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Surviving Sepsis Campaign 2012 Guideline Algorithm- haianlee

Overview for Initial Resuscitation for Surviving Sepsis. Geared at the medical student / general medical resident level.
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haian lee

on 22 February 2013

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Transcript of Surviving Sepsis Campaign 2012 Guideline Algorithm- haianlee

Surviving Sepsis Campaign:
2012 Guidelines SIRS Other Trauma Burns Pancreatitis Other Viremia Parasitemia Fungemia Bacteremia Sepsis Infection 2+ of the following:
THReW 1. T > 38°C or < 36°C
2. HR > 90
3. RR > 20 or PaCO2 < 32 mm Hg
4. WBC >12K, <4K, or >10% immature (band) forms Infection, documented or suspected, and "some" of the following: Fever (> 38.3°C)
Hypothermia (core temperature < 36°C)
Heart rate > 90/min–1 or more than two
sd above the normal value for age
Tachypnea
Altered mental status
Significant edema or positive fluid
balance (> 20 mL/kg over 24 hr)
Hyperglycemia (plasma glucose > 140
mg/dL or 7.7 mmol/L) in the
absence of diabetes Leukocytosis (WBC count > 12,000 μL–1)
Leukopenia (WBC count < 4000 μL–1)
Normal WBC count with greater than
10% immature forms
Plasma C-reactive protein more than two
sd above the normal value
Plasma procalcitonin more than two sd
above the normal value Arterial hypotension
SBP < 90 mm Hg
MAP < 70 mm Hg
or an SBP decrease > 40 mm Hg in
adults or less than two sd below
normal for age) Arterial hypoxemia (Pao2/Fio2 < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr
for at least 2 hrs despite adequate fluid resuscitation)
Creatinine increase > 0.5 mg/dL or 44.2 μmol/L
Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < 100,000 μL–1)
Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL
or 70 μmol/L) General Variables Inflammatory Variables Hemodynamic Variables Organ dysfunction variables Severe Sepsis = sepsis-induced tissue hypoperfusion or organ dysfunction
(any of the following thought to be due to the infection) Sepsis-induced hypotension
Lactate above upper limits laboratory normal
Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source
Creatinine > 2.0 mg/dL (176.8 μmol/L)
Bilirubin > 2 mg/dL (34.2 μmol/L)
Platelet count < 100,000 μL
Coagulopathy (international normalized ratio > 1.5) 1. Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ≥ 4 mmol/L). Goals during the first 6 hrs of resuscitation
a) CVP 8–12 mm Hg
b) MAP ≥ 65 mm Hg
c) Urine output ≥ 0.5 mL·kg·hr
d) Superior vena cava oxygenation saturation (Scvo2 % >70%) or
mixed venous oxygen saturation (Svo2>65%)(Grade 1C)
2. In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C). Initial Resuscitation DO NOT use IV hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. (2C)
Steroid not be used if there's no shock (1D)
USE IV hydrocortisone: 200 mg/day continuous infusion (grade 2C)
Taper hydrocortisone when vasopressors have been discontinued (2D) ACTH test NOT recommended (Grade 2B) Vasopressors (targeting MAP of at least 65 mmHg)
Norepinephrine (NE) is the vasopressor of choice (1B)
Epinephrine (EPI) if an additional agent is required; can be added to or substituted for NE (2B)
Vasopressin (0.03 units/minute) can be added to NE; it should not be titrated or used as a single agent (ungraded).
In selected patients (e.g., bradycardia or low-risk of tachyarrhythmia), dopamine may be considered (2C). *Low-dose dopamine (for renal protection) should not be used (1A).
Phenylephrine (PE) is not recommended, except if (1C):
*Serious NE associated arrhythmias
*Cardiac output can be measured and is increased with low MAP (PE can reduce cardiac output)
**Other therapies cannot achieve the target MAP
* Crystalloids as the intitial choice (1B)
* An initial fluid bolus of at least 30 mL/kg is recommended; crystalloids should be the initial fluid (1B)
* Consider albumin when “substantial” amounts of crystalloid have been given (2C).
* Use of hydroxyethyl starch is not recommended (1B)
* Fluid challenge be applied as there is hemodyanamic improvement, dyamic (pulse pressure) or static (ABP). Diagnosis 1. Cultures before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s) (1C).
-- B/Cx x2 (both aerobic & anaerobic) before antibiotics
-- Extra draws through each vascular access device, unless the device was recently (<48 hrs) inserted (1C).
-- Culture from other sigts (Urine, CSF, wound, body fluid) should also be obtained before antibiotics

