Surviving Sepsis Campaign Guidelines

Surviving Sepsis : 

Use of evidence-based guidelines in the management of severe sepsis and septic shock Furqan PathanMBBS (Manipal)HO, Emergency Dept, HDOK Surviving Sepsis

Severe Sepsis: Comparative Incidence and Mortality : 

Severe Sepsis: Comparative Incidence and Mortality Angus DC, et al. Crit Care Med. 2001; ACS. Incidence Cases/100,000 Mortality Deaths/Year

Mortality of Severe Sepsis by Age in the United States : 

Mortality of Severe Sepsis by Age in the United States Angus DC, et al. Crit Care Med. 2001.

Sepsis is a clinical syndrome : 

Sepsis is a clinical syndrome systemic response to infection exaggerated inflammatory response widespread tissue injury

SEPSIS: DEFINING A DISEASE CONTINUUM : 

SEPSIS: DEFINING A DISEASE CONTINUUM Adult Criteria* Temperature: >38oC, or <36oC HR: >90 beats/min Respirations: >20/min WBC count: >12,000/mm3, or <4,000/mm3, or >10% immature neutrophils (band forms) *modified SIRS criteria SIRS = Systemic Inflammatory Response Syndrome Bone et al. Chest. 1992;101:1644-1654. SIRS with a presumed or confirmed infectious process Sepsis SIRS Infection Severe Sepsis Sepsis with 1 sign of organ dysfunction, hypoperfusion or hypotension. Examples: Cardiovascular (refractory hypotension) Renal Respiratory Hepatic Hematologic CNS Unexplained metabolic acidosis

RECOGNITION CLINICALLY : 

RECOGNITION CLINICALLY Two or more: Temperature > 38 C or < 36 C Heart rate > 90 beats per minute Respiratory rate > 20 or PaCO2 <32mmHg

LAB PARAMETER : 

LAB PARAMETER WBC >12.000 cells/mm3, < 4000 cells/mm3, or > 10 % immature (band) form

Severe Sepsis : 

Severe Sepsis Hypotension (MAP <70, sbp <90) Acute Oliguria (u.o.<0.5cc/kg/hr for 2 hrs) Hypoxemia (PaO2/FiO2 <300) Thrombocytopenia (plt <100,000) Coagulation abnormalities (INR >1.5 or PTT >60sec) Hyperbilirubinemia (bil >2.0) Hyperlactatemia (lactate >2mmol/L)

IDENTIFYING ACUTE ORGAN DYSFUNCTION AS A MARKER OF SEVERE SEPSIS : 

IDENTIFYING ACUTE ORGAN DYSFUNCTION AS A MARKER OF SEVERE SEPSIS Tachycardia Systolic BP 90, or MAP 70 despite fluids Vasopressors Urine Output <0.5 mL/kg/hr despite fluids Creatinine >50% from baseline Acute dialysis  Platelets <100,000/mm3  PT/aPTT  D-dimer Liver Enzymes >2x ULN Altered Consciousness Reduced GCS Tachypnea PaO2/FiO2 250 Mechanical Ventilation PEEP >7.5 Balk RA. Crit Care Clin. 2000;16:179-192. Low pH with high lactate (eg, pH, 7.3 & lactate>ULN)

DefinitioN : 

DefinitioN In 1992 sepsis was defined as“the host response to infection” Sepsis: Infection PLUS SIRS criteria (20 % mortality) Severe Sepsis: Sepsis PLUS Organ dysfunction (40 % mortality ) Septic Shock: Sepsis PLUS Shock refractory to fluid resuscitation (60 % mortality)

SIRS Criteria : 

SIRS Criteria General Variables: Fever, hypothermia, tachycardia, tachypnea, altered mental status, significant edema, hyperglycemia Inflammatory variables: Leukocytosis, leukopenia, left shift, elevated CRP, elevated procalcitonin Other: SvO2 > 70%, Cardiac Index > 3.5 L/min/m2

Organ dysfunction variables : 

Organ dysfunction variables Organ dysfunction variables: Arterial hypoxemia, acute oliguria, creat >2.0, coagulopathy, thrombocytopenia, hyperbilirubinemia Tissue perfusion variables: Elevated serum lactate >2 mmol/L Hemodynamic variables: Arterial hypotension (MAP <70, SBP <90)

Sepsis Syndromes1992: SCCM/ACCP : 

Burns Trauma Sepsis Syndromes1992: SCCM/ACCP BSI Severe Sepsis Shock Severe SIRS Infection SIRS Sepsis

PathophysiologY : 

PathophysiologY Uncontrolled, unregulated, self-sustaining intravascular inflammation Simultaneous release of proinflammatory and anti-inflammatory elements out of balance and extending to otherwise normal tissue

Pathophysiology… : 

Pathophysiology… The significant consequences of a systemic pro-infl. Reaction include endothelial damage, microvascular dysfunction, and impaired tissue oxygenation and organ injury.

PathophysiologY… : 

PathophysiologY… The significant consequences of an excessive anti-inflammatory response include anergy and immunosuppression.

