The Sepsis Resuscitation And Management Bundles

Dr. Najm-us-saqibDr. Najm-us-saqibDepartment of Anaesthesia Department of Anaesthesia and intensive careand intensive careCombined Military Hospital Combined Military Hospital RawalpindiRawalpindi

The sepsis resuscitation and

management bundles

Sepsis:Sepsis:

SEPSISSuspected or proven infection Presence of at least 2 signs

• Temperature 38oC or 36oC• HR 90 beats/min• Respirations 20/min• WBC count 12,000/mm3 or 4,000/mm3 or >10%

immature bands

SepsisSepsisSIRSSIRSInfection /Infection /TraumaTrauma Severe SepsisSevere Sepsis

Infection

Acute organ dysfunction

Infection /Infection /TraumaTrauma SIRSSIRS SepsisSepsis Severe SepsisSevere Sepsis

Sepsis:Sepsis:

Septic shockSeptic shock

• SBP SBP << 90 mm Hg 90 mm Hg

• Reduction of 40 mm Hg or more Reduction of 40 mm Hg or more from baseline from baseline

• Oliguria Oliguria

• Lactic acidosisLactic acidosis

Common Common symptomssymptoms

Respiratory system dysfunctionRespiratory system dysfunction

Shock Shock

Renal system dysfunction Renal system dysfunction

The Institute for Healthcare The Institute for Healthcare Improvement (IHI)Improvement (IHI)

Surviving sepsis campaignSurviving sepsis campaign

Sepsis treatment Sepsis treatment bundlesbundles

ResuscitationResuscitation

ManagementManagement

Apply all elements in the bundle.Apply all elements in the bundle.

Resuscitation bundle Resuscitation bundle during the first 6 hoursduring the first 6 hours

1.1. Measure serum lactate level.Measure serum lactate level.

2.2. Blood cultures before antibiotic Blood cultures before antibiotic administration.administration.

3.3. Broad-spectrum antibiotics Within Broad-spectrum antibiotics Within

3 hours for emergency3 hours for emergency

1 hour for ICU admission1 hour for ICU admission

4.4. Hypotension Hypotension lactate > 4 mmol/Llactate > 4 mmol/L

Crystalloid 20 mL/kg (or colloid ) Crystalloid 20 mL/kg (or colloid )

Use VasopressorsUse Vasopressors

Maintain MAP Maintain MAP ≥≥ of 65 mm Hg of 65 mm Hg

Hypotension despite fluid Hypotension despite fluid resuscitationresuscitation5.5. Septic shock Septic shock

Lactate level > 4 mmol/L Lactate level > 4 mmol/L

CVP CVP ≥≥ 8 mm Hg 8 mm HgCentral venous oxygen saturation Central venous oxygen saturation ≥≥

70% 70% Mixed venous oxygen saturation Mixed venous oxygen saturation ≥≥

65% 65%

The sepsis The sepsis management bundle, management bundle, during the first 24 hoursduring the first 24 hours 1.1. Low-dose steroids Low-dose steroids

2.2. Activated drotrecogin alfa Activated drotrecogin alfa

3.3. Maintain glucose Maintain glucose

≥ ≥ the lower limit of normal the lower limit of normal but < 150 mg/dLbut < 150 mg/dL

4.4. In Plp < 30 cm H2OIn Plp < 30 cm H2O

ManagementManagementGoals during the first 6 hrs of resuscitationGoals during the first 6 hrs of resuscitation

CVP 8-12 mm HgCVP 8-12 mm HgMAP ≥ 65 mm HgMAP ≥ 65 mm HgUrine output ≥ 0.5 mL • kg-1 • hr -1Urine output ≥ 0.5 mL • kg-1 • hr -1Central venous oxygen saturation ≥ 70% Central venous oxygen saturation ≥ 70% Mixed venous ≥ 65%Mixed venous ≥ 65%

Grade 1C evidenceGrade 1C evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines

for Management of Severe Sepsis and Septic Shock: 2008for Management of Severe Sepsis and Septic Shock: 2008

HCT of ≥ 30% HCT of ≥ 30%

Dobutamine infusion Dobutamine infusion



DiagnoDiagnosissisAppropriate cultures before Appropriate cultures before

antibiotic administrationantibiotic administration

Two blood culturesTwo blood culturesPercutaneous Percutaneous Vascular access device, Vascular access device,

