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Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

Critical Care Compendium | Surviving Sepsis Campaign Guidelines 2008

Surviving Sepsis Campaign Guidelines 2008

by Chris Nickson, Last updated May 24, 2016

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  • These guidelines (and this webpage) has been superseded by the Surviving Sepsis Campaign Guidelines 2012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

  • CCC — Surviving Sepsis Campaign Guidelines 2012

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

  • ICN — Podcast 33: Delaney on EGDT, Surviving sepsis and ARISE
  • PulmCCM.org — Surviving Sepsis Guidelines Updated: Preview from SCCM Meeting
  • Surviving Sepsis Campaign

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About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. He coordinates the Alfred ICU's education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the 'Critically Ill Airway' course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of Lifeinthefastlane.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of two amazing children. On Twitter, he is @precordialthump.

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