2. Use of the 1,3 beta-D-glucan assay (2B), mannan and anti-mannan antibody assays (2C), if invasive candidiasis is in the differential dx

3. Imaging studies performed promptly to confirm a potential source of infection (UG). Antibiotics 1. Give effective IV antibiotics/antivirals/antifungals w/in the FIRST HOUR of recognition of septic shock (1B) and severe sepsis w/o septic shock (1C)

2 a. Initial empiric treatment: 1+ drugs against all likely pathogens (bacterial/fungal/viral) that penetrate into tissue source of sepsis (1B).
b. Regimen should be reassessed daily for potential deescalation (1B).

3.Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (2C).

4 a. Combo empiric tx for neutropenic pt w/ severe sepsis (2B) and for pt with difficult-to-treat, MDR bacterial pathogens like Acinetobacter and Pseudomonas spp. (2B). For pt w/ severe infxn assoc w/ respiratory failure & septic shock, combine tx w/ an extended spectrum beta-lactam + either a) aminoglycoside or b) a fluoroquinolone for P. aeruginosa bacteremia (2B). Combine of beta-lactam and macrolide for patients with septic shock from bacteremic S. pneumoniae infections (2B). 4b. Empiric combo tx should NOT be administered for more than 3–5 days. De-escalate to the most appropriate single therapy when the susceptibility profile is known (2B)

5. Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have:
* a slow clinical response
* undrainable foci of infection
* bacteremia with S. aureus
* some fungal and viral infections or immunologic deficiencies, including neutropenia (2C).

6. Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (2C).(such like: influenza)

7. Antimicrobial agents should NOT be used in patients with severe inflammatory states determined to be of noninfectious cause (UG). Source Control 1. Seek out a specific anatomic dx of infection source, diagnose and/or excluded ASAP (ex:soft tissue infection, peritonitis, cholangitis, intestinal infarction) and control w/in the FIRST TWELVE HOURS after diagnosis(1C).

2. When infected peripancreatic necrosis is identified as a potential source of infection, delay intervention until demarcation of viable and nonviable tissues is adequate(2B).

3. Use the least invasive and least harmful methods for source control if possible. (eg, percutaneous rather than surgical drainage of an abscess) (UG).

4. If intravascular access devices are a possible source of severe sepsis or septic shock, they should be removed after other vascular access has been established (UG). 1a. Oral and digestive decontamination should be introduced and investigated as a method to reduce the incidence of VAP (2B)

1b. Oral chlorhexidine gluconate be used as a form of oropharyngeal decontamination to reduce the risk of ventilator-associated pneumonia in ICU patients with severe sepsis (grade 2B). Infection Prevention <21-27% >21-27% Although less applicable to septic patients, results of a randomized trial in patients undergoing cardiac surgery with cardiopulmonary bypass support a restrictive transfusion strategy using a threshold hematocrit of < 24% (hemoglobin 8 g/dL) as equivalent to a transfusion threshold of hematocrit of < 30% (hemoglobin 10 g/dL)
Transfuse RBCs, if
Hgb <7.0 g/dL with a target Hgb of 7.0 –9.0 g/dL (1B).
Tissue hypoperfusion
The absence of extenuating circumstances (i.e. MI, hypoxemia, acute hemorrhage, or ischemic heart disease

Avoid using:
-- EPO for anemia associated with severe sepsis (1B).
-- FFP to correct lab abnormalities in the absence of bleeding or planned invasive procedures (2D).
-- antithrombin for the treatment of severe sepsis and septic shock (1B).

In patients with severe sepsis, administer Platelets
<10,000/mm^3 (<10 x 10^9/L) in the absence of apparent bleeding.
< 20K if the patient has a significant risk of bleeding
≥50K for active bleeding, surgery, or invasive procedures (2D). Blood Product Administration Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS) 1. TV of 6 mL/kg predicted BW (vs. 12 mL/kg) (1A).
2. Plateau pressure initial upper limit ≤30 cm H2O (1B).
3. PEEP to avoid alveolar collapse at end expiration (atelectotrauma) (1B).
4. Use higher rather than lower PEEP for sepsis-induced moderate or severe ARDS (2C).
5. Recruitment maneuvers be used in sepsis patients with severe refractory hypoxemia (2C).
6. Prone positioning be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio ≤ 100 mm Hg in facilities that have
experience with such practices (2B).
7. Head of bed elevated to 30-45 degrees to limit aspiration risk and to prevent the development of VAP (1B).
8. NIV used in a minority of patients in whom the benefits outweigh the risks (2B). insulin dosing when 2 consecutive blood glucose levels are >180 mg/dL. . POC glucose levels should be interpreted with caution, as such measurements may not accurately estimate arterial blood or plasma glucose values (UG).
1. Target: upper blood glucose </=180 mg/dL rather than an upper target blood glucose ≤ 110 mg/dL (1A).

