Surviving Sepsis Guidelines Updated: Preview from SCCM Meeting - PulmCCM
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Dec 272012
 
infectious disease sepsis review critical care review crit care med review  Surviving Sepsis Guidelines Updated: Preview from SCCM Meeting

More: Surviving Sepsis Guidelines Review / Update

The Surviving Sepsis Campaign is a collaboration between the U.S. Society of Critical Care Medicine (SCCM), the European Society of Intensive Care Medicine, and the International Sepsis Forum, whose recommendations on the management of sepsis are considered widely. At the 2012 SCCM meeting, the Surviving Sepsis committee revealed some of the planned revisions and additions in the upcoming 2012 updated Surviving Sepsis Guidelines. They will reportedly include:

Surviving Sepsis: New Fluid Resuscitation Recommendations
  • They gave a strong 1A recommendation for the use of crystalloids like normal saline as the initial fluid resuscitation for people with severe sepsis. They further advise that the initial fluid challenge should be 1L or more of crystalloid, and a minimum of 30 mL/kg of crystalloid (2.1 L in a 70 kg or 154-pound person) in the first 4-6 hours.
  • Incremental fluid boluses should be continued as long as patients continue to improve hemodynamically (in blood pressure, delta pulse pressure, or both) (Grade 1C).
  • They weakly recommended adding albumin to initial fluid resuscitation with crystalloid for severe sepsis and septic shock (Grade 2B).
  • Authors strongly recommended not using hetastarches/hydroxyethyl starches greater than 200 kDa in molecular weight (Grade 1B).
Surviving Sepsis: New Recommendations for Vasopressors, Inotropes
  • Authors strongly recommend norepinephrine (Levophed) as the first choice for vasopressor therapy (Grade 1B). Vasopressin 0.03 units / minute is an alternative to norepinephrine, or may be added to it (Grade 2A).
  • When a second agent is needed, epinephrine is their weakly-recommended vasopressor choice (Grade 2B).
  • Dopamine was only recommended in highly selected patients whose risk for arrhythmias was felt to be very low and who had a low heart rate and/or cardiac output (Grade 2C).
  • Dobutamine is strongly recommended (by itself or in addition to a vasopressor) for patients with cardiac dysfunction as evidenced by high filling pressures and low cardiac output, or clinical signs of hypoperfusion after achievement of restoration of blood pressure with effective volume resuscitation (Grade 1C).
Surviving Sepsis: Corticosteroid Recommendations

Authors suggest not providing intravenous corticosteroid therapy to patients with septic shock for whom fluid resuscitation and vasopressors can restore an adequate blood pressure. For those with vasopressor-refractory septic shock, they recommend IV hydrocortisone in a continuous infusion totaling 200 mg/24 hrs — a weak Grade 2C.

Surviving Sepsis: Mechanical Ventilation for ARDS

For patients with ARDS due to severe sepsis, the authors made several suggestions based on consensus opinion/weak evidence:

  • Using higher levels of PEEP (Grade 2C);
  • Recruitment maneuvers for patients with severe hypoxemia while receiving high PEEP and FiO2 (Grade 2C),
  • Prone positioning for patients with PaO2/FiO2 ratios < 100 despite such maneuvers (Grade 2C).
Other New Surviving Sepsis Guidelines

Some of the Surviving Sepsis committee’s other weak recommendations/suggestions included:

  • Using normalization of lactate levels as an alternate goal in early goal-directed therapy for severe sepsis, if central venous oxygenation monitoring is not available (Grade 2C).
  • For patients at risk for fungal infection as a source for severe sepsis, checking one of the newer assays for invasive candidiasis such as 1,3-beta-D-glucan, mannan, or anti-mannan ELISA antibody testing (Grade 2B/C).
  • When no infection can be found during empiric antibiotic therapy, consider using a low procalcitonin level as a supportive tool for the decision to stop antibiotics (Grade 2C).

The Surviving Sepsis project was criticized in the mid 2000s when it was revealed that Eli Lilly (makers of since-discontinued Xigris) provided a reported ~90% of the funding, without disclosure by the committee. Others argued such criticism was unfounded and unfair. The Surviving Sepsis website does not clearly show their current sources of funding, but they have set up a page to address any concerns about industry involvement. The name “Surviving Sepsis Campaign” is copyrighted by the Society for Critical Care Medicine.

Guide to Recommendations’ Strengths and Supporting Evidence in the Surviving Sepsis Guidelines:

  • 1 = strong recommendation;
  • 2 = weak recommendation or suggestion;
  • A = good evidence from randomized trials;
  • B = moderate strength evidence from small randomized trial(s) or upgraded observational trials;
  • C = low strength evidence, well-done observational trials with control randomized controlled trials
  • D = very low strength evidence, downgraded controlled studies or expert opinion.

- From the 2012 Society of Critical Care Meeting.

More: Surviving Sepsis Guidelines Review / Update

Also: Dellinger RP et al. Surviving Sepsis campaign guidleines. Intensive Care Med 2008.

PulmCCM is not affiliated with the Surviving Sepsis Guidelines or the Surviving Sepsis Campaign.

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  11 Responses to “Surviving Sepsis Guidelines Updated: Preview from SCCM Meeting”

  1. “…hetastarches/hydroxyethyl starches greater than 200 daltons…”
    Should it be 200 “kilodaltons” here?

  2. In my opinion, in light of the 6S trial, ought discouraged the use of hydroxyethyl starch in resuscitation of septic shock, until CHEST trial says otherwise. Although it is a potato starch in the trial 6S

  3. I guess the cHEST trial just buried the starches.

  4. […] Surviving Sepsis Guidelines Updated: Preview from SCCM Meeting […]

  5. It is a surprise that the committee did not remove the recommendation about blood transfusion.
    As per JAMA article there was no benefit from increasing hematocrit to above 30 in order to improve the mixed venous saturation. All previous study regarding blood transfusion has shown harm rather than benefit. I think intensive care physicians should be very selective when it comes to use blood as a treatment.

  6. Dr. Rivers’ own institute holds a patent on a device used in continuous oximetry. This is why he insists that continuous oximetry is superior to intermittant sampling despite very good evidence that there is no difference.

    Dr. Rivers’ insists that the SSC conclusively determined that we must use scvo2 and CVP in resuscitation. Yet the 2012 guidelines specifically state that these two benchmarks are NOT well-proven enough to be standards of care.

    Dr. Rivers is the Captain Ahab of continuous Scvo2.

    • Well if you want to get gossipy why not mention that there were allegations of improper handling of data raised by henry ford statisticians and a resident looking at the rivers trial data in a post hoc (which if true resulted in invalidation of the findings), and the hospital declined to share their data with independent observers (just assured everyone it passed an internal review) … and how about the fact that there is a financial relationship between edwards lifesciences and rivers’ hospital that has never been fully disclosed (rivers claims he has ‘no conflicts’ during presentations) … and that at one point rivers trademarked the phrases “EGDT” and “early goal directed therapy” (see bottom of page on second link) …. smells pretty fishy

      http://online.wsj.com/article/SB121867179036438865.html
      http://www.edwards.com/Products/mininvasive/Pages/egdtprotocol.aspx

  7. […] The use of CVP is largely cultural and deeply ingrained. There are some limited ways and pathologies in which it can be useful, but not as a measure of preload.  My friend Paul Marik published a piece that was both enlightening and entertaining in Chest a couple of years ago which I would have thought would have been the final nail in the coffin for the use of CVP as a preload tool, but it endures…even in the latest surviving sepsis guidelines… […]

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