“Surviving Sepsis, 2013, Update” Syllabus
Society of Cardiovascular Anesthesiologists Annual Meeting
New Orleans, Louisiana
March 30, 2014
Gregory E. Kerr MD, MBA, FCCM
I.
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Learning Objectives: At the conclusion of this educational activity, the
participants will be able to
a. Discuss the new Surviving Sepsis Guidelines
b. Describe ongoing controversies of the guidelines
No conflict of interest
History of the Surviving Sepsis Campaign
a. Phase I
i. A sepsis definitions conference held December 2001 to
determine if new data existed to inform updates to criteria
established in 1991.
ii. Campaign formed by the SCCM, ESICM, and the ISF and
launched at the ESICM Annual Meeting Fall 2002.
iii. Survey global public awareness at SCCM Congress 2003
b. Phase II
i. 2003 - Reps from 11 societies meet in UK to develop guidelines
for management of severe sepsis and septic shock
ii. 2004 - Guidelines published in CCM and ICM
c. Phase III
i. 2003 - Surviving Sepsis Campaign initiated with partnership
with IHI. Bundles evolved from collaboration
ii. 2004 Importance of American College of Emergency Physicians
recognized and they were invited to join campaign
iii. 2004 - 2006 - Brochures and manuals disseminated
d. Phase IV
i. 2013 - ESICM and SCCM announce a reinvigoration of
campaign
ii. Campaign incorporating new data
Definitions
a. SIRS
b. Sepsis
c. Severe Sepsis
d. Septic Shock
Understanding Recommendations
a. GRADE – Grading of Recommendations Assessment, Development and
Evaluation
b. Quality of evidence from high (A) to very low (D)
c. Strength of recommendation from strong (1) to weak or suggestion
(2)
d. Recommendations divided into three groups
VI.
i. Those directly targeting sepsis
ii. Those directly targeting general care of the critically ill patient
and considered high priority in sever sepsis
iii. Pediatric considerations
Management of Severe Sepsis ( ! – New changes to focus on)
a. Initial Resuscitation and Infection Issues
i. Initial resuscitation
ii. Screening for Sepsis
iii. Diagnosis !
1. Use 1,3 beta-D-glucan assay (grade 2B), mannan and
anti-mannan antibody assays (2C), if available and
invasive candidiasis is in differential
2. Use low procalcitonin levels or similar biomarkers to in
discontinuation of empiric antibiotics in patients who
initially appeared septic, but no subsequent evidence of
infection (grade 2C)
iv. Antimicrobial therapy
v. Source control
vi. Infection prevention
b. Hemodynamic support and adjunctive therapy
i. Fluid therapy !
1. Crystalloids initial fluid of choice (grade 1B)
2. Against hydroxyethyl starches for fluid resuscitation
(grade 1B)
3. Albumin for fluid resuscitation when patients need lots
of crystalloids (grade 2C)
4. Normalize lactate in patients with elevated lactate
levels to target resuscitation (grade 2C)
ii. Vaspressor and Inotropic therapy !
1. Norepinephrine first choice vasopressor (grade 1B)
2. Epinephrine (added to and potentially substituted for
norepinephrine) when additional agent needed for
blood pressure (grade 2B)
3. Dopamine as alternative vasopressor to norepinephrine
only in highly selected patients (grade 2C)
4. Do not use low-dose dopamine for renal protection
(grade 1A)
5. Dobutamine infusion be administered or added to
vasopressor (if in use) in presence of (a) myocardial
dysfunction (b) ongoing signs of hypoperfusion, despite
adequate intravascular volume and/or MAP (grade 1C)
iii. Corticosteroids!
1. Not using intravenous hydrocortisone to treat adult
septic shock patients if adequate fluid resuscitation and
vasopressor therapy restore hemodynamic stability
VII.
VIII.
2. If needed, use iv hydrocortisone alone at dose
200mg/day (grade 2C)
c. Supportive therapy
i. Blood product administration
ii. Immunoglobulins
iii. Selenium
iv. Mechanical ventilation of sepsis induced ARDS!
1. Use higher PEEP (grade 2C)
2. Use recruitment maneuvers in septic patients with
severe refractory hypoxemia (grade 2C)
3. Use prone positioning when PaO2/FiO2 ratio <
100mmHg in facilities with experience (grade 2B)
v. Glucose control
vi. Renal replacement therapy
vii. Stress ulcer prophylaxis
viii. Nutrition
Additional controversies
a. How did Xigris make the initial cut?
b. Early goal directed therapy and fluids. Avoiding excess fluids
c. Best way to determine optimal hemodyamics
Conclusion
References:
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International
Guidelines for Management for Severe Sepsis and Septic Shock, Crit Care Med 2013;
41:580–637
http://pulmccm.org/2012/randomized-controlled-trials/xigris-epitaph-prowessshock-results-nejm/
Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/SCCP/ATS/SIS International
Sepsis Definitions Conference. Crit Care Med 2003 31(4):1250-6
Maitland K, Kiguli S, Opoka RO, et al. Mortality after Fluid Bolus, NEJM 2011;
364(26); 2483-2494
Poole D, Bertolni G, Garrattini S, J Epidemiol Community Health, 2012; 66(7), 571572
Vincent JL, Rhodes A, Perel A, et al. Clinical Review: Update on hemodynamic
monitoring – a consensus of 16, Critical Care 2011, 15:229