2. Monitor BG Q1–2 hr until glucose and insulin infusion are stable; then Monitor Q4 hrs thereafter (1C). Sepsis Adapted from Levy MM, Fink MP, Marshall JC, et al: 2001 SCCM/ESICM/
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling Tissue perfusion variables Shock Septic Shock Sepsis-induced hypotension persisting despite adequate fluid resusciation Presented by Underlying Methodology Strenghth of recommendations Determination of the Quality of Evidence A (high) RCTsB (moderate) Downgraded RCTs or upgraded observational studiesC (low) Well-done observational studies with control RCTsD (very low) Downgraded controlled studies or expert opinion based on other evidence 1 Strong
2 Weak Management of Sepsis Source Control Antibiotics 1. Give effective IV antibiotics/antivirals/antifungals w/in the FIRST HOUR of recognition of septic shock (1B) and severe sepsis w/o septic shock (1C)

2 a. Initial empiric treatment: 1+ drugs against all likely pathogens (bacterial/fungal/viral) that penetrate into tissue source of sepsis (1B).
b. Regimen should be reassessed daily for potential deescalation (1B).

3.Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (2C).

4 a. Combo empiric tx for neutropenic pt w/ severe sepsis (2B) and for pt with difficult-to-treat, MDR bacterial pathogens like Acinetobacter and Pseudomonas spp. (2B). For pt w/ severe infxn assoc w/ respiratory failure & septic shock, combine tx w/ an extended spectrum beta-lactam + either a) aminoglycoside or b) a fluoroquinolone for P. aeruginosa bacteremia (2B). Combine of beta-lactam and macrolide for patients with septic shock from bacteremic S. pneumoniae infections (2B). 4b. Empiric combo tx should NOT be administered for more than 3–5 days. De-escalate to the most appropriate single therapy when the susceptibility profile is known (2B)

5. Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have:
* a slow clinical response
* undrainable foci of infection
* bacteremia with S. aureus
* some fungal and viral infections or immunologic deficiencies, including neutropenia (2C).

6. Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (2C).(such like: influenza)

7. Antimicrobial agents should NOT be used in patients with severe inflammatory states determined to be of noninfectious cause (UG). Antibiotics 1. Give effective IV antibiotics/antivirals/antifungals w/in the FIRST HOUR of recognition of septic shock (1B) and severe sepsis w/o septic shock (1C)

2 a. Initial empiric treatment: 1+ drugs against all likely pathogens (bacterial/fungal/viral) that penetrate into tissue source of sepsis (1B).
b. Regimen should be reassessed daily for potential deescalation (1B).

3.Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (2C).

4 a. Combo empiric tx for neutropenic pt w/ severe sepsis (2B) and for pt with difficult-to-treat, MDR bacterial pathogens like Acinetobacter and Pseudomonas spp. (2B). For pt w/ severe infxn assoc w/ respiratory failure & septic shock, combine tx w/ an extended spectrum beta-lactam + either a) aminoglycoside or b) a fluoroquinolone for P. aeruginosa bacteremia (2B). Combine of beta-lactam and macrolide for patients with septic shock from bacteremic S. pneumoniae infections (2B). 4b. Empiric combo tx should NOT be administered for more than 3–5 days. De-escalate to the most appropriate single therapy when the susceptibility profile is known (2B)

5. Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have:
* a slow clinical response
* undrainable foci of infection
* bacteremia with S. aureus
* some fungal and viral infections or immunologic deficiencies, including neutropenia (2C).

6. Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (2C).(such like: influenza)

7. Antimicrobial agents should NOT be used in patients with severe inflammatory states determined to be of noninfectious cause (UG). 1. A specific anatomical diagnosis of infection (soft tissue infection, peritonitis, cholangitis, intestinal infarction) requiring consideration for emergent source control be sought and diagnosed or excluded as rapidly as possible, and intervention be undertaken for source control within the first 12 hr after the diagnosis is made, if feasible (grade 1C).

2. When infected peripancreatic necrosis is identified as a potential source of infection, definitive intervention is best delayed until adequate demarcation of viable and nonviable tissues has occurred (grade 2B).

