sepsis new guidelines 2017

Surviving Sepsis CampaignInternational Guidelines for Management of Severe Sepsis and Septic Shock: 2016

Intensive Care Medicinedoi: 10.1007/s00134-017-4683-6Published online: 18 Jan 2017

STOPSEPSIS

Under supervision of

Prof DR

ANEES SINDIEdited 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 nowdefined 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 SEPSISManagement of Severe Sepsis

Initial Resuscitation Diagnosis Antibiotic

Therapy

Source Control Fluid Therapy Vasopressors

Corticosteroids Blood Product Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Initial Resuscitati

on

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

Initial Resuscitation 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.

Initial Resuscitation 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 infusion1. Continue to balance fluid resuscitation and vasopressor dose with attention to maintain tissue perfusion and minimize interstitial

edema2. 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 andNo ESRD on dialysis or CHF

Pneumonia or ALI with high flow oxygen requirements

ESRD on hemodialysisor CHF

Rapid infusionof 30 ml/kgCrystalloid*

Not intubated/mechanically ventilated

Intubated/mechanically ventilated Total of 30 ml/kg crystalloid*

with frequent reassessment of oxygenation

If no

IfYes

Considerintubation/mechanicalventilation to facilitate30 ml/kg crystalloid *

Rapid infusionof 30 ml/kgcrystalloid *

Total of 30 ml/kg withfrequent reassessment of

oxygenation

MANAGEMENT OF SEVERE SEPSISManagem

ent of Severe Sepsis

Initial Resuscitation Diagnosis

Antibiotic Therapy

Source Control Fluid Therapy

Vasopressors Corticosteroids Blood Product

Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Diagnosis

DiagnosisAppropriate 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).

MANAGEMENT OF SEVERE SEPSISManagem

ent of Severe Sepsis

Initial Resuscitation Diagnosis

Antibiotic Therapy

Source Control Fluid Therapy

Vasopressors Corticosteroids Blood Product

Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Antimicrobial Therapy

Antimicrobial Therapy Administration of IV anti- microbials

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).

Antimicrobial Therapy 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)

(strong recommendation, moderate quality of evidence).Empiric antimicrobial therapy be narrowed

once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted (BPS).

Antimicrobial Therapy

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

(weak recommendation, low quality of evidence).

Antimicrobial Therapy Measurement of procalcitonin levels can be

used to support shortening the duration of antimicrobial therapy in sepsis patients

(weak recommendation, low quality of evidence).

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

(weak recommendation, low quality of evidence).

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

against

GUIDELINES recommend that dosing strategies of antimicrobialsbe optimized based on accepted pharmacokinetic/ pharmacodynamicprinciples 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 initialmanagement of septic shock (weak recommendation, low quality of evidence).

GUIDELINES suggest that combination therapy not to be routinely used for ongoing treatment of most other serious infections, including bacteremia and sepsis without shock(weak recommendation, low quality of evidence).

NO Shock = No Combination

Shock = Combination

MANAGEMENT OF SEVERE SEPSISManagem

ent of Severe Sepsis

Initial Resuscitation Diagnosis

Antibiotic Therapy

Source Control Fluid Therapy

Vasopressors Corticosteroids Blood Product

Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Source Control

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

MANAGEMENT OF SEVERE SEPSISManagem

ent of Severe Sepsis

Initial Resuscitation Diagnosis

Antibiotic Therapy

Source Control Fluid Therapy

Vasopressors Corticosteroids Blood Product

Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Fluid Therapy

Fluid TherapyCrystalloids are the fluid of choice for

initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock

(strong recommendation, moderate quality of evidence).

Against using hydroxyethyl starches (HESs) for intravascular volume replacement in patients with sepsis or septic shock

(strong recommendation, high quality of evidence).

Fluid TherapyUsing 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

(weak recommendation, low quality of evidence).

MANAGEMENT OF SEVERE SEPSISManagem

ent of Severe Sepsis

Initial Resuscitation Diagnosis

Antibiotic Therapy

Source Control Fluid Therapy

Vasopressors Corticosteroids Blood Product

Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Vasopressors Norepinephrine as the first choice

vasopressor (strong recommendation, moderate quality of evidence). 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)

(weak recommendation, low quality of evidence).

Against using low-dose dopamine for renal protection

(strong recommendation, high quality of evidence).

Vasopressors Using dobutamine in patients who

show evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents

(weak recommendation, low quality of evidence).

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 beinaccurate.

Vasopressor Use for Adult Septic Shock (with guidance for steroid administration)

Initiate norepinephrine (NE) and titrate up to 35-90 μg/minto achieve MAP target 65 mm Hg

MAP targetachieved

Continue norepinephrine alone oradd vasopressin 0.03 units/minwith anticipation of decreasing

norepinephrine dose

MAP target not achievedand judged

poorly responsive to NE

Add vasopressin up to0.03 units/min to achieve

MAP target*

MAP targetachieved

MAP targetnot achieved

Add epinephrine up to20-50 μg/min to achieve MAP

target**

MAP targetachieved

MAP targetnot 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.

MANAGEMENT OF SEVERE SEPSISManagem

ent of Severe Sepsis

Initial Resuscitation Diagnosis

Antibiotic Therapy

Source Control Fluid Therapy

Vasopressors Corticosteroids Blood Product

Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

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

(weak recommendation, low quality of evidence).• Use it only systolic blood pressure < 90 mm Hg despitefluid resuscitation and vasopressors for more than one hour)

MANAGEMENT OF SEVERE SEPSISManagem

ent of Severe Sepsis

Initial Resuscitation Diagnosis

Antibiotic Therapy

Source Control Fluid Therapy

Vasopressors Corticosteroids Blood Product

Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Blood Products

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

(strong recommendation, high quality of evidence).

Blood Product Administration 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

(weak recommendation, very low quality of evidence).

Blood Product Administration

GUIDELINES are Against the use of erythropoietin for treatment of anemia associated with sepsis . Why??**

(strong recommendation, moderate quality of evidence).

**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 correctclotting abnormalities in the absence of bleeding or planned invasive procedures (weak recommendation, very low quality of evidence).

MANAGEMENT OF SEVERE SEPSISManagem

ent of Severe Sepsis

Initial Resuscitation Diagnosis

Antibiotic Therapy

Source Control Fluid Therapy

Vasopressors Corticosteroids Blood Product

Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Glucose Control

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

(strong recommendation, high quality of evidence).

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??**(weak recommendation, low quality of evidence).

**capillary blood is not accurate to estimate arterial blood or plasma glucose values (BPS).

MANAGEMENT OF SEVERE SEPSISManagem

ent of Severe Sepsis

Initial Resuscitation Diagnosis

Antibiotic Therapy

Source Control Fluid Therapy

Vasopressors Corticosteroids Blood Product

Glucose Control

Bicarbonate Therapy Sepsis Guidelines 2016

Bicarbonate Therapy

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).