Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008 Crit Care Med 2008; 36:296-327

1. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008 Volume 36(1), January 2008, pp 296-327 summarized by sun yaicheng http://decode-medicine.blogspot.com/

2. MANAGEMENT OF SEVERE SEPSIS Sepsis Guidelines 2008

3. Initial Resuscitation (First 6 hrs) Begin resuscitation immediately in patients with hypotension or serum lactate > 4 mmol/L; do not delay pending ICU admission Resuscitation goals: CVP 8–12 mm Hg MAP ≥ 65 mm Hg Urine output ≥ 0.5 mL. kg-1.hr-1 Central venous O2 saturation ≥ 70%, or mixed venous ≥ 65% If venous O2 saturation target not achieved: consider further fluid transfuse pRBC to Hct ≥ 30% and/or dobutamine infusion max 20 μg.kg-1.min-1

4. Diagnosis Obtain appropriate cultures before starting antibiotics. Perform imaging studies promptly in order to confirm and sample any source of infection.

5. Antibiotic Therapy Begin antibiotics as early as possible, and always within the first hour of recognizing severe sepsis and septic shock.

6. Source Control

8. Fluid Therapy Fluid-resuscitate using crystalloids or colloids. Target CVP ≥ 8 mmHg (≥ 12 mmHg if mechanically ventilated) Give fluid challenges of 1000 ml of crystalloids or 300–500 ml of colloids over 30 min.

9. Vasopressors Maintain MAP ≥ 65 mm Hg. Norepinephrine or dopamine centrally administered are the initial vasopressors of choice. Use epinephrine as the first alternative agent in septic shock when BP is poorly responsive to norepinephrine or dopamine. In patients requiring vasopressors, insert an arterial catheter as soon as practical.

10. Steroids Consider intravenous hydrocortisone for adult septic shock when hypotension remains poorly responsive to adequate fluid resuscitation and vasopressors. Hydrocortisone dose should be < 300 mg/day.

11. Recombinant human activated protein C (rhAPC) Consider rhAPC in adult patients with sepsis-induced organ dysfunction with clinical assessment of high risk of death (APACHE II ≥ 25 or multiple organ failure) if there are no contraindications. ( for post-operative patients)

12. Blood Product Administration Give RBC when Hb < 7.0 g/dl to target HB 7.0–9.0 g/dl in adults. Administer platelets when: platelet counts are < 5,000/mm3regardless of bleeding. platelet counts are 5000 to 30,000/mm3 and there is significant bleeding risk. platelet counts ≥ 50,000/mm3 are required for surgery or invasive procedures.

13. Glucose Control Use IV insulin to control hyperglycemia in severe sepsis Keep blood glucose < 150 mg/dl

14. Bicarbonate Therapy Do not use bicarbonate therapy when treating hypoperfusion-induced lactic acidemia with pH ≥ 7.15