OVERVIEW
- These guidelines (and this webpage) has been superseded by the Surviving Sepsis Campaign Guidelines 2012
- 6 key parts of the bundle: 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 RBCs to haematocrit >30% and/or start dobutamine
INFECTION ISSUES
Diagnosis
- culture but don’t delay antibiotics
- get 2 or more blood cultures: at least one percutaneous; culture samples off all lines >48h old
- culture other appropriate sites
- imaging studies
Antibiotic Therapy
- give within 1 hour in severe sepsis or shock
- broad spectrum
- reassess antibiotics daily
- use combinations in Pseudomonas, the neutropenic and in the severely 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 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
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 it 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: no longer marketed following lack of benefit seen in the PROWESS-SHOCK trial
- vasopressor: we don’t use dopamine and are more likely to use adrenaline or noradrenaline
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
References and Links
Lifeinthefastlane.com
Journal articles and textbooks
- Dellinger RP, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008 Jan;36(1):296-327. Erratum in: Crit Care Med. 2008 Apr;36(4):1394-6. PubMed PMID: 18158437. [Fulltext]
- Hicks P, Cooper DJ, Webb S, Myburgh J, Seppelt I, Peake S, Joyce C, Stephens D, Turner A, French C, Hart G, Jenkins I, Burrell A. The Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. An assessment by the Australian and New Zealand intensive care society. Anaesth Intensive Care. 2008 Mar;36(2):149-51. PubMed PMID: 18361003. [CCR version in fulltext]
- Marik PE. Surviving sepsis: going beyond the guidelines. Ann Intensive Care. 2011 Jun 7;1(1):17. doi: 10.1186/2110-5820-1-17. PubMed PMID: 21906348; PubMed Central PMCID: PMC3224476.
- Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. PubMed PMID: 11794169. [Fulltext]
Social media and web resources
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