Guideline for management of sepsis and septic shock: Surviving sepsis campaign
USA: A recent international guideline published in the journal Intensive Care Medicine provides recommendations for the management of sepsis and septic shock 2021. The guideline is a part of the surviving sepsis campaign -- a global initiative to bring together professional organizations in reducing mortality from sepsis.
According to Laura Evans, University of Washington, Seattle, WA, USA, and the team, the recommendations are intended to provide guidance for the clinician caring for adult patients with sepsis or septic shock in the hospital setting. However, they further added that recommendations from these guidelines cannot replace the clinician's decision-making capability when presented with a unique patient's clinical variables. These guidelines are intended to reflect best practices.
Sepsis is a life-threatening organ dysfunction caused by the dysregulated host response to infection. Sepsis and septic shock are major healthcare problems that impact millions of people globally and kill between one in three and one in six of those it affects. Early identification and appropriate management in the initial hours after the development of sepsis improve outcomes.
Screening for patients with sepsis and septic shock
- For hospitals and health systems, the authors recommend using a performance improvement programme for sepsis, including sepsis screening for acutely ill, high-risk patients and standard operating procedures for treatment.
- They recommend against using qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock.
- For adults suspected of having sepsis, measuring of blood lactate is suggested.
Initial resuscitation
- Sepsis and septic shock are medical emergencies, and the authors recommend that treatment and resuscitation begin immediately.
- For patients with sepsis induced hypoperfusion or septic shock it is suggested to give at least 30 mL/kg of intravenous (IV) crystalloid fluid within the first 3 h of resuscitation.
- For adults with sepsis or septic shock, it is suggested to use dynamic measures to guide fluid resuscitation, over physical examination or static parameters alone.
- For adults with sepsis or septic shock, the authors suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate level, over not using serum lactate.
- For adults with septic shock, the authors suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion.
Mean arterial pressure
- For adults with septic shock on vasopressors, the authors recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets.
Admission to intensive care
- For adults with sepsis or septic shock who require ICU admission, the authors suggest admitting the patients to the ICU within 6 h.
Diagnosis of infection
- For adults with suspected sepsis or septic shock but unconfirmed infection, the authors recommend continuously re-evaluating and searching for alternative diagnoses and discontinuing empiric antimicrobials if an alternative cause of illness is demonstrated or strongly suspected.
Time to antibiotics
- For adults with possible septic shock or a high likelihood for sepsis, the authors recommend administering antimicrobials immediately, ideally within 1 h of recognition.
- For adults with possible sepsis without shock, the authors recommend rapid assessment of the likelihood of infectious versus non-infectious causes of acute illness.
- For adults with a low likelihood of infection and without shock, the authors suggest deferring antimicrobials while continuing to closely monitor the patient.
Biomarkers to start antibiotics
- For adults with suspected sepsis or septic shock, the authors suggest against using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone.
Antimicrobial choice
- For adults with sepsis or septic shock at high risk of methicillin resistant staph aureus (MRSA), the authors recommend using empiric antimicrobials with MRSA coverage over using antimicrobials without MRSA coverage.
- For adults with sepsis or septic shock at low risk of methicillin resistant staph aureus (MRSA), the authors suggest against using empiric antimicrobials with MRSA coverage, as compared with using antimicrobials without MRSA coverage.
- For adults with sepsis or septic shock and high risk for multidrug resistant (MDR) organisms, the authors suggest using two antimicrobials with gram-negative coverage for empiric treatment over one gram-negative agent.
- For adults with sepsis or septic shock and low risk for MDR organisms, the authors suggest against using two Gram-negative agents for empiric treatment, as compared to one Gram-negative agent.
- For adults with sepsis or septic shock, the authors suggest against using double gram-negative coverage once the causative pathogen and the susceptibilities are known.
Antifungal therapy
- For adults with sepsis or septic shock at high risk of fungal infection, the authors suggest using empiric antifungal therapy over no antifungal therapy.
- For adults with sepsis or septic shock at low risk of fungal infection, the authors suggest against empiric use of antifungal therapy.
Antiviral therapy
- The authors make no recommendation on the use of antiviral agents.
Delivery of antibiotics
- For adults with sepsis or septic shock, the authors suggest using a prolonged infusion of beta-lactams for maintenance (after an initial bolus) over conventional bolus infusion.
Pharmacokinetics and pharmacodynamics
- For adults with sepsis or septic shock, the authors recommend optimizing dosing strategies of antimicrobials based on accepted pharmacokinetic/
pharmacodynamic (PK/PD) principles and specific drug properties.
Source control
- For adults with sepsis or septic shock, we recommend rapidly identifying or excluding a specific anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical.
- For adults with sepsis or septic shock, the authors recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established.
Source : Intensive Care Medicine
