Surviving Sepsis Guidelines Part I

INITIAL RESUSCITATION

SOURCE CONTROL

SCREENING FOR SEPSIS & PERFORMANCE IMPROVEMENT

FLUID THERAPY

DIAGNOSIS

VASOACTIVE MEDICATIONS

ANTIMICROBIAL THERAPY

CORTICOSTEROIDS

INITIAL RESUSCITATION

SOURCE CONTROL

SCREENING FOR SEPSIS & PERFORMANCE IMPROVEMENT

FLUID THERAPY

DIAGNOSIS

VASOACTIVE MEDICATIONS

ANTIMICROBIAL THERAPY

CORTICOSTEROIDS

INITIAL RESUSCITATION

1. Treatment and resuscitation begun immediately 2. If sepsis-induced hypoperfusion • Give at least 30mL/kg of IV crystalloid fluid within first 3 hours. 3. Do frequent and further hemodynamic assessment (ex. assess cardiac function). 4. For Px req. vasopressors • Initial target MAP = 65mmHg 5. Normalize lactate in Px w/ elevated lactate levels.

INITIAL RESUSCITATION

SOURCE CONTROL

SCREENING FOR SEPSIS & PERFORMANCE IMPROVEMENT

FLUID THERAPY

DIAGNOSIS

VASOACTIVE MEDICATIONS

ANTIMICROBIAL THERAPY

CORTICOSTEROIDS

SCREEN FOR SEPSIS &PERFORMANCE IMPROVEMENT

1. Hospitals and hospital systems should have a performance improvement program for sepsis, incl. sepsis screening for acutely ill, high risk patients.

INITIAL RESUSCITATION

SOURCE CONTROL

SCREENING FOR SEPSIS & PERFORMANCE IMPROVEMENT

FLUID THERAPY

DIAGNOSIS

VASOACTIVE MEDICATIONS

ANTIMICROBIAL THERAPY

CORTICOSTEROIDS

DIAGNOSIS

1. Do appropriate routine microbiologic cultures before antimicrobial therapy ** Always include at least 2 sets of blood cultures (aerobic and anaerobic).

INITIAL RESUSCITATION

SOURCE CONTROL

SCREENING FOR SEPSIS & PERFORMANCE IMPROVEMENT

FLUID THERAPY

DIAGNOSIS

VASOACTIVE MEDICATIONS

ANTIMICROBIAL THERAPY

CORTICOSTEROIDS

ANTIMICROBIAL THERAPY

1. IV antimicrobials initiated ASAP after recognition and within 1hour 2. Use empiric broad-spectrum therapy w/ 1 or more antimicrobials 3. Narrow down therapy once pathogen ID and sensitivities established 4. Not recommended — Use for sustained systemic antimicrobial prophylaxis in Px w/ severe inflammatory states of noninfectious origin

ANTIMICROBIAL THERAPY

5. DOSING — optimize based on accepted pharmacokinetic/pharmacodynamic principles and drug properties

ANTIMICROBIAL THERAPY

6. COMBINATION THERAPY • Empiric combo therapy (at least 2 antibiotics of diff antimicrobial classes) • Routine use for ongoing treatment of most other serious infections is not recommended • Combo therapy for treatment of neutropenic sepsis/bacteremia is not recommended • IF used — De-escalation w/ discontinuation of combination therapy within first few days in response to improvement

ANTIMICROBIAL THERAPY

8. Duration • 7-10 days • Longer courses may be appropriate in Px w. slow clinical response, undeniable foci of infection, bacteremia with S. aureus, etc. • Shorter courses may be appropriate 9. Do daily assessment for de-escalation 10.Measure procalcitonin levels to support shortening duration of therapy

INITIAL RESUSCITATION

SOURCE CONTROL

SCREENING FOR SEPSIS & PERFORMANCE IMPROVEMENT

FLUID THERAPY

DIAGNOSIS

VASOACTIVE MEDICATIONS

ANTIMICROBIAL THERAPY

CORTICOSTEROIDS

SOURCE CONTROL

1. ID the source of infection • Specific anatomic diagnosis of infection 2. Prompt removal of intravascular access devices that may be source

INITIAL RESUSCITATION

SOURCE CONTROL

SCREENING FOR SEPSIS & PERFORMANCE IMPROVEMENT

FLUID THERAPY

DIAGNOSIS

VASOACTIVE MEDICATIONS

ANTIMICROBIAL THERAPY

CORTICOSTEROIDS

FLUID THERAPY

1. Apply fluid challenge technique where fluid administration is continued 2. Crystalloids = fluid of choice for intravascular volume replacement • Balanced crystalloids or saline for fluid resuscitation • Albumin in addition to crystalloids when Px req. substantial amounts of crystalloids • Crystalloids over gelatins when resuscitating Px 3. Not recommended: Hydroxyethyl starches

INITIAL RESUSCITATION

SOURCE CONTROL

SCREENING FOR SEPSIS & PERFORMANCE IMPROVEMENT

FLUID THERAPY

DIAGNOSIS

VASOACTIVE MEDICATIONS

ANTIMICROBIAL THERAPY

CORTICOSTEROIDS

VASOACTIVE MEDICATIONS

1. Norepinephrine = first-choice vasopressor • Add vasopressin (up to 0.03 U/min) or epinephrine to w/ intent of inc. MAP to target • Add vasopressin (up to 0.03 U/min) to decrease norepinephrine 2. Dopamine as alternative only in highly selected patients • Not recommended — Low-dose for renal protection

VASOACTIVE MEDICATIONS

3. Dobutamine — for Px who show evidence of persistent hypo perfusion 4. Placement of arterial catheter for patients requiring vasopressors

INITIAL RESUSCITATION

SOURCE CONTROL

SCREENING FOR SEPSIS & PERFORMANCE IMPROVEMENT

FLUID THERAPY

DIAGNOSIS

VASOACTIVE MEDICATIONS

ANTIMICROBIAL THERAPY

CORTICOSTEROIDS

CORTICOSTEROIDS

1. IV hydrocortisone • Not recommended — if adequate fluid resuscitation and vasopressor therapy can restore hemodynamic stability • If needed — IV hydrocortisone at 200mg per day