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Practice Guideline
. 2013 Feb;41(2):580-637.
doi: 10.1097/CCM.0b013e31827e83af.

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

Collaborators, Affiliations
Practice Guideline

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

R Phillip Dellinger et al. Crit Care Med. .

Abstract

Objective: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008.

Design: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.

Methods: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations.

Results: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C).

Conclusions: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

Comment in

  • New recommendations for the use of serum albumin in patients with severe sepsis and septic shock.
    Latour-Pérez J. Latour-Pérez J. Crit Care Med. 2013 Oct;41(10):e289. doi: 10.1097/CCM.0b013e31828ced28. Crit Care Med. 2013. PMID: 24060790 No abstract available.
  • The authors reply.
    Jaeschke R, Webb SA, Annane D, Dellinger RP. Jaeschke R, et al. Crit Care Med. 2013 Oct;41(10):e289-90. doi: 10.1097/CCM.0b013e3182a42e78. Crit Care Med. 2013. PMID: 24060791 No abstract available.
  • Sepsis-induced disseminated intravascular coagulation, symmetrical peripheral gangrene, and amputations.
    Hotchkiss RS, Levy JH, Levi M. Hotchkiss RS, et al. Crit Care Med. 2013 Oct;41(10):e290-1. doi: 10.1097/CCM.0b013e31828cef48. Crit Care Med. 2013. PMID: 24060792 No abstract available.
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    Zimmerman JL, Gerlach H, Moreno R. Zimmerman JL, et al. Crit Care Med. 2013 Oct;41(10):e291-2. doi: 10.1097/CCM.0b013e31829caf52. Crit Care Med. 2013. PMID: 24060793 No abstract available.
  • Surviving sepsis.
    Marik PE. Marik PE. Crit Care Med. 2013 Oct;41(10):e292-3. doi: 10.1097/CCM.0b013e31828cec2d. Crit Care Med. 2013. PMID: 24060794 No abstract available.
  • The authors reply.
    Osborn TM, Levy M, Dellinger RP, Annane D. Osborn TM, et al. Crit Care Med. 2013 Oct;41(10):e293-4. doi: 10.1097/CCM.0b013e3182a51d07. Crit Care Med. 2013. PMID: 24060795 No abstract available.
  • Use of hydrocortisone for refractory shock in children.
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  • The authors reply.
    Carcillo JA, Randolph AG, Hazelzet JA, Dellinger RP. Carcillo JA, et al. Crit Care Med. 2013 Oct;41(10):e295. doi: 10.1097/CCM.0b013e3182a51cf0. Crit Care Med. 2013. PMID: 24060797 No abstract available.
  • 2B or not 2B for selective decontamination of the digestive tract in the surviving sepsis campaign guidelines.
    Petros AJ, Silvestri L, van Saene HK, Zandstra DF, de la Cal MA, Viviani M, Peric M, Gullo A. Petros AJ, et al. Crit Care Med. 2013 Nov;41(11):e385-6. doi: 10.1097/CCM.0b013e3182916fa2. Crit Care Med. 2013. PMID: 24162689 No abstract available.
  • The authors reply.
    Opal SM, Dellinger RP. Opal SM, et al. Crit Care Med. 2013 Nov;41(11):e386-7. doi: 10.1097/CCM.0b013e3182a635c1. Crit Care Med. 2013. PMID: 24162690 No abstract available.
  • Making the GRADE: how useful are the new Surviving Sepsis Campaign guidelines?
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  • The authors reply.
    Annane D, Jaeschke R, Dellinger RP. Annane D, et al. Crit Care Med. 2013 Dec;41(12):e483. doi: 10.1097/CCM.0000000000000014. Crit Care Med. 2013. PMID: 24275411 No abstract available.
  • Vasopressor dosing in septic shock.
    Alaniz C, Pollard S. Alaniz C, et al. Crit Care Med. 2013 Dec;41(12):e483-4. doi: 10.1097/CCM.0b013e3182916fe7. Crit Care Med. 2013. PMID: 24275412 No abstract available.
  • The authors reply.
    Annane D, Dellinger RP. Annane D, et al. Crit Care Med. 2013 Dec;41(12):e484. doi: 10.1097/CCM.0000000000000015. Crit Care Med. 2013. PMID: 24275413 No abstract available.
  • Fluid therapy in severe sepsis and septic shock.
    De la Puente-Diaz de Leon VM, Rivero-Sigarroa E, Domiguez-Cherit G, Namendys-Silva SA. De la Puente-Diaz de Leon VM, et al. Crit Care Med. 2013 Dec;41(12):e484-5. doi: 10.1097/CCM.0b013e31829644fe. Crit Care Med. 2013. PMID: 24275414 No abstract available.
  • The authors reply.
    Annane D, Dellinger RP. Annane D, et al. Crit Care Med. 2013 Dec;41(12):e485. doi: 10.1097/CCM.0000000000000016. Crit Care Med. 2013. PMID: 24275415 No abstract available.
  • Surviving sepsis guidelines 2012.
    Vassalos A, Rooney K. Vassalos A, et al. Crit Care Med. 2013 Dec;41(12):e485-6. doi: 10.1097/CCM.0b013e31829644e8. Crit Care Med. 2013. PMID: 24275416 No abstract available.
  • The author replies.
    Dellinger RP. Dellinger RP. Crit Care Med. 2013 Dec;41(12):e486. doi: 10.1097/CCM.0000000000000056. Crit Care Med. 2013. PMID: 24275417 No abstract available.
  • Comments on surviving sepsis guideline 2012.
    Ghosh S. Ghosh S. Crit Care Med. 2013 Dec;41(12):e486-7. doi: 10.1097/CCM.0b013e3182978cc8. Crit Care Med. 2013. PMID: 24275418 No abstract available.
  • The authors reply.
    Dellinger RP, Jaeschke R. Dellinger RP, et al. Crit Care Med. 2013 Dec;41(12):e487. doi: 10.1097/CCM.0000000000000055. Crit Care Med. 2013. PMID: 24275419 No abstract available.
  • Evidence base for the use of corticosteroids in septic shock in children.
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  • The author replies.
    Carcillo JA; Surviving Sepsis Campaign Guidelines Pediatric Subcommittee, Children’s Hospital of Pittsburgh, Pittsburgh, PA. Carcillo JA, et al. Crit Care Med. 2014 Jan;42(1):e84-5. doi: 10.1097/CCM.0000000000000057. Crit Care Med. 2014. PMID: 24346553 No abstract available.

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