Surviving Sepsis Campaign Guidelines (2008)
Dellinger RP et al (2008) “Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock.” Intensive Care Medicine; 34:17-60
and Crit Care Med; 36(1) 296-327
IIMOSH
Initial Resuscitation
- resuscitate aggressively in first 6 hours
- goals: CVP 8-12, MAP > 65, U/O >0.5mL/kg/hr, ScvO2 >70%
- if SVO2 < 70% -> consider RBC’s to haematocrit >30% or start dobutamine
Infection issues
Diagnosis
- culture but don’t delay antibiotics
- get blood cultures +/- relevant sites
- image
Antibiotic Therapy
- give within 1 hour in severe sepsis or shock
- broad spectrum
- reassess antibiotics daily
- use combination in Pseudomonas, the neutropenic and in the really unwell with de-escalation after 3 days
- typically limit treatment to 7-10 days
Source identification and control
- identify source within 6 hours -> decide whether can be controlled
- control with measure that is maximally effective and minimally invasive
- remove intravascular access if could be culprit
Mechanical Ventilation
- lung protective ventilation: TV <6mL/kg, Plateau pressure <30cmH2O, permissive hypercapnoea, high PEEP
- nurse head up
- consider prone ventilation
- wean + spontaneous breathing trials
- conservative fluid strategy after resuscitation phase
- NIV may be indicated in selected cases
Other Supportive Care
Sedation, analgesia and neuromuscular blockade
- target sedation
- daily interruptions
- avoid paralysis if possible
Glucose control
- control with IV insulin
- provide a glucose source
Renal Replacement
- IHD and CVVH are equivalent
- CVVH offers easier management in the haemodynamically unstable
DVT prophylaxis
- use a heparin + SCDs/TEDS
Stress ulcer prophylaxis
- use H2 antagonist or PPI
- benefit of decreased GI risk must be weighed against risk of VAP
Limiting support
- keep family in loop and plan
Special Drugs
Steroids
- consider IV hydrocortisone when shock doesn’t respond well to fluid and pressors.
- wean once pressors no longer required
- < 300mg/day of hydrocortisone
Recombinant Activated Protein C
- consider in adults with MODS and high risk of death (APACHE II > 25 or MOF)
- supported in PROWESS and ENHANCE trial, but not in ADDRESS trial
Bicarbonate therapy
- don’t use to improve haemodynamics or treat lactic acidosis
Haemodynamic Support
Fluid Therapy
- use crystalloids or colloids
- give volume if volume responsive
Vasopressors
- insert arterial line ASAP
- use noradrenaline or dopamine
- add in vasopressin 0.03u/min
Inotropic Therapy
- low Q -> use dobutamine
- don’t use aim for supranormal cardiac index
Blood product administration
- aim for Hb 70-90 g/dL unless requires higher
- don’t use EPO
- don’t correct coagulopathy unless patient is bleeding
- give platelets if count less than 5
- give appropriate therapy if invasive lines required
EVALUATION
Hicks, P and Cooper, J – ANZICS Position Statement on SSG (CCR, 2008)
Strengths
- comprehensive
- synthesis of all information on sepsis
- attempt to try and decrease mortality from sepsis (common problem)
- reputable authors
- bench mark for quality of care
- many elements supported by ANZICS
Weaknesses
- Australasia doesn’t practice many of the suggested therapies -> evidence is not strong and are awaiting higher quality trials.
- not proven superior to our current practice
- EGDT: Rivers trial inherently flawed, we don’t practice and yet our mortality rate is lower.
- tight glycaemic control: now shown to increase mortality from hypoglycaemia
- steroids: shown to reverse shock quicker but no change in mortality
- APC: awaiting PROWESS-SHOCK trial data, very real risk of increased intracerebral haemorrhage.
- vasopressor: we don’t use dopamine and are more likely to use adrenaline
Overall position
- accept the attempt to synthesize the data
- many of the suggested management is founded on questionable or contentious data -> can’t accept all of its recommendations
- await further high quality trial data
Jeremy Fernando (2011)