The International Guidelines for Management of Severe Sepsis and Septic Shock have been updated, and the details were previewed at the 2012 Society of Critical Care Medicine meeting.
HOUSTON—Later this year, the Surviving Sepsis Campaign—a collaboration of the European Society of Intensive Care Medicine (ESICM), the International Sepsis Forum (ISF), and the Society of Critical Care Medicine—will publish an updated version of the International Guidelines for Management of Severe Sepsis and Septic Shock originally published in 2004 and last updated in 2008. Some of the details were presented at the Society of Critical Care Medicine’s 41st Critical Care Congress.
R. Phillip Dellinger, MD, from Cooper University Hospital, Camden, New Jersey, and colleagues collaborated to develop the new recommendations and revise current ones. The researchers used the Grades of Recommendation, Assessment, Development, and Evaluation system to determine the quality of evidence for each recommendation from high (A) to very low (D).
Initial Resuscitation, Diagnosis, and Antibiotic Therapy
“We’ve added a recommendation for performance improvement measures in severe sepsis to be put in place at individual hospitals, and we continue to recommend early goal-directed therapy pending the results of numerous ongoing trials,” Dellinger said.
In addition, the researchers suggest that in the initial resuscitation phase of severe sepsis and septic shock, patients with elevated lactate levels—a marker of tissue hypoperfusion—should be normalized as quickly as possible in facilities that do not have the capability to target central venous oxygen saturation (weak recommendation; Grade 2C).
“We’ve added a suggestion for obtaining one of the numerous assays [1,3 beta-D-glucan assay (Grade 2B), mannan, and anti-mannan antibody assays (Grade 2C)] that are available for early diagnosis of invasive candidiasis for patients at risk for fungal severe sepsis (weak recommendation),” Dellinger said.
The guidelines committee does not recommend or suggest the use of procalcitonin as a diagnostic tool for severe sepsis. In antibiotic therapy, however, they suggest that clinicians use low procalcitonin levels as a marker to discontinue empiric antibiotics when no infection is found (weak recommendation; Grade 2C).
The researchers also suggest that selective digestive tract decontamination and selective oropharyngeal decontamination be introduced and investigated as a method to reduce the incidence of ventilator-associated pneumonia (weak recommendation; Grade 2B). “This infection control measure can then be continued in healthcare settings and regions where it is demonstrated to be effective,” Dellinger elaborated.
Additions to Fluid Therapy Recommendations
With regard to fluid therapy, the use of crystalloids in the initial fluid resuscitation in severe sepsis is recommended (strong recommendation; Grade 1A). The researchers also suggest adding albumin to the initial fluid resuscitation for severe sepsis and septic shock (weak recommendation; Grade 2B). They recommend against the use of hydroxyethyl starches (hetastarches) with molecular weight greater than 200 dalton or a degree of substitution of more than 0.4 (strong recommendation; Grade 1B). “We are silent on the use of hetastarches of lower molecular weight pending the results of ongoing trials and we are also silent on the use of gelatins,” Dellinger noted.
“We recommend that initial fluid challenge in patients with sepsis-induced tissue perfusion with suspicion of hypovolemnic be 1,000 mL of crystalloids or more to achieve a minimum of 30 mL/kg of crystalloids in the first four to six hours,” Dellinger stated. The committee also recommends that a fluid challenge technique using incremental fluid boluses be continued for as long as patients improve hemodynamically based on dynamic (eg, delta pulse pressure) or static (eg, arterial pressure) variables (strong recommendation; Grade 1C).
Vasopressors and Inotrophic Therapy
The researchers recommend using norepinephrine as the first choice vasopressor (strong recommendation; Grade 1B) and adding or substituting epinephrine when an additional drug is needed to maintain adequate blood pressure (strong recommendation; Grade 2B). Vasopressin 0.03 units per minute may be added or substituted for norepinephrine (weak recommendation; Grade 2A). Dopamine was suggested as an alternative vasopressor, but only in highly selected patients at very low risk of arrhythmias and with a low cardiac output and/or low heart rate (weak recommendation; Grade 2C).
The researchers recommend that a dobutamine infusion be started or added to a vasopressor in myocardial dysfunction (elevated cardiac filling pressure and low cardiac output) or ongoing signs of hypoperfusion, even after adequate intravascular volume and mean arterial pressure are achieved (strong recommendation; Grade 1C).
Steroids and Mechanical Ventilation of Sepsis-Induced ARDS
In adult septic shock patients, it is suggested not to use IV corticosteroids if fluid resuscitation or vasopressor therapy is able to restore the patient to hemodynamic stability. When hemodynamic stability cannot be achieved, the researchers recommend IV hydrocortisone 200 mg daily given with continuous infusion (weak recommendation; Grade 2C).
“We suggest higher levels of PEEP in patients with severe ARDS [weak recommendation; grade 2C],” Dellinger said.
The researchers suggest recruitment maneuvers in patients with severe refractory hypoxemia (weak recommendation; Grade 2C). They also suggest prone positioning for patients with severe ARDS whose PaO2 /FiO2 rates are less than 100 despite such maneuvers (weak recommendation; Grade 2C).
—Andrea C. Friswell
Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36(1):296-327.