Surviving sepsis Guidelines 2012

Surviving Sepsis Campaign

International Guidelines for Management of Severe Sepsis & Septic

Shock Dr Rimita Dey & Dr Raja Basu

Department of Critical Care Medicine Peerless Hospital & B K Roy Research Center

Kolkata

Disclaimer: This presentation contains information on the topic based on recent published literature & international guidelines. The user/presenter of this presentation at his discretion, may modify the contents as may be required. However, the modified version of the presentation shall be reviewed by AstraZeneca Medical Team, before it can be presented in AstraZeneca driven CMEs. For product information, kindly refer to the full prescribing information.”

R. Phillip Dellinger, Crit Care Med 2013; 41:580–637

Systemic Inflammatory Response Syndrome(SIRS) To SEPTIC SHOCK

Diagnostic Criteria for SepsisInfection(documented or suspected)

& some of the following :

General Variables

Fever > 100.9 F Hypothermia < 96.8 FHeart rate >90 Respiratory rate > 20Altered Mental status Hyperglycemia >140

(absence of Diabetes)Significant edema or positive Fluid Balance ( >20 ml/kg over 24 hrs)

Inflammatory variables Leucocytosis (WCC > 12000) Leucopenia ( WCC < 4000)Normal WCC with > 10 % immature formsPlasma CRP > two SD above the normal Plasma Procalcitonin > two SD above the normal

Hemodynamic VariablesArterial Hypotension ( SBP < 90, MAP < 70, OR an SBP decrease > 40 in adults OR SBP Less than two SD below normal for age) WCC- White Cell Count, CRP- C Reactive Protein, SD- Standard Deviation, SBP- Systolic Blood Pressure, MAP- Mean Arterial Pressure

Organ Dysfunction Variables (Severe Sepsis Criteria)Arterial Hypoxemia (PaO2 /FiO2 <300)Acute Oliguria (UO< 0.5 ml/kg/hr for at least

2 hours despite fluid resuscitation)Creatinine increase > 0.5 mg/dlCoagulation abnormalities (INR> 1.5 or aPTT >60s)Ileus (absent bowel sounds)Thrombocytopenia ( < I lakh)Hyperbilirubinemia ( > 4 mg/dl)

Tissue Perfusion VariablesHyperLactaemia ( > 1 mmol/L)Decreased Capillary Refilling Time or Mottling

SURVIVING SEPSIS CARE BUNDLES

TO BE COMPLETED WITHIN 3 HOURS

1.Measure Lactate Levels2.Obtain Blood Cultures prior to administration

of Antibiotics.3.Administer broad spectrum Antibiotics4.Administer 30ml/kg Crystalloid for low BP or

lactate level – 4

TO BE COMPLETED WITHIN 6 HOURS5. Apply Vasopressors (for hypotension that does

not respond to the initial fluid resuscitation) to maintain a MAP > 65.

6. In the event of persistent hypotension despite volume resuscitation (septic Shock) Or

initial lactate being > 4 - Measure CVP & CVP saturation(ScvO2)

7. Remeasure Lactate levels if the initial lactate was elevated.

MAP = Diastolic BP + (Systolic BP – Diastolic BP)

3

SURVIVING SEPSIS CARE BUNDLES

Initial Resuscitation• Begin Resuscitation immediately in patients

with low BP or elevated serum lactate > 4; DONOT delay pending ITU admission.

• Resuscitation Goals:CVP 8-12 mm HgMAP > 65mm HgUrine output > 0.5ml/Kg/HrCentral Venous O2 saturation >70%, or mixed venous >65%.

If venous o2 saturation target is not achieved :

• Consider further fluids• Transfuse Packed RBCs to achieve a

haematocrit of > 30% And/ or• Dobutamine infusion max 20 mic/kg/min

A higher target CVP of 12-15 mm Hg is recommended in the presence of mechanical ventilation or pre-existing decreased ventricular compliance.

DiagnosisObtain appropriate Blood cultures beforestarting antibiotics provided this does notsignificantly delay antimicrobial administration

• obtain two or more blood cultures(BCs).• one or more BCs should be percutaneous.• one BC from each vascular access device in place >48hrs.• Culture other sites as clinically indicated (CSF, Ascitic

Fluid).

Perform imaging studies promptly in order toConfirm & sample any source of infection; if safeto do so.

