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Surviving Sepsis
Campaign
International
Guidelines for
Management of
Severe Sepsis and
Septic Shock: 2016
Intensive Care M...
Under supervision of
Prof DR
ANEES SINDI
Edited by ..
Mohamed Kharabish
Sepsis
is life-threatening organ dysfunction caused by a
dysregulated host response to infection .
Sepsis and septic shock...
As these guidelines were being developed , new
definitions for sepsis and septic shock (Sepsis-3)
were published.
Sepsis i...
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Initial
Resuscitation
Initial Resuscitation
Sepsis and septic shock are medical
emergencies, and It is recommended
that treatment and resuscitat...
This 80 kg bw pt (( in septic shock) needs
how much fluids to be resus ..??.
80 × 30 = 2400 ml
Initial Resuscitation
Following initial fluid resuscitation,
additional fluids be guided by frequent
reassessment of hemod...
Initial Resuscitation
An initial target MAP of 65 mmHg in
patients with septic shock requiring
vasopressors
(strong recomm...
Application of Fluid Resuscitation in Adult Septic Shock
Considerations post 30ml/kg crystalloid infusion
1. Continue to b...
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Diagnosis
Diagnosis
Appropriate routine microbiologic cultures
(including blood) be obtained before starting
antimicrobial therapy i...
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Antimicrobial Therapy
Antimicrobial Therapy
Administration of IV anti- microbials
must be initiated as soon as possible
after recognition and wi...
Antimicrobial Therapy
Empiric broad-spectrum therapy with one or
more antimicrobials for patients
presenting with sepsis o...
Antimicrobial Therapy
Antimicrobial treatment duration of 7–10
days is adequate for most serious
infections associated wit...
Antimicrobial Therapy
Measurement of procalcitonin levels can be
used to support shortening the duration
of antimicrobial ...
GUIDELINES recommend
sustained systemic antimicrobial
prophylaxis in patients with severe
inflammatory states of non-infec...
GUIDELINES recommend that dosing
strategies of antimicrobials
be optimized based on accepted
pharmacokinetic/ pharmacodyna...
GUIDELINES suggest empiric combination
therapy (using at least two antibiotics of
different antimicrobial classes)
aimed a...
GUIDELINES suggest that combination therapy
not to be routinely used for ongoing treatment
of most other serious infection...
NO Shock = No Combination
Shock = Combination
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Source
Control
Source Control
A specific anatomic diagnosis of infection
requiring emergent source control be
identified or excluded as r...
Source Control
Prompt removal of intravascular access
devices that are a possible source of
sepsis or septic shock after o...
To Be Removed after other vascular access
has been established
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Fluid Therapy
Crystalloids are the fluid of choice for
initial resuscitation and subsequent
intravascular volume replaceme...
Fluid Therapy
Using Albumin in addition to
crystalloids for initial resuscitation and
subsequent intravascular volume
repl...
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Vasopressors
Norepinephrine as the first choice
vasopressor
(strong recommendation, moderate quality of evidence).
Adding ...
Vasopressors
Using dopamine as an alternative
vasopressor agent to norepinephrine only
in highly selected patients (e.g., ...
Vasopressors
Using dobutamine in patients who
show evidence of persistent
hypoperfusion despite adequate fluid
loading and...
Vasopressors
All patients requiring vasopressors have an
arterial catheter placed as soon as
practical if resources are av...
Vasopressor Use for Adult Septic Shock
(with guidance for steroid administration)
Initiate norepinephrine (NE) and titrate...
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Corticosteroids
Guidelines are Against using IV
hydrocortisone to treat septic shock
patients if adequate fluid resuscitat...
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Blood Products
Blood Product Administration
RBC transfusion occur only when
hemoglobin concentration decreases to
< 7.0 g/ dL in adults i...
Blood Product Administration
Prophylactic platelet transfusion
when counts are <10,000/mm3 in the
absence of apparent blee...
Blood Product Administration
GUIDELINES are Against the use of
erythropoietin for treatment of anemia
associated with seps...
