Surviving Sepsis Campaign Guidelines 2008

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• These guidelines (and this webpage) has been superseded by the Surviving Sepsis Campaign Guidelines 2012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