Slide 17: 

Global tissue hypoxia stimulates the systemic inflammatory response syndrome and endothelial activation. Microcirculatory failure, refractory tissue hypoxia, and organ dysfunction are caused by endothelial activation and loss of balance among coagulation, vascular tone, and vascular permeability systems

To Sum it UP! : 

To Sum it UP! Microvascular dysfunction  Inflammation  Coagulation  Fibrinolysis Hypoperfusion/hypoxia Microvascular thrombosis Endothelial dysfunction Organ dysfunction Global tissue hypoxia Direct tissue damage  

Recommendations and Guidelines : 

Recommendations and Guidelines Goal-directed resuscitation should begin immediately upon recognition of the syndrome and target: CVP 8-12mmHg MAP >65mmHg Urine Output >.5cc/kg/hr Central Venous Oxygen Saturation >70%

Recommendations, con’t : 

Recommendations, con’t Within the first 6 hours, if central venous oxygen sat is less than 70%, RBC transfusion or dobutamine should be employed. Appropriate cultures should be immediately obtained Antibiotics should be started within the first hour, but after cultures have been obtained

Recommendations, con’t : 

Recommendations, con’t Important to identify source of infection if possible so that proper treatment can occur: Drainage (abdom abcess, empyema, etc) Debridement ( nec fasciitis, mediastinitis, etc) Device removal (catheter, implant, etc) Definitive removal (chole, amputation,etc)

Antibiotic Guidelines in Sepsis by Suspected Site : 

Antibiotic Guidelines in Sepsis by Suspected Site Community-Acquired Sepsis Pneumonia-Quinolone PLUS B-lactam Abdominal-Carbapenem OR Pip-Tazo Skin/Soft Tissue-Vanco PLUS Carbapenem or Pip-Tazo Urinary Tract-Quinolone PLUS Amp/Vanco Unknown-Vanco PLUS B-lactam

Antibiotic Guidelines in Sepsis by Suspected Site : 

Antibiotic Guidelines in Sepsis by Suspected Site Health-Care Associated Sepsis Lung-B-lactam PLUS Vanco Bloodstream -B-lactam PLUS Vanco +/- Antifungal Surgical Site -B-lactam PLUS Vanco +/- Anaerobic coverage Suspected Candida-Caspofungin Unknown-B-lactam PLUS Vanco

Recommendations, con’t : 

Recommendations, con’t Crystalloid or colloid solutions are equally effective in resuscitation and should be given at a rate of 500-1000cc over 30’ and repeated as needed Either norepinephrine or dopamine are first-choice vasopressor agents No LOW-DOSE dopamine!!!

Recommendations, con’t : 

Recommendations, con’t Dobutamine should be used if cardiac output is low (as evidenced by low venous O2 sat) after adequate fluid resuscitation Steroids are appropriate if, after adequate fluid resuscitation, patients require pressors (solucortef 100 mg Q 8 hours) rhAPC is recommended in patients with APACHE II >25 and no contraind.

Recommendations, con’t : 

Recommendations, con’t Sedation protocols with daily interruption Neuromuscular blockade is a last resort Intensive insulin protocols using insulin infusions to maintain serum glucose <150 mg/dl Nutrition protocols with preference for enteral route

Recommendations, con’t : 

Recommendations, con’t Continuous venovenous hemofiltration (CVVH) is equivalent to intermittent hemodialysis in hemodynamically stable patients Bicarbonate therapy has not been proven to improve hemodynamics or reduce need for pressors and is not recommended in the treatment of lactic acidemia if pH is greater than 7.15

Recommendations, con’t : 

Recommendations, con’t DVT prophylaxis with either LMWH or low-dose UFH. If severely coagulopathic, or actively bleeding, SCD’s should be used. Stress ulcer prophylaxis with H2 blockers. It is not known if PPIs are superior to H2B Advance directive discussion and advance care planning

SUMMARY: SEPSIS GUIDELINES 2008 : 

SUMMARY: SEPSIS GUIDELINES 2008 Strong Recommendation (1): Recommended DVT Prophylaxis H2 Blocker PUD Prophylaxis No Routine Use of SGC A D C B Glycemic Control Consider Limiting Support BC prior to Abx Antibiotics within 1 hr for Septic Shock EGDT and Protocolized Resuscitation Antibiotics within 1 hr in No septic Shock Patients De-escalation Antibiotic Therapy 7-10 day Antibiotic Duration Source Control Fluid Challenge Dopamine or Norepinephrine Limit P plateau <30 cm H2O PEEP Conservative Fluid in ALI with no Shock No Renal Dose Dopamine No High Dose Steroids Weaning Protocol/SBT Avoid NMB PPI PUD Prophylaxis Crystalloid = Colloid Limited Transfusion Low VT for ALI HOB >45 Intermittent = Continuous sedation No Antithrombin II No Erythropoietin

SUMMARY: SEPSIS GUIDELINES 2008 : 

SUMMARY: SEPSIS GUIDELINES 2008 Weak Recommendation (2): Suggested APC in high risk and non-surgical A D C B equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis Wean Steroids Low dose steroids for septic shock B/S < 150 APC for high risk and surgical PRBCs or Dobutamine ACTH test not to be done Prone Position in ARDS NIV for ALI/ARDS mild/moderate hypoxemia

References : 

References Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock; Dellinger et al; Crit Care Med 2004 Vol. 32, No. 3. Early Goal-directed Therapy in the Treatment of Severe Sepsis and septic shock; Rivers et al; NEJM 2001;345:1368-1377. Efficacy and safety of recombinant human activated protein C for severe sepsis. NEJM 2001;344-699-709.