GUIDELINES are against the use of fresh
frozen plasma to correct
clotting abnormalities in the absence of
bleeding or plan...
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Glucose Control
Glucose Control
A protocolized approach to blood
glucose management in ICU patients
with severe sepsis commencing insulin
...
Glucose Control
Blood glucose values be monitored
every 1–2 hrs until glucose values
and insulin infusion rates are stable...
Glucose Control
GUIDELINES Suggest the use of arterial
blood rather than capillary blood for
point-of-care testing using g...
MANAGEMENT OF SEVERE SEPSIS
Management of Severe Sepsis
Initial
Resuscitation Diagnosis Antibiotic
Therapy
Source
Control
...
Bicarbonate Therapy
Bicarbonate Therapy
Against the use of sodium bicarbonate
therapy to improve hemodynamics or
to reduce vasopressor require...
sepsis new guidelines 2017
sepsis new guidelines 2017
sepsis new guidelines 2017
sepsis new guidelines 2017
sepsis new guidelines 2017
sepsis new guidelines 2017
sepsis new guidelines 2017
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  1. 1. Surviving Sepsis Campaign International Guidelines for Management of Severe Sepsis and Septic Shock: 2016 Intensive Care Medicine doi: 10.1007/s00134-017-4683-6 Published online: 18 Jan 2017
  2. 2. Under supervision of Prof DR ANEES SINDI Edited by .. Mohamed Kharabish
  3. 3. Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection . Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, and killing as many as one in four (and often more) .Similar to polytrauma, acute myocardial infarction, or stroke, early identification and appropriate management in the initial hours after sepsis develops improves outcomes.
  4. 4. As these guidelines were being developed , new definitions for sepsis and septic shock (Sepsis-3) were published. Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality
  5. 5. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  6. 6. Initial Resuscitation
  7. 7. Initial Resuscitation Sepsis and septic shock are medical emergencies, and It is recommended that treatment and resuscitation begin immediately (best practice statements, BPS). In the resuscitation from sepsis-induced hypoperfusion, at least 30 mL/kg of IV crystalloid fluid be given within the first 3 h (strong recommendation, low quality of evidence).
  8. 8. This 80 kg bw pt (( in septic shock) needs how much fluids to be resus ..??. 80 × 30 = 2400 ml
  9. 9. Initial Resuscitation Following initial fluid resuscitation, additional fluids be guided by frequent reassessment of hemodynamic status (BPS). Remarks Reassessment should include a thorough clinical examination and evaluation of available physiologic variables (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, and others, as available) as well as other noninvasive or invasive monitoring, as available.
  10. 10. Initial Resuscitation An initial target MAP of 65 mmHg in patients with septic shock requiring vasopressors (strong recommendation, moderate quality of evidence). Guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (weak recommendation, low quality of evidence).
  11. 11. Application of Fluid Resuscitation in Adult Septic Shock Considerations post 30ml/kg crystalloid infusion 1. Continue to balance fluid resuscitation and vasopressor dose with attention to maintain tissue perfusion and minimize interstitial edema 2. Implement some combination of the list below to aid in further resuscitation choices that may include additional fluid or inotrope therapy • blood pressure/heart rate response, • urine output, • cardiothoracic ultrasound, • CVP, ScvO2, • pulse pressure variation • lactate clearance/ normalization or • dynamic measurement such as response of flow to fluid bolus or passive leg raising 3. Consider albumin fluid resuscitation, when large volumes of crystalloid are required to maintain intravascular volume. Sepsis-induced hypotension or lactate > 4 mmol/L No high flow oxygen and No ESRD on dialysis or CHF Pneumonia or ALI with high flow oxygen requirements ESRD on hemodialysis or CHF Rapid infusion of 30 ml/kg Crystalloid* Not intubated/ mechanically ventilated Intubated/ mechanically ventilated Total of 30 ml/kg crystalloid* with frequent reassessment of oxygenation If no If Yes Consider intubation/mechanical ventilation to facilitate 30 ml/kg crystalloid * Rapid infusion of 30 ml/kg crystalloid * Total of 30 ml/kg with frequent reassessment of oxygenation
  12. 12. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  13. 13. Diagnosis
  14. 14. Diagnosis Appropriate routine microbiologic cultures (including blood) be obtained before starting antimicrobial therapy in patients with suspected sepsis or septic shock if doing so results in no substantial delay in the start of antimicrobials (BPS). Remarks Appropriate routine microbiologic cultures always include at least two sets of blood cultures (aerobic and anaerobic).