Cultures of other sites Cultures of other sites Grade 1C evidenceGrade 1C evidence

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

Imaging Imaging studies studies Source of Source of

InfectionInfectionSamplingSampling

In unstable patients In unstable patients Bedside ultrasound Bedside ultrasound

Grade 1C evidenceGrade 1C evidence


Antibiotic TherapyAntibiotic Therapy

IV antibiotic therapy IV antibiotic therapy first hourfirst hour

Grade 1B evidenceGrade 1B evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines


Cultures should not delay Cultures should not delay antimicrobial therapy antimicrobial therapy

Grade 1D evidenceGrade 1D evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines


Initial empirical therapyInitial empirical therapy



Antimicrobial regimen should be Antimicrobial regimen should be reassessed daily reassessed daily



Combination therapy is Combination therapy is recommended for 3 -5 daysrecommended for 3 -5 days

Pseudomonas infectionsPseudomonas infections

Neutropenic patientsNeutropenic patients

De-escalation to the single therapy De-escalation to the single therapy as soon as the sensitivity is knownas soon as the sensitivity is known



Duration of antibiotic therapy should be 7-10 Duration of antibiotic therapy should be 7-10 days days

Longer courses:Longer courses:– Slow clinical response Slow clinical response – Undrainable foci of infectionUndrainable foci of infection– Immunologic deficiencies Immunologic deficiencies



In Noninfectious causeIn Noninfectious cause

Antimicrobial therapy is stopped so that patient Antimicrobial therapy is stopped so that patient may not bemay not be

Infected with resistant pathogen Infected with resistant pathogen Drug-related adverse effectDrug-related adverse effect



Source ControlSource Control

Specific anatomical diagnosis of infection Specific anatomical diagnosis of infection should be made within the first 6 hrs should be made within the first 6 hrs



Patients should be evaluated for Patients should be evaluated for

Drainage Drainage DebridementDebridementRemoval of a potentially infected device Removal of a potentially infected device The definitive control of ongoing microbial The definitive control of ongoing microbial

contamination contamination



The least physiologic insult should be The least physiologic insult should be given given

Percutaneous Percutaneous Surgical drainageSurgical drainage



Intravascular access devices should Intravascular access devices should be changed.be changed.



Fluid Fluid TherapyTherapyFluid resuscitation Fluid resuscitation

– Natural/artificial colloids Natural/artificial colloids – Crystalloids Crystalloids

There is no evidence-based support for There is no evidence-based support for one type of fluid over another one type of fluid over another



Central venous Central venous pressurepressureTarget CVP of ≥ 8 mm Hg Target CVP of ≥ 8 mm Hg

(12 mm Hg in mechanically ventilated (12 mm Hg in mechanically ventilated patients)patients)

Further fluid therapy is often required Further fluid therapy is often required



Fluid challengeFluid challengeIn Hypovolemia In Hypovolemia

≥≥1000 mL of crystalloids 1000 mL of crystalloids 300-500 mL of colloids over 30 mins300-500 mL of colloids over 30 mins

More rapid and greater amounts of fluid may be More rapid and greater amounts of fluid may be needed in patients with septic shock.needed in patients with septic shock.



fluid resuscitation end fluid resuscitation end pointpointContinue fluid resuscitation as long as Continue fluid resuscitation as long as

the Hemodynamic improvement the Hemodynamic improvement continues continues

– Arterial pressure Arterial pressure – Heart rate Heart rate – Urine outputUrine output



Reduce Rate of fluid Reduce Rate of fluid administrationadministration When cardiac filling pressures increase When cardiac filling pressures increase

Without Without

Hemodynamic improvement Hemodynamic improvement



VasopressVasopressorsors

MAP should be maintained ≥ 65 mm Hg MAP should be maintained ≥ 65 mm Hg



First choice First choice vasopressor agentvasopressor agent

Norepinephrine or dopamine Norepinephrine or dopamine

(Administered through a central catheter (Administered through a central catheter as soon as one is available) as soon as one is available)



