intravascular access if could be culprit

MECHANICAL VENTILATION

  • lung protective ventilation: TV <6mL/kg, Plateau pressure <30cmH2O, permissive hypercapnoea, high PEEP
  • nurse head up
  • consider prone ventilation
  • wean + spontaneous breathing trials
  • conservative fluid strategy after resuscitation phase
  • NIV may be indicated in selected cases

OTHER SUPPORTIVE CARE

Sedation, analgesia and neuromuscular blockade

  • target sedation
  • daily interruptions
  • avoid paralysis if possible

Glucose control

  • control with IV insulin
  • provide a glucose source

Renal Replacement

  • IHD and CVVH are equivalent
  • CVVH offers easier management in the haemodynamically unstable

DVT prophylaxis

  • use a heparin + SCDs/TEDS

Stress ulcer prophylaxis

  • use H2 antagonist or PPI
  • benefit of decreased GI risk must be weighed against risk of VAP

Limiting support

  • keep family in loop and plan

SPECIAL DRUGS

Steroids

  • consider IV hydrocortisone when shock doesn’t respond to fluid and pressors
  • wean once pressors no longer required
  • < 300mg/day of hydrocortisone
  • Recombinant Activated Protein C – consider in adults with MODS and high risk of death (APACHE II > 25 or MOF)
  • supported in PROWESS and ENHANCE trial, but not in ADDRESS trial

Bicarbonate therapy

  • don’t use to improve haemodynamics or treat lactic acidosis

HAEMODYNAMIC SUPPORT

Fluid Therapy

  • use crystalloids or colloids
  • give volume if volume responsive

Vasopressors

  • insert arterial line ASAP
  • use noradrenaline or dopamine
  • add in vasopressin 0.03u/min

Inotropic Therapy

  • low Q -> use dobutamine
  • don’t use aim for supranormal cardiac index

Blood product administration

  • aim for Hb 70-90 g/dL unless requires higher
  • don’t use EPO
  • don’t correct coagulopathy unless patient is bleeding
  • give platelets if count less than 5
  • give appropriate therapy if invasive lines required

EVALUATION

Strengths

  • comprehensive
  • synthesis of all information on sepsis
  • attempt to try and decrease mortality from sepsis (common problem)
  • reputable authors
  • bench mark for quality of care
  • many elements supported by ANZICS

Weaknesses

  • Australasia doesn’t practice many of the suggested therapies -> evidence is not strong and are awaiting higher quality trials.
  • not proven superior to our current practice
  • EGDT: Rivers trial inherently flawed, we don’t practice it and yet our mortality rate is lower.
  • tight glycaemic control: now shown to increase mortality from hypoglycaemia
  • steroids: shown to reverse shock quicker but no change in mortality
  • APC: no longer marketed following lack of benefit seen in the PROWESS-SHOCK trial
  • vasopressor: we don’t use dopamine and are more likely to use adrenaline or noradrenaline

Overall position

  • accept the attempt to synthesize the data
  • many of the suggested management is founded on questionable or contentious data -> can’t accept all of its recommendations
  • await further high quality trial data

References and Links

LITFL

Journal articles and textbooks

  • Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008 Jan;36(1):296-327. Erratum in: Crit Care Med. 2008 Apr;36(4):1394-6. PubMed PMID: 18158437. [Fulltext]
  • Hicks P, Cooper DJ, Webb S, Myburgh J, Seppelt I, Peake S, Joyce C, Stephens D, Turner A, French C, Hart G, Jenkins I, Burrell A. The Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. An assessment by the Australian and New Zealand intensive care society. Anaesth Intensive Care. 2008 Mar;36(2):149-51. PubMed PMID: 18361003. [CCR version in fulltext]
  • Marik PE. Surviving sepsis: going beyond the guidelines. Ann Intensive Care. 2011 Jun 7;1(1):17. doi: 10.1186/2110-5820-1-17. PubMed PMID: 21906348; PubMed Central PMCID: PMC3224476.
  • Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. PubMed PMID: 11794169. [Fulltext]

Social media and web resources


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Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and informatics. Asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | vocortex |

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