Crit Care Med 2013; 41:580–637
Intensive Care Med 2013; 39 (2):165 - 228
Surviving sepsis guidelines
Dr Jojo K John. MD, DNB, DM, EDIC
Consultant Intensivist
Medical Trust Hospital
In rigor mortis
• Starch solutions
• Dopamine
• “TIGHT” glucose
Humpty Dumpties still on the wall
• Steroids for all shock
• CVP targets, ScVo2
New on the block
• Lactate clearance
• Biomarkers- procalcitonin, beta D mannan,
galactomannan
• Better indicators of fluid responsiveness
• Kumar A, Roberts D, Wood KE, et al. Crit Care
Med 2006;34(6):1589–96
Antimicrobial Therapy
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Administration of effective intravenous antimicrobials within the first hour of recognition of
septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of
therapy.
Initial empiric anti-infective therapy of one or more drugs that have activity against all likely
pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations
into tissues presumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be
reassessed daily for potential deescalation (grade 1B).
Use of low procalcitonin levels or similar biomarkers to assist the clinician in the
discontinuation of empiric antibiotics in patients who initially appeared septic, but have no
subsequent evidence of infection (grade 2C).
Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and
for patients with difficult-to-treat, multidrugresistant bacterial pathogens such as
Acinetobacter and Pseudomonas spp. (grade 2B). Empiric combination therapy should not be
administered for more than 3–5 days. De-escalation to the most appropriate single therapy
should be performed as soon as the susceptibility profile is known (grade 2B).
Duration of therapy typically 7–10 days; longer courses may be appropriate 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 (grade 2C).
Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock
of viral origin (grade 2C).
Antimicrobial agents should not be used in patients with severe inflammatory states
determined to be of noninfectious cause (UG).
Fluid therapy
1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and
septic shock (grade 1B).
2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and
septic shock (grade 1B).
3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients
require substantial amounts of crystalloids (grade 2C).
4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with
suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a
portion of this may be albumin equivalent). More rapid administration and greater
amounts of fluid may be needed in some patients (grade 1C).
5. Fluid challenge technique be applied wherein fluid administration is continued as
long as there is hemodynamic improvement either based on dynamic (eg, change
in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart
rate) variables (UG).
The role of albumin as a resuscitation fluid for patients with sepsis: A systematic
review and meta-analysis*
Delaney, Anthony P. MD, FCICM; Dan, Arina MD, FCICM; McCaffrey, John MD,
FCICM; Finfer, Simon MD, FCICM
Seventeen studies that randomized 1977 participants were included in the meta-analysis.
There were eight studies that included only patients with sepsis and nine where patients
with sepsis were a subgroup of the study population. There was no evidence of
heterogeneity, I2 = 0%.
The use of albumin for resuscitation of patients with sepsis was associated with a
reduction in mortality with the pooled estimate of the odds ratio of 0.82 (95% confidence
limits 0.67–1.0, p = .047).
Objective: To determine whether the early administration of albumin as an expander and
antioxidant would improve survival on the 28th day for septic shock patients.
Design: Prospective, multicenter, randomized, controlled versus saline, stratified on
nosocomial infection and center.
Setting: 27 Intensive Care Units (ICU) in France
Coordinator: Pr J.P. Mira and Dr J. Charpentier - Cochin Hospital- Paris
Patients: 800 patients could be included during the first 6 hours of their septic shock.
Vasopressors
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Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65 mm Hg
(grade 1C).
Norepinephrine as the first choice vasopressor (grade 1B).
Epinephrine (added to and potentially substituted for norepinephrine) when an
additional agent is needed to maintain adequate blood pressure (grade 2B).
Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intent of
either raising MAP or decreasing NE dosage (UG).
Dopamine as an alternative vasopressor agent to norepinephrine only in highly
selected patients (eg, patients with low risk of tachyarrhythmias and absolute or
relative bradycardia) (grade 2C).
Low-dose dopamine should not be used for renal protection (grade 1A).
All patients requiring vasopressors have an arterial catheter placed as soon as
practical if resources are available (UG).
CVP for FLUID RESUSCITATION
CVP should not be used to make clinical decisions regarding fluid management
CHEST.July 2008;134(1):172-178. doi:10.1378/chest.07-2331
Mitchel Levi in SCCM sepsis presentation Jan 2013
Flowrates
• 20 g : 40 ml / minute
• 18 g : 75 m l / minute
• 16 g : 150 ml / minute
• 14 g : 300 ml / minute
• 16 G CVC of 16 cm length : 50 mL / minute only !
Certain Drug infusions need central access
Management of sepsis in Indian ICUs: Indian data
from the MOSAICS study
J Divatia
• Prospective cohort study of 162 adult patients with severe
sepsis admitted to 17 ICUs in India in July 2009.
• Hospital mortality was 38.3% (62/162)
• Compliance rate for the entire resuscitation and management
bundle was 6.8% (11/162)
• Compliance with the resuscitation bundles was associated
with mortality rates of 18.2%, while mortality rates with
noncompliance was 39.7%
Sepsis in liver disease
• Identification of sepsis and severity difficult
• central venous SO2 in patients with end-stage liver disease is
higher than normal because of the vasodilated hyperdynamic
state. therefore, the ScvO2 cut off value of 70% proposed by SSC
guidelines could be inappropriate in this context.
• Lactate may reflect hepatic failure rather than
tissuehypoperfusion
• the typical hypoalbuminemic and vasodilated state of cirrhotic
patients can require a very large fluid infusion before achieving
the suggested CVP values with an increased risk of interstitial and
pulmonary edema.
• a rapid increase of CVP values in cirrhotic patients can cause an
additional risk in relation to the increase of portal pressure with
bleeding complications and large ascites formation
Effectiveness of sepsis bundle application in
cirrhotic patients with septic shock: a singlecenter experience. Laura Rinaldi
• The 6-hour, 24-hour, and all bundles were completed in 50 %, 52%,
and 39% of the patients, respectively. The characteristics at
admission and the 30-day mortality of patients with all-bundle
compliance (n = 15; mortality 86.6%) were similar to those of
patients without bundle compliance (n = 23; mortality 78.2%),
except for central venous O2 saturation.
• Unadjusted and adjusted regression analysis showed that none of
the single sepsis interventions and bundles were independently
associated with 30-day mortality.
Journal of Critical Care Volume 28, Issue 2 April 2013
•Sepsis kills, it’s a medical emergency
•Bundle compliance improves outcomes
•Early goal directed therapies