What are the management guidelines for sepsis and septic shock according to the Surviving Sepsis Guidelines 2021?

Management of Sepsis and Septic Shock According to Surviving Sepsis Guidelines 2021

The Surviving Sepsis Campaign Guidelines 2021 emphasize that sepsis and septic shock are medical emergencies requiring immediate treatment with early fluid resuscitation, prompt antimicrobial therapy, and ongoing hemodynamic support to reduce mortality and improve outcomes. 1

Initial Recognition and Resuscitation

Screening and Diagnosis

• Implement systematic screening for sepsis in high-risk patients 2, 1
• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures) before starting antimicrobials if no substantial delay occurs 2
• Use clinical assessment, laboratory values, and physiological monitoring to identify sepsis early 1

Initial Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion (downgraded from strong to weak recommendation in 2021) 1, 3
• Use balanced crystalloids rather than saline (new weak recommendation in 2021) 3
• Following initial fluid resuscitation, guide additional fluid therapy by frequent reassessment of hemodynamic status 2, 1
  • Use dynamic variables (passive leg raise, fluid challenges) rather than static variables when available 1
  • Continue fluid administration only as long as hemodynamic factors improve 1

Antimicrobial Therapy

Timing and Selection

• Administer IV antimicrobials within 1 hour of sepsis or septic shock recognition (strong recommendation) 2, 1
• Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, potentially fungal or viral) 2, 1
• New recommendation for uncertain diagnosis: If sepsis is possible but unlikely cause of organ dysfunction without shock, await focused diagnostics before broad-spectrum antibiotics; if unclear within 3 hours, administer antibiotics 4

Optimization and De-escalation

• Narrow antimicrobial therapy once pathogen identification and sensitivities are established or clinical improvement occurs 2
• Consider beta-lactam antibiotics as prolonged or continuous infusion after initial loading dose 4
• Reassess antimicrobial regimen daily for potential de-escalation 2
• Shorter rather than longer duration of antimicrobial therapy is preferred when appropriate 4
• Procalcitonin can support clinical decision to stop (not start) antibiotic treatment 4

Hemodynamic Support

Vasopressors

• Begin norepinephrine as first-choice vasopressor if fluid resuscitation inadequate to restore perfusion 1
• Target mean arterial pressure (MAP) of 65 mmHg 2, 1
• New weak recommendation: Consider peripheral initiation of vasopressors rather than delaying to obtain central venous access 3
• Consider adding vasopressin (0.03 units/minute) to norepinephrine to improve blood pressure or decrease norepinephrine requirements 1
• For refractory shock, consider epinephrine as additional agent 1, 5
  • Epinephrine dosing: 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired MAP 5
  • Adjust dosage every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min 5
  • After stabilization, wean incrementally over 12-24 hours 5

Corticosteroids

• Consider intravenous corticosteroids for septic shock when there is ongoing vasopressor requirement (new weak recommendation in 2021) 3

Source Control

• Identify source of infection as rapidly as possible 1
• Implement source control interventions as soon as logistically possible 4
• Remove intravascular access devices if potentially infected 1

Supportive Care

Ventilation Support

• Use lung-protective strategies for sepsis-induced ARDS (tidal volume of 6 mL/kg) 1

Nutrition

• Initiate early enteral feeding rather than complete fast or IV glucose only in patients who can be fed enterally 2
• Consider either early trophic/hypocaloric or early full enteral feeding; advance feeds according to patient tolerance 2
• Avoid routine monitoring of gastric residual volumes except in patients with feeding intolerance or high aspiration risk 2
• Consider prokinetic agents for feeding intolerance 2
• Consider post-pyloric feeding tubes for patients with feeding intolerance or high aspiration risk 2

Blood Transfusion

• Transfuse blood only when hemoglobin decreases below 7.0 g/dL in absence of active bleeding or other complications 1

Glucose Control

• Maintain glucose levels between 110-149 mg/dL (6.1-8.3 mmol/L) 1

Supplements to Avoid

• Do not use omega-3 fatty acids as immune supplement 2
• Do not use IV selenium 2
• Do not use arginine 2
• Do not use glutamine 2
• No recommendation about carnitine use 2

Long-Term Outcomes and Goals of Care (New Section in 2021)

• Discuss goals of care and prognosis with patients and families 2, 1
• Address goals of care early, no later than 72 hours after ICU admission 2, 3
• Screen for economic and social support needs and make appropriate referrals 3
• Use shared decision-making in post-ICU and hospital discharge planning 3
• Reconcile medications at both ICU and hospital discharge 3
• Provide written and verbal information about sepsis and its sequelae in hospital discharge summary 3
• Provide assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge 3

Implementation Considerations

• Establish hospital-based performance improvement programs for sepsis 2
• Use protocolized approaches to improve time to antibiotics and other critical interventions 6
• Ensure interdisciplinary and interprofessional collaboration for early recognition and treatment 4

The 2021 Surviving Sepsis Guidelines represent an evolution in sepsis management, with several new recommendations and modifications to previous guidance that aim to improve patient outcomes through evidence-based practices across the continuum of care.