sepsis new guidelines 2017

Surviving Sepsis
Campaign
International
Guidelines for
Management of
Severe Sepsis and
Septic Shock: 2016
Intensive Care Medicine
doi: 10.1007/s00134-017-4683-6
Published online: 18 Jan 2017

Under supervision of
Prof DR
ANEES SINDI
Edited by ..
Mohamed Kharabish

Sepsis
is life-threatening organ dysfunction caused by a
dysregulated host response to infection .
Sepsis and septic shock are major healthcare
problems, affecting millions of people around the
world each year, and killing as many as one in four
(and often more) .Similar to polytrauma, acute
myocardial infarction, or stroke, early identification
and appropriate management in the initial hours
after sepsis develops improves outcomes.

As these guidelines were being developed , new
definitions for sepsis and septic shock (Sepsis-3)
were published.
Sepsis is now
defined as life-threatening organ dysfunction
caused by a dysregulated host response to
infection.
Septic shock is a subset of sepsis with circulatory
and cellular/metabolic dysfunction associated with
a higher risk of mortality

MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
Fluid Therapy Vasopressors
Corticosteroids Blood Product
Glucose
Control
Bicarbonate
Therapy

Initial Resuscitation
Sepsis and septic shock are medical
emergencies, and It is recommended
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).

This 80 kg bw pt (( in septic shock) needs
how much fluids to be resus ..??.
80 × 30 = 2400 ml

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.

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 infusion
1. Continue to balance fluid resuscitation and vasopressor dose with attention to maintain tissue perfusion and minimize interstitial edema
2. Implement some combination of the list below to aid in further resuscitation choices that may include additional fluid or inotrope therapy
• blood pressure/heart rate response,
• urine output,
• cardiothoracic ultrasound,
• CVP, ScvO2,
• pulse pressure variation
• lactate clearance/ normalization or
• dynamic measurement such as response of flow to fluid bolus or passive leg raising
3. Consider albumin fluid resuscitation, when large volumes of crystalloid are required to maintain intravascular volume.
Sepsis-induced hypotension or lactate > 4 mmol/L
No high flow oxygen and
No ESRD on dialysis or CHF
Pneumonia or ALI with high
flow oxygen requirements
ESRD on hemodialysis
or CHF
Rapid infusion
of 30 ml/kg
Crystalloid*
Not intubated/
mechanically ventilated
Intubated/
mechanically ventilated Total of 30 ml/kg crystalloid*
with frequent reassessment
of oxygenation
If no
If
Yes
Consider
intubation/mechanical
ventilation to facilitate
30 ml/kg crystalloid *
Rapid infusion
of 30 ml/kg
crystalloid *
Total of 30 ml/kg with
frequent reassessment of
oxygenation

Diagnosis
Appropriate 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
Administration of IV antimicrobials
must 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).

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

Antimicrobial treatment duration of 7–10
days is adequate for most serious
infections associated with sepsis and
septic shock

Measurement of procalcitonin levels can be
used to support shortening the duration
of antimicrobial therapy in sepsis
patients
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

GUIDELINES recommend
sustained systemic antimicrobial
prophylaxis in patients with severe
inflammatory states of non-infectious origin
(e.g., severe pancreatitis, burn
injury) (BPS).
WHY????.
against

GUIDELINES recommend that dosing
strategies of antimicrobials
be optimized based on accepted
pharmacokinetic/ pharmacodynamic
principles and specific drug properties in
patients with sepsis or septic shock (BPS).

GUIDELINES suggest 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

GUIDELINES suggest that combination therapy
not to be routinely used for ongoing treatment
of most other serious infections, including
bacteremia and sepsis without shock

NO Shock = No Combination
Shock = Combination

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).

To Be Removed after other vascular access
has been established

Fluid Therapy
Crystalloids are the fluid of choice for
initial resuscitation and subsequent
intravascular volume replacement in
patients with sepsis and septic shock
Against using hydroxyethyl starches (HESs)
for intravascular volume replacement in
patients with sepsis or septic shock
(strong recommendation, high quality of evidence).

Fluid Therapy
Using Albumin in addition to
crystalloids for initial resuscitation and
subsequent intravascular volume
replacement in patients with sepsis and
septic shock when patients need more
crystalloids

Vasopressors
Norepinephrine as the first choice
vasopressor
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)
Against using low-dose dopamine for renal
protection

Vasopressors
Using dobutamine in patients who
show evidence of persistent
hypoperfusion despite adequate fluid
loading and the use of vasopressor
agents

Vasopressors
All patients requiring vasopressors have an
arterial catheter placed as soon as
practical if resources are available WHY?**
(weak recommendation, very low quality of evidence).
**In shock states, estimation of blood pressure
using a cuff, especially an automated
measurement system, may be
inaccurate.

Vasopressor Use for Adult Septic Shock
(with guidance for steroid administration)
Initiate norepinephrine (NE) and titrate up to 35-90 μg/min
to achieve MAP target 65 mm Hg
MAP target
achieved
Continue norepinephrine alone or
add vasopressin 0.03 units/min
with anticipation of decreasing
norepinephrine dose
MAP target not achieved
and judged
poorly responsive to NE
Add vasopressin up to
0.03 units/min to achieve
MAP target*
MAP target
achieved
MAP target
not achieved
Add epinephrine up to
20-50 μg/min to achieve MAP
target**
MAP target
achieved
MAP target
not achieved
Add phenylephrine up to
200-300 μg/min to
achieve MAP target***
* Consider IV steroid administration
** 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
interpretation of the literature that does exist and personal
preference/experience. Maximum doses in any individual
patient should be considered based on physiologic
response and side effects.

Corticosteroids
Guidelines are 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, IV hydrocortisone
at a dose of 200 mg per day
• Use it only systolic blood pressure < 90 mm Hg despite
fluid resuscitation and vasopressors for more than one
hour)

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

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

GUIDELINES are Against the use of
erythropoietin for treatment of anemia
associated with sepsis . Why??**
**Erythropoietin administration may be associated with an
increased incidence of thrombotic events in the critically ill.

GUIDELINES are against the use of fresh
frozen plasma to correct
clotting abnormalities in the absence of
bleeding or planned invasive procedures

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

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).

Glucose Control
GUIDELINES Suggest the use of arterial
blood rather than capillary blood for
point-of-care testing using glucose
meters if patients have arterial catheters
WHY??**
**capillary blood is not accurate to estimate arterial blood or
plasma glucose values (BPS).

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).

sepsis new guidelines 2017

sepsis new guidelines 2017

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