Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008

Volume 36(1), January 2008, pp 296-327summarized by sun yaichenghttp://decode-medicine.blogspot.com/

MANAGEMENT OF SEVERE SEPSISManagement of Severe Sepsis

Initial Resuscitation Diagnosis Antibiotic

Therapy

Source Control Fluid Therapy Vasopressors

Inotropic Therapy CorticosteroidsRecombinant

Human Activated Protein C (rhAPC)

Blood Product Administration

Sepsis Guidelines 2008

Initial Resuscitation (First 6 hrs)• Begin resuscitation immediately

in patients with hypotension

or serum lactate > 4 mmol/L;

do not delay pending ICU admission

• Resuscitation goals:– CVP 8–12 mm Hg– MAP ≥ 65 mm Hg– Urine output ≥ 0.5 mL. kg-1.hr-1

– Central venous O2 saturation ≥ 70%,

or mixed venous ≥ 65%

• If venous O2 saturation target not achieved: – consider further fluid– transfuse pRBC to Hct ≥ 30% and/or – dobutamine infusion max 20 μg.kg-1.min-1

Diagnosis

• Obtain appropriate cultures before starting antibiotics.

• Perform imaging studies promptly in order to confirm and sample any source of infection.

Antibiotic Therapy

• Begin antibiotics as early as possible, and always within the first hour of recognizing severe sepsis and septic shock.

Source Control

Source Control Examples

Drainage • Intra-abdominal abscess

  • Thoracic empyema

  • Septic arthritis

Debridement • Pyelonephritis, cholangitis

  • Infected pancreatic necrosis

  • Intestinal infarction

  • Mediastinitis

Device removal • Infected vascular catheter

  • Urinary catheter

  • Infected intrauterine contraceptive device

Definitive control • Sigmoid resection for diverticulitis

  • Cholecystectomy for gangrenous cholecystitis

  • Amputation for clostridial myonecrosis

Fluid Therapy

• Fluid-resuscitate using crystalloids or colloids.

• Target CVP ≥ 8 mmHg (≥ 12 mmHg if mechanically ventilated)

• Give fluid challenges of 1000 ml of crystalloids or 300–500 ml of colloids over 30 min.

Vasopressors

• Maintain MAP ≥ 65 mm Hg.• Norepinephrine or dopamine centrally

administered are the initial vasopressors of choice.

• Use epinephrine as the first alternative agent in septic shock when BP is poorly responsive to norepinephrine or dopamine.

• In patients requiring vasopressors, insert an arterial catheter as soon as practical.

Steroids

• Consider intravenous hydrocortisone for adult septic shock when hypotension remains poorly responsive to adequate fluid resuscitation and vasopressors.

• Hydrocortisone dose should be < 300 mg/day.

SCC: sepsis guidelines 2008

Recombinant human activated protein C (rhAPC)

Consider rhAPC in adult patients with sepsis-induced organ dysfunction with clinical assessment of high risk of death (APACHE II ≥ 25 or multiple organ failure) if there are no contraindications.

( for post-operative patients)

Blood Product Administration

• Give RBC when Hb < 7.0 g/dl to target HB 7.0–9.0 g/dl in adults.

• Administer platelets when: – platelet counts are < 5,000/mm3

regardless of bleeding. – platelet counts are 5000 to

30,000/mm3 and there is significant bleeding risk.

– platelet counts ≥ 50,000/mm3 are required for surgery or invasive procedures.

Glucose Control

• Use IV insulin to control hyperglycemia in severe sepsis

• Keep blood glucose < 150 mg/dl

Bicarbonate Therapy

Do not use bicarbonate therapy when treating hypoperfusion-induced lactic acidemia with pH ≥ 7.15