Surviving sepsis 2017

Great update on sepsis by JournalWatch. For those who do not have access:


Daniel M. Lindberg, MD Reviewing Rhodes A et al., Intensive Care Med 2017 Jan 18;
This revision of the 2012 guidelines focuses on early management in adults.
Sponsoring Organizations: Surviving Sepsis Campaign, Society of Critical Care Medicine, and European Society of Intensive Care Medicine
Target Population: Clinicians who care for adult patients with sepsis and septic shock in a hospital setting.
Background and Objective
Sepsis remains incompletely understood, imperfectly defined, underrecognized, and exceptionally lethal. The Surviving Sepsis Campaign convened 55 experts from 25 organizations to undertake a systematic review and grading of evidence to update guidelines for the management of sepsis and septic shock in adult patients (NEJM JW Emerg Med Apr 2013 and Crit Care Med 2013; 41:580). This revision was conducted before publication of the Sepsis-3 definitions and does not incorporate them (NEJM JW Gen Med Mar 15 2016 and JAMA 2016 Feb 23; 315:801).
Key Recommendations
  • Patients with hypoperfusion should receive at least 30 mL/kg of IV crystalloid within 3 hours (strong recommendation, low quality of evidence), and should be re-assessed frequently (best practice statement).
  • For patients who require vasopressors, the initial target mean arterial pressure should be 65 mm Hg (strong recommendation, moderate quality of evidence).
  • IV antibiotics should be started within 1 hour of sepsis recognition (strong recommendation, moderate quality of evidence), and should include combination therapy (at least two classes of antibiotics to cover a known or suspected pathogen) for patients with septic shock. Combination therapy should not routinely be used for patients without shock.
  • Norepinephrine is the first choice for patients who need vasopressors. Vasopressin or epinephrine can be added. For patients who remain unstable, dobutamine is recommended.
  • IV hydrocortisone (200 mg/day) is suggested for patients who are hemodynamically unstable despite fluids and vasopressors.
  • Blood transfusion should be reserved for patients with hemoglobin concentration <7.0 g/dL, except in special circumstances such as hemorrhage and myocardial ischemia (strong recommendation, high quality of evidence). Platelets should be given if the platelet count is <10,000/mm3 or <20,000/mmwith bleeding.
  • Sodium bicarbonate should not be used for most patients with pH ≥7.15.
What's Changed
With publication of the PROCESS and ARISE trials, these guidelines de-emphasize protocolization of care and invasive monitoring, instead suggesting that patients be re-evaluated frequently.
Comment
We continue to search for new definitions, diagnostic tests, antimicrobials, and treatments for patients with sepsis. However, improving outcomes probably has as much to do with increasing adherence to the practices we already know are effective and embedding automated passive alerting functions in the electronic medical record. For patients with sepsis, provide early, aggressive treatment with fluids and antibiotics, coupled with frequent re-assessment.

CITATION(S):
  1. Rhodes A et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 2017 Jan 18; [e-pub]. (http://dx.doi.org/10.1007/s00134-017-4683-6)