New Surviving Sepsis Guidelines 2012: The Highlights

Knowing how to aggressively treat shock is critical with trauma patients, and the type of shock we see in the trauma resuscitation bay is usually hemorrhagic or hypovolemic shock.  However, it is not uncommon to treat patients with sepsis or septic shock in our trauma ICU.  In this discussion, I will highlight some key guidelines in treating sepsis.

 

In January 2013, the updated 2012 Surviving Sepsis Guidelines were released, to follow up on the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock” which were last published in 2008.[i] Included below are some key points included in these updated guidelines, with emphasis (bolded) on those recommendations that are new or revised since the 2008 guidelines, or those guidelines that often discussed or disputed on rounds.

This is by no means a complete set of highlights or guidelines, only those that I felt most relevant. For a complete discussion of the guidelines, please see the referenced article.

 

Initial Resuscitation

• Protocolized, quantitative resuscitation for those with sepsis-induced tissue hypoperfusion, defined as hyopotension persisting after initial fluid challenge or blood lactate concentration ≥ 4 mmol/L

Goals for first 6 hrs:

a) Central venous pressure 8–12mm Hg

b) Mean arterial pressure (MAP) ≥ 65mm Hg

c) Urine output ≥ 0.5 mL/kg/hr

d) Central venous (superior vena cava) (ScvO²)or mixed venous oxygen saturation (SvO²)70% or 65%, respectively (grade 1C).

• If  ScvO² monitoring not available, then lactate clearance (lactate normalization) may be used as alternative endpoint (or combined endpoint if ScvO²  available) (grade 2 C)

 

Source Control

• The goal is to identify an anatomic source of infection as rapidly as possible, and that the intervention for source control in undertaken in the first 12 hrs after diagnosis. (grade 1C) The exception is in the case of infected pancreatic necrosis, when definitive intervention should be delayed.

 

Fluid therapy

• Crystalloid fluid remains as the initial resuscitative fluid of choice (Grade 1 A recommendation).

• Albumin can be considered as an addition to initial fluid resuscitation (Grade 2B)

• Starch based fluids (e.g. hetastarch) are not recommended (Grade 1 C)

 

Vasopressor/Ionotropic Therapy

• Vasopressor therapy to target  MAP of 65 mm Hg (grade 1C)

• Norepinephrine (Levophed) is the first choice agent. (grade 1B)

• Epinephrine or Vasopressin (0.03 units/min) may be added as additional agents to maintain MAP or decrease norepinephrine usage.

• Dopamine has a minimal role. May be used as alternative to norepinephrine in highly selected patients (pts with low risk of tachyarrythmias and absolute or relative bradycardia), and low-dose dopamine should not be used for renal protection

• Dobutamine may be administered as a trial (up to 20 µg/kg/min) as an additonal agent if signs of mycocardial dysfunction present or there are ongoing signs of hypoperfusion despite adequate MAP and volume resuscitation (grade 1 C)

• Phenylephrine (Neosynephrine) has no role in septic shock treatment, except as salvage (last-resort) therapy or if norepinephrine is associated with serious arrhythmias. (grade 1 C)

 

Antimicrobial Therapy

• Early goal directed therapy with IV antimicrobials within the first hour of recognition of septic shock or severe sepsis is still the standard goal of therapy (grade 1B/1C)

• Two sets of blood cultures should be obtained, within 45 minutes, before initiating antibiotic therapy.

• There are diagnostic assays available now that may be used (if available) if invasive candidiasis is suspected.

 

Corticosteroid Therapy

• IV hydrocortisone should only be used (at a dose of 200 mg/day) if fluid resuscitation and vasopressor therapy are inefective in restoring hemodynamic stability. (grade 2C)

• ACTH stimulation test does not have a role in identifying those patients who should receive steroids.

• Corticosteroids should not be administered in the absence of shock. (grade 1D)

 

Bicarbonate Therapy

• Bicarbonate administration as a means to improve hemodynamics and vasopressor efficacy only when ph ≤ 7.15. (grade 2B)

 

Blood Product Administration

• Administrate pRBC when Hgb drops below 7.0g/dL with goal 7.0-9.0g/dL (may be administered at higher thresholds if present of extenuating circumstances, such as myocardial ischemia or severe hypoxemia). (grade 1 B)

• Fresh frozen plasma (FFP) should only be administered to correct an elevated lab value in the presence of bleeding or planned invasive procedure (grade 2D)

• In the setting of severe sepsis, platelets can be administered prophylactically when counts are <10,000/mm3 in the absence of bleeding, <20,000/mm3 if there is a high bleeding risk, or < 50,000/mm3 if there is active bleeding or surgery planned

 

Mechanical Ventilation of Sepsis-Induced ARDS

• Target tidal volume of 6mL/kg (vs 12 ml/kg) predicted body weight in patients with sepsis induced ARDS (grade 1A)

• Plateau pressure goal ≤  30 cm H2O (grade 1B)

• Strategies utilizing higher PEEP settings should be practiced .

• Pulmonary artery catheters not recommended in the setting of sepsis induced ARDS

• Fluids should be administered conservatively in the established setting of sepsis induced ARDS (provided there is no ongoing tissue hypoperfusion). (grade 1C)

 

-Faaiza Vaince

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[i]Crit Care Med. 2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af.

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR,Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis CampaignGuidelines Committee including the Pediatric Subgroup.