Surviving Sepsis Guidelines 2012

Surviving Sepsis Guidelines 2012 from Sun Yai-Cheng

Surviving Sepsis Campaign

International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

Critical Care Medicine 2013 Feb;41(2):580-637

Guide to Recommendations’ Strengths and Supporting Evidence:

• 1 = strong recommendation;
• 2 = weak recommendation or suggestion;
• A = good evidence from randomized trials;
• B = moderate strength evidence from small randomized trial(s) or multiple good observational trials;
• C = weak or absent evidence, mostly driven by consensus opinion.

Initial Resuscitation

Goals during the first 6 hrs of resuscitation:

1. CVP 8–12 mmHg
2. MAP ≥ 65 mm Hg
3. Urine output ≥ 0.5 mL/kg/hr
4. ScvO2 70% or 65%, respectively (grade 1C).

Surviving Sepsis Campaign Bundles

  TO BE COMPLETED WITHIN 3 HOURS:

• Measure lactate level
• Obtain blood cultures prior to administration of antibiotics
• Administer broad spectrum antibiotics
• Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L

  TO BE COMPLETED WITHIN 6 HOURS:

• Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP ≥65 mmHg
• In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L :

• Measure CVP
• Measure ScvO2

• Remeasure lactate if initial lactate was elevated

Diagnosis

• Cultures as clinically appropriate before antimicrobial therapy if no significant delay ( > 45 mins) in the start of antimicrobial (grade 1C).
• At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently inserted (grade 1C).
• Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available, and invasive candidiasis is in differential diagnosis of cause of infection.
• Imaging studies performed promptly to confirm a potential source of infection.

Antimicrobial Therapy

• Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy.
• 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 (grade 2C).
• Empiric combination therapy should not be administered for more than 3–5 days.
• De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).

Source Control

• Intervention be undertaken for source control within the first 12 hr after the diagnosis is made, if feasible (grade 1C).
• 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).

Fluid Therapy

• Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).
• Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B).
• Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (grade 2C).
• Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (grade 1C).

Vasopressors

• Vasopressor therapy initially to target a MAP of 65 mmHg (grade 1C).
• Norepinephrine as the first choice vasopressor (grade 1B).
• Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg, patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (grade 2C).

Corticosteroids

• Not using intravenous hydrocortisone to treat adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability.
• In case this is not achievable, we suggest intravenous hydrocortisone alone at a dose of 200 mg per day (grade 2C).
• When hydrocortisone is given, use continuous flow (grade 2D).

Blood Product Administration

• Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that RBC transfusion occur only when hemoglobin < 7.0 g/dL to target a hemoglobin of 7.0 ~ 9.0 g/dL in adults (grade 1B).
• In patients with severe sepsis, administer platelets prophylactically when counts are < 10,000/mm3 in the absence of apparent bleeding.
• We suggest prophylactic platelet transfusion 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 (grade 2D).

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 (grade 1A).

Bicarbonate Therapy

• Not using sodium bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH ≥7.15 (grade 2B).

相關文章：SSC Surviving Sepsis Guidelines 2008

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《Surviving Sepsis Guidelines 2012 改版摘要》

1. 不建議使用 hydroxyethyl starches 作為急救輸液
2. 第一線強心劑首選：Levophed
3. 若無ScvO2可監測，可追蹤 lactate 作為復甦成效的指標
4. 黴菌感染高危險群，可驗 1,3-beta-D-glucan, mannan, or anti-mannan ELISA antibody assays
5.  經驗性抗生素治療後，若無證據顯示感染，可驗 procalcitonin。若 procalcitonin 低，可停用抗生素
6. recombinant human activated protein C (Xigris) 於 2011年下架
7. 血糖控制目標 < 180 mg/dl [2008版 Glu < 150 mg/dl]
8. 輸血小板時機：
   
   • 血小板 < 10,000，不管有無出血 (2008版 Plt < 5000 )
   • 血小板 < 20,000，有出血風險 (2008版 Plt < 30,000 )
   • 血小板 < 50,000，有出血或執行侵入性處置 ( 同2008版 )

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