10/21/2017 Surviving Sepsis 2017 Guidelines Overview Core EM

Surviving Sepsis 2017 Guidelines Overview

Background

The new Surviving Sepsis Guidelines were released in January 2017 as an update to the 2012 guidelines. The 2012 sepsis criteria
maintained the model of early goal-directed therapy (EGDT) as a guiding principle which became the standard of care after
the groundbreaking Emmanuel Rivers study in 2001 (Rivers 2001 (https://www.ncbi.nlm.nih.gov/pubmed/11794169)). The 2017
Surviving Sepsis Guidelines now reflect the results of the PROCESS, PROMISE, and ARISE trials; 3 large multicenter studies
demonstrating no significant difference in the primary outcome of mortality between EGDT and usual care. (ProCESS
Investigators 2014 (https://www.ncbi.nlm.nih.gov/pubmed/24635773), ARISE Investigators 2014
(https://www.ncbi.nlm.nih.gov/pubmed/25272316), Mouncey 2015 (https://www.ncbi.nlm.nih.gov/pubmed/25776532))

Definitions

2012 Guidelines
Sepsis: A systemic manifestation of infection (i.e. Systemic Inflammatory response Syndrome [SIRS] criteria) +
suspected infection
Severe sepsis was defined as sepsis + end organ damage
Septic shock was defined as severe sepsis + hypotension not reversed with fluid resuscitation (Dellinger 2012
(https://www.ncbi.nlm.nih.gov/pubmed/23353941))
2017 Guidelines
Redefine sepsis as agreed upon by The Society of Critical Care Medicine (SCCM) and the European Society of Intensive
Care Medicine (ESICM) as the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
(Singer 2016 (https://www.ncbi.nlm.nih.gov/pubmed/26903338))
Sepsis:life-threatening organ dysfunction caused by a dysregulated host response to infection. End organ damage
is identified as an acute change in total Sequential [Sepsis-related] Organ Failure Assessment score (SOFA) 2.
(Rhodes 2017 (https://www.ncbi.nlm.nih.gov/pubmed/28098591))
Septic shock: A subset of sepsis in which circulatory, cellular, and metabolic abnormalities are associated with a
greater risk of mortality than with sepsis alone. These patients can be clinically identified by a vasopressor
requirement to maintain a MAP 65mmHg and serum lactate >2mmol/L in the absence of hypovolemia (Singer 2016
(https://www.ncbi.nlm.nih.gov/pubmed/26903338))
Severe sepsis category was deemed to be superfluous and is no longer recommended for clinical use
SIRS criteria
No longer considered in defining sepsis and septic shock
Instead, adult patients outside of the ICU with suspected infection are identified as being at heightened risk of
mortality if they have quickSOFA (qSOFA) score meeting 2 of the following criteria: respiratory rate of 22/min or
greater, altered mentation, or systolic blood pressure of 100mmHg or less (Singer 2016
(https://www.ncbi.nlm.nih.gov/pubmed/26903338))

Significant Changes

Fluid Resuscitation
Initial fluid resuscitation
Unchanged from 2012 guidelines
30ml/kg of IV crystalloid fluid (normal saline or balanced salt solution) within the first 3 hours of sepsis
presentation.
Patients may require greater volumes of fluid as guided by frequent reassessment of volume responsiveness.
Consider 4% albumin in refractory hypotension.
Static fluid status measurements (i.e. Central Venous Pressure)

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No longer recommended as lone guiding principles as they carry limited value for measuring fluid
responsiveness
2017 guidelines recommend the use of dynamic variables over static variables to predict fluid responsiveness (ie
passive leg raise, pulse pressure variation, stroke volume variation)
Weak suggestion to guide resuscitation to normal lactate
Use clinical judgement. For instance, if patient has adequate BP and urine output and is down-titrating
vasopressors, but has a persistently elevated lactate, additional fluid carries the risk of over-resuscitation.
Antibiotics
First priority is source control and obtaining cultures. Cultures should be obtained prior to administration of
antibiotics when feasible
Give antibiotics within 1 hour of identification of septic shock
Antibiotic Regimen
Begin with broad spectrum coverage when the potential pathogen is not immediately obvious
Narrow once pathogen identification and sensitivities are established
Vancomycin
Goal to achieve a trough of 15-20mg/L
IV loading dose of 25-30mg/kg in septic shock
For -lactams, achieve higher Time-Dependent Killing (T>MIC) by increasing frequency of dosing
Fluoroquinolones should be given at their optimal nontoxic dose
Aminoglycosides should be dosed using once-daily dosing
Average duration: 7-10 days is recommended in most patients
Consider using procalcitonin to guide de-escalation of antibiotics
Other:
Vasopressors
Useful in patients who remain hypotensive despite adequate fluid resuscitation
Target mean arterial pressure (MAP) of 65mmHg
First line vasopressor: norepinephrine
Dose: start 2-12 mcg/min (no true maximum dose)
Administer vasopressin (up to 0.03) and epinephrine as add-on therapies if not at target MAP or to decrease
norepinephrine dose
Consider inotropes in low cardiac output states i.e. septic cardiomyopathy, which can be common in these
patients
Steroids
Indicated for patients with septic shock in which fluids and vasopressors fail to achieve hemodynamic stability
Transfusion indicated in majority of patients only when hemoglobin <7.0g/dL
Target glucose <180mg/dL
Bicarb not recommended when pH>7.15
Mechanical Ventilation (unchanged from 2012 guidelines)
Lung Protective Ventilation Strategy
Target a tidal volume of 6mL/kg of ideal body weight
Plateau pressure of <30cm H20
PEEP: incresae with FiO2 as per ARDSnet protocol
Recommend prone over supine position in patients with sepsis-induced ARDS and Pa/Fio2 ratio<150
Recommendation against high frequency oscillatory ventilation/lung protective ventilation

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ARDSnet Protocol

Take Home Points

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection
EGDT is no longer recommended for treatment of sepsis
Begin broad spectrum, empiric antibiotic therapy within 1 hour in septic shock
Initial fluid resuscitation of 30ml/kg, use frequent dynamic resuscitation markers, and the addition of vasopressors to
target MAP of 65mmHg

Surviving Sepsis Campaign Highlights (EMCrit)

Read More:

REBEL EM: Sepsis 3.0 (http://rebelem.com/sepsis-3-0/)

REBEL EM: Fluid Responsiveness and the Six Guiding Principles of Fluid Resuscitation (http://rebelem.com/fluid-
responsiveness-and-the-six-guiding-principles-of-fluid-resuscitation/)

FOAMcast: Surviving Sepsis Campaign Guidelines 2017 (http://foamcast.org/2017/01/19/suviving-sepsis-campaign-guidelines-

2017/)

EMCrit: Surviving Sepsis Campaign (SSC) Guidelines 2016 Podcast (https://emcrit.org/practicalevidence/ssc-guidelines-2016/)

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