Antibiotic Therapy• Begin IV Antibiotics as early as possible, & always within the

first hour of recognizing severe sepsis and septic shock. (Grade 1B)

• Broad-spectrum : one or more agents active against likely bacterial/ fungal pathogens & with good penetration into the presumed source. (Grade 1B)

• Duration of therapy typically limited to 7-10 days; longer if response is slow, undrainable foci of infection, or immunogenic deficiencies & neutropenic patients, or Bacteremia with S.Aureus. (Grade 2C)

• Use of low Procalcitonin level or similar biomarkers to assist discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection. (Grade 2C)

• Antiviral initiated as early as possible in severe sepsis of viral origin.

• Reassess antimicrobial regimen daily to optimize efficacy, prevent resistance, avoid toxicity & minimize costs.– Consider combination therapy in Pseudomonas & Acenetobacter

infection– Treat with an extended spectrum Beta-lactum & either an

aminoglycoside or a fluroquinolone for Pseudomonas bacteremia.– A combination of Beta-lactum & Macrolide for patients with

Streptococcus Pneumoniae infections– Consider combination empiric therapy in neutropenic patients– Combination therapy no more than 3-5 days &

de-escalation following susceptibilities.

• Antimicrobials should NOT be used in patients with severe inflammatory states determined to be of noninfectious cause.

Source Identification & control• A specific anatomic site of infection should be

established as rapidly as possible & within the first 6 hours of presentation.

• Formally evaluate patient for a focus of infection amenable to source control measures (e.g. abscess drainage, tissue debridement)

• Implement source control as soon as possible following successful initial resuscitation.

– Exception : infected pancreatic necrosis, where surgical intervention is best delayed.

• Remove Intravascular access devices if potentially infected.

Infection Prevention

• Selective oral decontamination and selective digestive decontamination should be introduced and investigated as a method to reduce the incidence of ventilator-associated pneumonia.

• Oral chlorhexidine gluconate be used as a form of oropharyngeal decontamination to reduce the risk of ventilator-associated pneumonia in ICU patients. (Grade 2B)

Fluid Therapy

Crystalloids Solutions

Vasopressors

• Dopamine as an alternative to NA is recommended only for patients with low risk of tachyarrhythmia & absolute or relative bradycardia.

• Phenylephrine is NOT recommended for septic shock except in (Grade 1C)

– NA associated serious arrhythmias– C.Output is known to be high but BP is low– As salvage therapy when combined vasopressor-inotrope

drugs & low dose vasopressin have all failed to achieve MAP.

• Do NOT use low dose dopamine for Renal Protection.(Grade 1A)

• All patients requiring Vasopressors should have an arterial catheter placed as soon as practical.

Ionotropic Therapy

• A trial of Dobutamine infusion of up to 20microgm/kg/min may be administered alone or added to vasopressor in presence of

–Myocardial dysfunction suggested by elevated cardiac filling pressures & low cardiac output, or–Ongoing signs of hypo perfusion, despite

achieving intravascular volume & adequate MAP. (Grade 1C)

Corticosteroids• Do NOT use IV Hydrocortisone to treat adult septic

shock if adequate fluid resuscitation & vasopressor therapy is able to restore hemodynamic stability. Incase this is not achieved IV Hydrocortisone alone @ 200mg IV OD may be used.(Grade 2C)

• ACTH stimulation test is NOT to be used to identify adults with septic shock receiving Hydrocortisone.

• When Hydrocortisone is given, use continuous flow. • Steroid therapy may be weaned when vasopressors

are no longer required.• Do NOT use corticosteroids to treat sepsis in the

absence of shock.

Blood Product Administration• Transfuse Red Blood Cells when Hb decreases to < 7

& target a Hb of 7-9 in adults.(Grade 1B)

• Higher Hb level may be required in presence of myocardial ischemia, severe hypoxemia, or acute hemorrhage.

• Erythropoietin not recommended as a treatment of sepsis related severe anemia.(Grade 1B)

• FFP should only be used to correct clotting abnormalities in the presence of bleeding or planned invasive procedures. (Grade 2D)

• Antithrombin should not be used for the treatment of severe sepsis. (Grade 1B)

Mechanical ventilation in Sepsis induced ARDS

• Target a Tidal volume of 6ml/kg of predicted body wt.(vs. 12ml/kg). (Grade 1A)

• Plateau pressure should be measured in pts with ARDS & Target an initial upper limit pressure <30 cm H2o in a passively inflated lung.

• PEEP should be applied to avoid alveolar collapse at end expiration (atelectrauma). (Grade 1B)

• Higher rather than lower levels of PEEP should be used in sepsis associated ARDS. (Grade 2C)

• Recruitment maneuvers should be used in sepsis patients with severe refractory hypoxemia.

