Cập nhật hướng dẫn Surviving sepsis

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Aim

● Discuss various components of the Surviving Sepsis

Guidelines

● Appraise evidence briefly

● Discuss critiques of the guidelines

● Identify strategies to apply guidelines with equipoise in

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Review of the 2018 update

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Definitions have changed

●

<i><b>Seps is</b></i>

: Life-threatening organ dysfunction

caused by dysregulated host response to

infection

●

<i><b>Septic Shock</b></i>

: Subset of sepsis with

circulatory and cellular/metabolic

dysfunction associated with higher risk of

mortality

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Clinical criteria (SEP-3 vs SIRS)

SEP 3 definitions using qSOFA are not incorporated in the

guidelines.

Suggest use of qSOFA in place of SIRS criteria

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1 hour bundle

● Measure lactate level. (repeat later if high)

● Obtain blood cultures before administering antibiotics.
● Administer broad-spectrum antibiotics.

● Begin rapid administration of 30mL/kg crystalloid for
hypotension or lactate ≥4 mmol/L.

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Resuscitation: Changes from 2012

3 and 6 hour bundles no longer endorsed.

Dynamic indices of perfusion prefered over static numbers.

More focus on acting quickly and monitoring response.

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Critiques

30 ml/kg in 3 hours is a very high fluid load. Potentially
dangerous in multiple clinical settings.

Quality of evidence is low to moderate but recommendations

are classified as “Strong”.

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Antibiotics and Source control

● Anatomic site for source control be identified/excluded

ASAP

● Antimicrobials be initiated as soon as possible after

recognition and within 1 h for both sepsis and septic shock.

● Empiric broad-spectrum therapy with one or more

antimicrobials to cover all likely pathogens. Get cultures if
no major delay.

● De-escalation is encouraged as soon as feasible. Shorter

courses recommended.

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Problems...

● No definite study to prove that short delays in antibiotics

worsens mortality. Time to intervention studies are hard to
replicate.

● IDSA has NOT endorsed the 1 hour window, procalcitonin

use, double coverage and days of antibiotics.

● Attempt to focus on disease specific combination therapy

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Fluids

Use crystalloids and avoid colloids.

Use dynamic indices and fluid challenges to assess
responsiveness.

Differentiate responsiveness from need for fluid.
Suggest albumin if crystalloid amount used is high.

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Practical issues

● For the developing world mentioning albumin in a guideline

is a concern.

● ALBIOS and SAFE trials don't show a major benefit for
albumin. Glycocalyx based models suggest no benefit.

● Not all dynamic indices are equal. Ultrasound based (aortic

doppler, IVC) or PLR based methods are attractive but have
their flaws.

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Vasopressors

Norepinephrine is first choice, target a MAP of 65 mmHg.

Epinephrine and vasopressin (fixed dose) may be added
(sequentially)

Dopamine in highly selected cases only - renal perfusion is not a
good indication.

Suggest use of arterial catheters

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Concerns

● Sequential pressors may not always be good. May lead to

very high levels of one agent.

● Epinephrine may raise lactate - but that may be a good

thing.

● Arterial catheters may not be necessary and probably

should not be mandated. The quality of evidence was

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Steroids

Suggest adding if fluids and pressors are not able to restore
stability.

Hydrocortisone 200 mg per day (continuous infusion)

Recommend against ACTH stim test.

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Insights

Recent trial (ADRENAL) with hydrocortisone showed no
difference in mortality.

The APROCCHSS study showed benefit mortality with
fludrocortisone + hydrocortisone.

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Blood sugars

● Protocolized management.

● Keep levels below 180

● Monitor every 1-2 hrs initially

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Blood products

● Transfusion trigger is 7.0 mg/dl
● Avoid erythropoetin

● Avoid FFP to correct lab abnormalities in the absence of

bleeding.

● Platelet transfusion trigger is <10,000/mm^3 in the absence

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Mechanical Ventilation

● TV 6 ml/kg and early proning for severe cases.
● Suggest high rather than low PEEP

● No recommendation on NIV

● Suggest recruitment maneuvers
● Early NMBA for <48 hrs is ok

● Avoid beta 2 agonists (if bronchospasm is absent), PA

catheters.

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● Use weaning protocols, spontaneous breathing trials and

conservative fluid strategies.

● Elevate head end by 30-45 degrees for VAP prevention.

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Renal

If pH is above 7.15 avoid bicarbonate therapy.

Either continuous or intermittent is acceptable.

Oliguria and creatinine elevation are not good indication.

CRRT may be preferred in unstable patients.

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Nutrition

Avoid early parenteral nutrition if enteral feeding is possible.

Early trophic feeding is acceptable. Parenteral nutrition is not
needed in the first 7 days.

Arginine/Omega 3 FA, glutamine, selenium are not
recommended.

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VTE and Stress ulcer prophylaxis

● Use pharmacological means.
● LMWH is preferred.

● Combined mechanical and pharmacological is suggested.

(weak evidence)

● Give SUP for patients at risk. Avoid if no risk factors are

present.

● PPI or H2B suggested.

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Comments

● Evidence for SUP and VTE is changing.

● SUP ICU (Nejm 2018) was a negative study for SUP in the ICU

● If nutrition and supportive care has improved then it is likely

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Goals of care

● Address goals of care as early as possible.

● Discuss prognosis with patients and family

● Integrate goals of care into end of life care plan and

palliative care.

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References

1. Jones, Alan E et al. “Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized
clinical trial” JAMAvol. 303,8 (2010): 739-46.

2. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock
(Sepsis-3). <i>JAMA</i>. 2016;315(8):801-10.

3. Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.
Intensive Care Med. 2017

4. Pepper DJ,et al. Evidence Underpinning the Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock
Management Bundle (SEP-1): A Systematic Review. Ann Intern Med.

5. Gore DC, Jahoor F, Hibbert JM, DeMaria EJ. Lactic acidosis during sepsis is related to increased pyruvate production, not
deficits in tissue oxygen availability. <i>Ann Surg</i>. 1996;224(1):97-102.

6. Does Central Venous Pressure Predict Fluid Responsiveness?*: A Systematic Review of the Literature and the Tale of

Seven Mares Marik, Paul E. et al. CHEST , Volume 134

7. Sterling SA, Miller WR, Pryor J, Puskarich MA, Jones AE. The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis
and Septic Shock: A Systematic Review and Meta-Analysis. <i>Crit Care Med</i>. 2015;43(9):1907-15.

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