  15. 15. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  16. 16. Antimicrobial Therapy
  17. 17. Antimicrobial Therapy Administration of IV anti- microbials must be initiated as soon as possible after recognition and within 1 h for both sepsis and septic shock (strong recommendation, moderate quality of evidence; grade applies to both conditions).
  18. 18. Antimicrobial Therapy Empiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens (including bacterial and potentially fungal or viral coverage) (strong recommendation, moderate quality of evidence). Empiric antimicrobial therapy be narrowed once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted (BPS).
  19. 19. Antimicrobial Therapy Antimicrobial treatment duration of 7–10 days is adequate for most serious infections associated with sepsis and septic shock (weak recommendation, low quality of evidence).
  20. 20. Antimicrobial Therapy Measurement of procalcitonin levels can be used to support shortening the duration of antimicrobial therapy in sepsis patients (weak recommendation, low quality of evidence). Procalcitonin levels can be used to support the discontinuation of empiric antibiotics in patients who initially appeared to have sepsis, but subsequently have limited clinical evidence of infection (weak recommendation, low quality of evidence).
  21. 21. GUIDELINES recommend sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of non-infectious origin (e.g., severe pancreatitis, burn injury) (BPS). WHY????. against
  22. 22. GUIDELINES recommend that dosing strategies of antimicrobials be optimized based on accepted pharmacokinetic/ pharmacodynamic principles and specific drug properties in patients with sepsis or septic shock (BPS).
  23. 23. GUIDELINES suggest empiric combination therapy (using at least two antibiotics of different antimicrobial classes) aimed at the most likely bacterial pathogen(s) for the initial management of septic shock (weak recommendation, low quality of evidence).
  24. 24. GUIDELINES suggest that combination therapy not to be routinely used for ongoing treatment of most other serious infections, including bacteremia and sepsis without shock (weak recommendation, low quality of evidence).
  25. 25. NO Shock = No Combination Shock = Combination
  26. 26. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  27. 27. Source Control
  28. 28. Source Control A specific anatomic diagnosis of infection requiring emergent source control be identified or excluded as rapidly as possible in patients with sepsis or septic shock, and that any required source control intervention be implemented as soon as medically and logistically practical after the diagnosis is made (BPS).
  29. 29. Source Control Prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established (BPS).
  30. 30. To Be Removed after other vascular access has been established
  31. 31. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  32. 32. Fluid Therapy Crystalloids are the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock (strong recommendation, moderate quality of evidence). Against using hydroxyethyl starches (HESs) for intravascular volume replacement in patients with sepsis or septic shock (strong recommendation, high quality of evidence).
  33. 33. Fluid Therapy Using Albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock when patients need more crystalloids (weak recommendation, low quality of evidence).
  34. 34. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  35. 35. Vasopressors Norepinephrine as the first choice vasopressor (strong recommendation, moderate quality of evidence). Adding either vasopressin (up to 0.03 U/min) (weak recommendation, moderate quality of evidence) or epinephrine (weak recommendation, low quality of evidence) to norepinephrine with the intent of raising MAP to target, or adding vasopressin (up to 0.03 U/min) (weak recommendation, moderate quality of evidence) to decrease norepinephrine dosage.
  36. 36. Vasopressors Using dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (weak recommendation, low quality of evidence). Against using low-dose dopamine for renal protection (strong recommendation, high quality of evidence).
  37. 37. Vasopressors Using dobutamine in patients who show evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents (weak recommendation, low quality of evidence).
  38. 38. Vasopressors All patients requiring vasopressors have an arterial catheter placed as soon as practical if resources are available WHY?** (weak recommendation, very low quality of evidence). **In shock states, estimation of blood pressure using a cuff, especially an automated measurement system, may be inaccurate.