EpinephrineEpinephrinePhenylephrinePhenylephrineVasopressin Vasopressin

Should not be administered as the initial Should not be administered as the initial vasopressor in septic shock vasopressor in septic shock



Vasopressin 0.03 units/min may be Vasopressin 0.03 units/min may be added to norepinephrineadded to norepinephrine

Alternative agent in septic shock Alternative agent in septic shock Epinephrine Epinephrine



Low dose dopamineLow dose dopamine

Low-dose dopamine should not be used for Low-dose dopamine should not be used for renal protection renal protection

Grade 2A evidenceGrade 2A evidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines


Arterial Arterial lineline

If resources are available arterial line If resources are available arterial line should be placed as soon as practicalshould be placed as soon as practical



Inotropic TherapyInotropic Therapy

Dobutamine Dobutamine

Myocardial dysfunctionMyocardial dysfunction



cardiac index cardiac index

predetermined supranormal levels predetermined supranormal levels



CorticosteroidsCorticosteroids

Intravenous hydrocortisone Intravenous hydrocortisone

adultadult

poorly responsivepoorly responsive



SteroidsSteroids

ACTH stimulation testACTH stimulation test



SteroidsSteroids

Hydrocortisone Hydrocortisone

Dexamethasone Dexamethasone



SteroidsSteroids

Oral fludrocortisone (50 µg)Oral fludrocortisone (50 µg)++

Steroid (no significant Steroid (no significant mineralocorticoid activity) mineralocorticoid activity)



SteroidSteroidssWean from steroid therapy when Wean from steroid therapy when

Vasopressors are no longer Vasopressors are no longer required required



Doses Doses

> 300 mg of hydrocortisone> 300 mg of hydrocortisone ××



Corticosteroids should not be Corticosteroids should not be administered in the absence of administered in the absence of

shock.shock.



Recombinant Human Recombinant Human Activated Protein C Activated Protein C (rhAPC)(rhAPC)Adult patients with severe sepsis should Adult patients with severe sepsis should

receive rhAPCreceive rhAPC

High risk of deathHigh risk of deathAPACHE II score ≥ 25 APACHE II score ≥ 25 Multiple organ failure Multiple organ failure



should not receive rhAPCshould not receive rhAPC

Low risk of death Low risk of death APACHE II < 20 APACHE II < 20 One organ failureOne organ failure



Blood Product Blood Product AdministrationAdministrationOnce tissue hypoperfusion has resolved and in the Once tissue hypoperfusion has resolved and in the

absence ofabsence ofMyocardial ischemiaMyocardial ischemiaSevere hypoxemia Severe hypoxemia Acute hemorrhage Acute hemorrhage Cyanotic heart disease Cyanotic heart disease Lactic acidosisLactic acidosisRBC transfusionRBC transfusion

Hb < 7.0 g/dLHb < 7.0 g/dL

Target Hb 7.0-9.0 g/dL in adults Target Hb 7.0-9.0 g/dL in adults Grade 1B evidenceGrade 1B evidence


Erythropoietin should not be used Erythropoietin should not be used as a specific treatment of anemia as a specific treatment of anemia



Fresh frozen plasmaFresh frozen plasma

Should not be given in the Absence of Should not be given in the Absence of

– Bleeding Bleeding – Planned invasive procedures Planned invasive procedures



AntithrombinAntithrombin



Platelet transfusionPlatelet transfusionTransfusion requiredTransfusion required

< 5000/mm3 < 5000/mm3

May be considered when counts areMay be considered when counts are 5000-30,000/mm3 5000-30,000/mm3 significant risk of bleedingsignificant risk of bleeding

≥ ≥ 50,000/mm3 is required 50,000/mm3 is required surgery surgery invasive proceduresinvasive procedures



Mechanical Ventilation Mechanical Ventilation

Sepsis-Induced ALI/ARDSSepsis-Induced ALI/ARDS

Target a tidal volume of 6 mL/kg Target a tidal volume of 6 mL/kg



Plateau pressure ≤ 30 cm H2O Plateau pressure ≤ 30 cm H2O

Permissive hypercapniaPermissive hypercapnia

PEEPPEEP



Prone positioningProne positioningHigh Fio2 High Fio2 Increased Plateau pressure Increased Plateau pressure

Not at high riskNot at high risk In experienced facilitiesIn experienced facilities