3. When source control in a severely septic patient is required, the effective intervention associated with the least physiologic insult should be used (eg, percutaneous rather than surgical drainage of an abscess) (UG).

4. If intravascular access devices are a possible source of severe sepsis or septic shock, they should be removed promptly after other vascular access has been established (UG). 1. Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C).

2. Hospital–based performance improvement efforts in severe sepsis (UG). Screening for Sepsis and Performance Improvement Initinal Resuscitation and Infection Issues
Hemodynamic Support and Adjunctive Therapy
Supportive Therapy of Severe Sepsis Fluid therapy Vasopressors 1. A trial of dobutamine infusion up to 20 micrograms/kg/min be administered or added to vasopressor (if in use) in the presence of
(a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output
(b) ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP (grade 1C).
2. Not using a strategy to increase cardiac index to predetermined supranormal levels (grade 1B). Inotropic Therapy Not using IVIG in adult pt with severe sepsis or shock (2B)
Not using IV selenium for severe sepsis (2C)
No longer available for rhAPC
Not using HCO3 to improve hemodynamics with lactic acidemia pH>7.15 (2B) Management of Sepsis Initinal Resuscitation and Infection Issues
Hemodynamic Support and Adjunctive Therapy
Supportive Therapy of Severe Sepsis 9. Weaning protocol in place and mechanically ventilated patients with severe sepsis undergo SBT regularly to evaluate the ability to discontinue mechanical ventilation when they satisfy the following criteria:
a) arousable
b) hemodynamically stable (without vasopressor agents)
c) no new potentially serious conditions
d) low ventilatory and end-expiratory pressure requirements;
e) low Fio2 requirements which can be met safely delivered with a face mask or NC. If successful, consider extubation (1A).
10. Against the routine use of the pulmonary artery catheter for patients with sepsis-induced ARDS (1A).
11. A conservative rather than liberal fluid strategy for patients with established sepsis-induced ARDS who do not have evidence of
tissue hypoperfusion (1C).
12. In the absence of specific indications such as bronchospasm, not using beta 2-agonists for treatment of sepsis-induced ARDS (grade 1B). Renal Replacement Therapy 1. Continuous renal replacement therapies and intermittent hemodialysis are equivalent in patients with severe sepsis and acute renal failure (grade 2B).
2. Use continuous therapies to facilitate management of fluid balance in hemodynamically unstable septic patients (grade 2D). Deep Vein Thrombosis Prophylaxis 1. Patients with severe sepsis receive daily pharmacoprophylaxis against venous thromboembolism (VTE) (grade 1B).
This should be accomplished with daily subcutaneous low-molecular weight heparin (LMWH) (grade 1B versus twice daily UFH, grade 2C versus three times daily UFH).
If creatinine clearance is <30 mL/min, use dalteparin (grade 1A) or another form of LMWH that has a low degree of renal metabolism (grade 2C) or UFH (grade 1A).
2. Patients with severe sepsis be treated with a combination of pharmacologic therapy and intermittent pneumatic compression devices whenever possible (grade 2C).
3. Septic patients who have a contraindication for heparin use (eg, thrombocytopenia, severe coagulopathy, active bleeding, recent intracerebral hemorrhage) not receive pharmacoprophylaxis (grade 1B), but receive mechanical prophylactic treatment, such as graduated compression stockings or intermittent compression devices (grade 2C), unless contraindicated. When the risk decreases start pharmacoprophylaxis (grade 2C). Stress Ulcer Prophylaxis 1. Stress ulcer prophylaxis using H2 blocker or proton pump inhibitor be given to patients with severe sepsis/septic shock who have bleeding risk factors (grade 1B).
2. When stress ulcer prophylaxis is used, proton pump inhibitors rather than H2RA (grade 2D)
3. Patients without risk factors do not receive prophylaxis (grade 2B). Nutrition 1. Administer oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hours after a diagnosis of severe sepsis/septic shock (grade 2C).
2. Avoid mandatory full caloric feeding in the first week but rather suggest low dose feeding (eg, up to 500 calories per day), advancing only as tolerated (grade 2B).
3. Use intravenous glucose and enteral nutrition rather than total parenteral nutrition (TPN) alone or parenteral nutrition in conjunction with enteral feeding in the first 7 days after a diagnosis of severe sepsis/septic shock (grade 2B).
4. Use nutrition with no specific immunomodulating supplementation rather than nutrition providing specific immunomodulating supplementation in patients with severe sepsis (grade 2C).
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