  39. 39. Vasopressor Use for Adult Septic Shock (with guidance for steroid administration) Initiate norepinephrine (NE) and titrate up to 35-90 μg/min to achieve MAP target 65 mm Hg MAP target achieved Continue norepinephrine alone or add vasopressin 0.03 units/min with anticipation of decreasing norepinephrine dose MAP target not achieved and judged poorly responsive to NE Add vasopressin up to 0.03 units/min to achieve MAP target* MAP target achieved MAP target not achieved Add epinephrine up to 20-50 μg/min to achieve MAP target** MAP target achieved MAP target not achieved Add phenylephrine up to 200-300 μg/min to achieve MAP target*** * Consider IV steroid administration ** Administer IV steroids *** SSC guidelines are silent on phenylephrine Notes: • Consider dopamine as niche vasopressor in the presence of sinus bradycardia. • Consider phenylephrine when serious tachyarrhythmias occur with norepinephrine or epinephrine. • Evidence based medicine does not allow the firm establishment of upper dose ranges of norepinephrine, epinephrine and phenylephrine and the dose ranges expressed in this figure are based on the authors interpretation of the literature that does exist and personal preference/experience. Maximum doses in any individual patient should be considered based on physiologic response and side effects.
  40. 40. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  41. 41. Corticosteroids Guidelines are Against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, IV hydrocortisone at a dose of 200 mg per day (weak recommendation, low quality of evidence). • Use it only systolic blood pressure < 90 mm Hg despite fluid resuscitation and vasopressors for more than one hour)
  42. 42. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  43. 43. Blood Products
  44. 44. Blood Product Administration RBC transfusion occur only when hemoglobin concentration decreases to < 7.0 g/ dL in adults in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, or acute hemorrhage (strong recommendation, high quality of evidence).
  45. 45. Blood Product Administration Prophylactic platelet transfusion when counts are <10,000/mm3 in the absence of apparent bleeding and when counts are <20,000/mm3 if the patient has a significant risk of bleeding. Higher platelet counts (≥50,000/mm3) are advised for active bleeding, surgery, or invasive procedures (weak recommendation, very low quality of evidence).
  46. 46. Blood Product Administration GUIDELINES are Against the use of erythropoietin for treatment of anemia associated with sepsis . Why??** (strong recommendation, moderate quality of evidence). **Erythropoietin administration may be associated with an increased incidence of thrombotic events in the critically ill.
  47. 47. GUIDELINES are against the use of fresh frozen plasma to correct clotting abnormalities in the absence of bleeding or planned invasive procedures (weak recommendation, very low quality of evidence).
  48. 48. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  49. 49. Glucose Control
  50. 50. Glucose Control A protocolized approach to blood glucose management in ICU patients with severe sepsis commencing insulin dosing when 2 consecutive blood glucose levels are >180 mg/dL. This protocolized approach should target an upper blood glucose ≤180 mg/dL rather than an upper target blood glucose ≤ 110 mg/dL (strong recommendation, high quality of evidence).
  51. 51. Glucose Control Blood glucose values be monitored every 1–2 hrs until glucose values and insulin infusion rates are stable and then every 4 hrs thereafter in patients receiving insulin infusions (BPS).
  52. 52. Glucose Control GUIDELINES Suggest the use of arterial blood rather than capillary blood for point-of-care testing using glucose meters if patients have arterial catheters WHY??** (weak recommendation, low quality of evidence). **capillary blood is not accurate to estimate arterial blood or plasma glucose values (BPS).
  53. 53. MANAGEMENT OF SEVERE SEPSIS Management of Severe Sepsis Initial Resuscitation Diagnosis Antibiotic Therapy Source Control Fluid Therapy Vasopressors Corticosteroids Blood Product Glucose Control Bicarbonate Therapy
  54. 54. Bicarbonate Therapy
  55. 55. Bicarbonate Therapy Against the use of sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH ≥ 7.15 (weak recommendation, moderate quality of evidence).
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