Grade 2CevidenceGrade 2CevidenceSurviving Sepsis Campaign: International Guidelines Surviving Sepsis Campaign: International Guidelines


Head of the bed elevated Head of the bed elevated



Head of bed be elevated approx Head of bed be elevated approx 30-45° 30-45°



Non invasive Non invasive ventilationventilation

Mild-moderate hypoxemiaMild-moderate hypoxemiaWith stable Hemodynamics With stable Hemodynamics Who are able to protect the airwayWho are able to protect the airwayClear secretionsClear secretionsAnticipated to recover rapidlyAnticipated to recover rapidly



Spontaneous breathing trialSpontaneous breathing trial

Pressure support Pressure support CPAP (~5 cm H2O)CPAP (~5 cm H2O)T-pieceT-piece

Discontinue mechanical ventilationDiscontinue mechanical ventilation

ArousableArousableHemodynamically stableHemodynamically stableNo new serious conditions No new serious conditions Low pressures Low pressures Low Fio2 requirementsLow Fio2 requirements



Pulmonary artery catheter Pulmonary artery catheter for patients with ALI/ARDS for patients with ALI/ARDS



Conservative fluid strategy Conservative fluid strategy

Acute lung injury Acute lung injury

(Tissue hypoperfusion) (Tissue hypoperfusion)



Sedation, AnalgesiaSedation, Analgesia

Sedation protocolsSedation protocolsSedation goal Sedation goal



Intermittent bolus sedation Intermittent bolus sedation

Continuous infusion sedation Continuous infusion sedation (to predetermined end points) (to predetermined end points)

Daily interruption/lightening of Daily interruption/lightening of continuous infusion sedation continuous infusion sedation



Neuromuscular Neuromuscular Blockade in SepsisBlockade in Sepsis

NMBAs can be given asNMBAs can be given asIntermittent bolus Intermittent bolus Continuous infusion Continuous infusion

Avoid NMBAs if possibleAvoid NMBAs if possible

Monitoring with train-of-fourMonitoring with train-of-four



Glucose ControlGlucose Control

Intravenous insulin therapy to Intravenous insulin therapy to reduce blood glucose levels reduce blood glucose levels



Validated protocol for insulin dose Validated protocol for insulin dose adjustments adjustments

Targeting glucose levels to the Targeting glucose levels to the < 150 mg/dL < 150 mg/dL



Give glucose calorie source to patientGive glucose calorie source to patient

Monitor every 1-2 hrs until stable Monitor every 1-2 hrs until stable Then every 4 hrly Then every 4 hrly



Renal ReplacementRenal Replacement Continuous renal replacement therapyContinuous renal replacement therapyIntermittent hemodialysis Intermittent hemodialysis



Continuous therapies Continuous therapies Hemodynamically unstable septic patients Hemodynamically unstable septic patients



Bicarbonate TherapyBicarbonate Therapy

Do not use sodium bicarbonate Do not use sodium bicarbonate When pH ≥ 7.15 When pH ≥ 7.15



Deep Vein Thrombosis Deep Vein Thrombosis ProphylaxisProphylaxis

Low-dose UFHLow-dose UFH 2-3 times per day 2-3 times per dayLMWHLMWHMechanical deviceMechanical device

Graduated compression stockingsGraduated compression stockings

Intermittent compression devicesIntermittent compression devices



HHigh-risk igh-risk

Pharmacologic Pharmacologic LMWH LMWH

Mechanical therapy Mechanical therapy



Stress Ulcer Stress Ulcer ProphylaxisProphylaxisH2 blocker H2 blocker



Proton pump inhibitor Proton pump inhibitor



Selective Digest Tract Selective Digest Tract Decontamination (SDD)Decontamination (SDD)

Approved by the entire committee Approved by the entire committee



Although this document is static, the Although this document is static, the optimum treatment of severe sepsis optimum treatment of severe sepsis and septic shock is a dynamic and and septic shock is a dynamic and evolving process. evolving process.

New interventions will be proven and, as New interventions will be proven and, as stated in the current stated in the current recommendations, these interventions recommendations, these interventions may need modification in the future. may need modification in the future.

Thank youThank you

The Sepsis Resuscitation And Management Bundles

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