The Surviving Sepsis Campaign, a collaboration among the U.S. Society of Critical Care Medicine (SCCM), the European Society of Intensive Care Medicine, and the International Sepsis Forum, released updates to its sepsis guidelines during its 42nd Critical Care Congress in January 2013. Thirty international professional organizations support the new guidelines.
Sepsis is a systemic response to infection that can eventually progress to severe sepsis and septic shock. Both outcomes are serious and affect millions of people around the world each year. One in four dies.
Some of the strongest recommendations announced related to fluid resuscitation and vasopressor therapy. The new guidelines strongly recommend the use of crystalloids, such as normal saline, for initial fluid resuscitation in severe sepsis cases. The recommended initial fluid challenge should be 1 liter or more with a minimum of 30 mL/kg in the first 4 to 6 hours. The campaign also strongly recommends the use of hetastarches/hydroxyethyl starches greater than 200 kDa in molecular weight. Another recommendation urges the continuation of incremental fluid boluses as long as the patient’s blood pressure or delta pulse pressure continues to improve. Other recommendations for fluid resuscitation include adding albumin to initial fluid resuscitation.
New Recommendations for Vasopressors and Inotropes
Recommendations for vasopressors and inotropes encouraged the use of norepinephrine (Levophed) as the first choice for vasopressor therapy. Vasopressin can be administered as an alternate to norepinephrine or may be added to it. Epinephrine is recommended when a second agent is needed.
Administering dopamine was recommended only in patients with low heart rate or cardiac output whose risk for arrhythmias was very low. Dobutamine should be administered either alone or in addition to a vasopressor in patients with cardiac dysfunction after blood pressure is restored through fluid resuscitation.
The new guidelines specify that intravenous corticosteroid therapy should be provided to patients if fluid resuscitation and vasopressors cannot restore blood pressure. For patients with vasopressor-refractory septic shock, a continuous intravenous infusion of hydrocortisone that totals 200 mg over 24 hours was included in the new guidelines.
Other Guidelines in Special Cases
Several suggestions for patients with acute respiratory distress syndrome (ARDS) due to severe sepsis were based on consensus opinion and included the use of recruitment maneuvers for patients with severe hypoxemia and prone positioning. Other recommendations included normalizing lactate levels if central venous oxygenation monitoring is not available, administering one of the newer assays for invasive candidiasis for patients at risk for fungal infection (as a source for severe sepsis) and, when no infection can be found during empiric antibiotic therapy, using a low procalcitonin level to substantiate the decision to stop antibiotics.
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