Surviving sepsis guidelines

1. Crit Care Med 2013; 41:580–637 Intensive Care Med 2013; 39 (2):165 - 228 Surviving sepsisguidelines Dr Jojo K John. MD, DNB, DM, EDIC Consultant Intensivist Medical Trust Hospital

11. Starch solutions Dopamine “TIGHT” glucose In rigor mortis

12. Humpty Dumpties still on the wall • Steroids for all shock • CVP targets, ScVo2

13. New on the block • Lactate clearance • Biomarkers- procalcitonin, beta D mannan, galactomannan • Better indicators of fluid responsiveness

17. Kumar A, Roberts D, Wood KE, et al. Crit Care Med 2006;34(6):1589–96

19. Antimicrobial Therapy • 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).

21. 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).

22. 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.

23. Vasopressors • 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).

27. 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

28. Mitchel Levi in SCCM sepsis presentation Jan 2013

29. F l o w r a t e s • 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 !

30. Certain Drug infusions need central access

31. Management of sepsis in Indian ICUs: Indian data from the MOSAICS studyJ 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%

32. 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

33. Effectiveness of sepsis bundle application in cirrhotic patients with septic shock: a single-center 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

34. Sepsis kills, it’s a medical emergency • Bundle compliance improves outcomes • Early goal directed therapies