• Prone positioning should be considered in ARDS pts requiring potentially injurious levels of FiO2 or plateau pressures.

• Ventilated pts should be positioned at 30-45’ head elevation to limit aspiration risk & VAP.(Grade 1B)

• NIV should be in only that minority of ARDS patients with mild to moderate hypoxemic respiratory failure. The pts need to be haemodynamically stable, comfortable easily arousable, able to protect /clear their airway & expected to recover rapidly.

• Use a weaning protocol & a spontaneous breathing trial (SBT) regularly to evaluate the potential for discontinuing mechanical ventilation. (Grade 1A)

• SBT options include a low level of pressure support with CPAP 5 or a T-piece.

• Before SBT pts should be– Arousable– Haemodynamically stable– Have no new potentially serious conditions– Have low ventilatory & end-expiratory pressure requirement– Require FiO2 that can be safely delivered with a face mask or nasal cannula.

• Do Not use a pulmonary catheter for the routine monitoring of pts with ARDS . (Grade IA)

• Use a conservative rather than liberal fluid strategy for ARDS pts without any evidence of tissue hypo perfusion.

• Do NOT use beta 2-agonists for the treatment of sepsis induced ARDS unless there is specific indication such as bronchospasm.

Sedation, Analgesia & Neuromuscular Blocking Agents(NBMAs)

• Continuous or intermittent sedation should be minimized in mechanically ventilated sepsis pts targeting specific titration endpoints. (Grade 1B)

• NBMAs should be avoided if possible in septic pts without ARDS.(due to risk of prolonged NM blockade following discontinuation)

• If NMBAs are needed, either intermittent bolus as required or continuous infusion with Train of Four monitoring of the depth of blockade is advised. (Grade 1C)

• A short course of NMBA of NOT greater than 48hrs for pts with early sepsis induced ARDS & a PaO2/ FiO2 < 150 is advised.

Glucose Control• In patients with severe sepsis start insulin dosing when 2

consecutive blood sugar reading are > 180.• A protocolized approach should target an upper level of <

180 rather than a upper target blood glucose level of < 110. (Grade 1A)

• Blood glucose monitoring every 1-2 hrs until glucose values & insulin infusion rates are stable & thereafter every 4hrs. (Grade 1C)

• Use IV insulin in pts with severe sepsis.• Interpret with caution low glucose levels obtained with

point of care testing as these techniques may overestimate arterial blood or plasma glucose values

Renal Replacement Therapy& Bicarbonate

• CRRT & Intermittent HD are equivalent in Severe Sepsis and ARF. (Grade 2B)

• Use continuous therapies to facilitate management of fluid balance in hemodynamically unstable septic pts.

• Do NOT use Sodium Bicarbonate for the purpose of improving hemodynamics or reducing vasopressor requirements when treating hypo perfusion induced lactic acidemia with a pH>7.15 (Grade 2B)

DVT Prophylaxis• Pts with severe sepsis should receive daily

phamacoprophylaxis against VTE. (Grade 1B)

• Use once daily S/C LMWH (vs BD dosing of UFH & vs TDS dosing of UFH). (Grade 1B)

• If CrCl <30 use Dalteparin. (Grade 1A)

• Whenever possible treat with a combination of pharmacological therapy & intermittent pneumatic compression.

• Where heparin is C/I (low platelets, severe coagulopathy, active bleeding or recent ICH) mechanical prophylactic treatment (compression stocking or devices) should be used.

Stress Ulcer Prophylaxis• Use H2 Blocker or Proton Pump Inhibitor in pts

who have bleeding risk factors. (Grade 1B)

• When stress ulcer prophylaxis is needed use PPI rather than H2 RA.

• Pts without risk factors should not receive prophylaxis

Nutrition• Give oral or enteral feeding, as tolerated rather than

either complete fasting or only IV glucose within the first 48 hrs of diagnosing severe sepsis.

• Avoid mandatory full caloric feeding in the first week instead suggest low dose feeding (e.g. upto 500 calories per day) then advancing only as tolerated.

• Use IV glucose & Enteral Nutrition rather than TPN alone or Parenteral nutrition in conjugation with enteral feeding during the first 7 days of diagnosis.

• Use nutrition with no specific immunomodulating supplementation (rather than nutrition providing specific immunomodulating supplementation) in severe sepsis.

Setting Goals of Care

• Discuss prognosis & goals of care with patients & their families.

• Incorporate goals of care into the treatment & end-of-life planning, utilizing the palliative care principles, where possible.

• Address goals of care as early as feasable, but no later than within 72 hrs of admission.

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