Surviving Sepsis Campaign Previews Updated Guidelines for 2012
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's 41st Critical Care Congress.
Initial Resuscitation, Diagnosis, and Antibiotic Therapy
- In the initial resuscitation phase of severe sepsis and septic shock, patients with elevated lactate levels 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).
- 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).
- Don't use of procalcitonin as a diagnostic tool for severe sepsis. In antibiotic therapy, using low procalcitonin levels as a marker to discontinue empiric antibiotics when no infection is found (weak recommendation; Grade 2C).
- 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).
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). Adding albumin to the initial fluid resuscitation for severe sepsis and septic shock (weak recommendation; Grade 2B).
- 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).
- 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 4 to 6 hours. 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
- 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).
- 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, 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).
- Recruitment maneuvers in patients with severe refractory hypoxemia (weak recommendation; Grade 2C). Prone positioning for patients with severe ARDS whose PaO2 /FiO2 rates are less than 100 despite such maneuvers (weak recommendation; Grade 2C).
資參考料：
Pulmonary Reviews: Surviving Sepsis Campaign Previews Updated Guidelines for 2012
ACEP NEWS: Revised Sepsis Guidelines Forthcoming, Emphasize Best Practices
相關文章：
SSC Surviving Sepsis Guidelines 2008
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