What are the recommendations for managing sepsis according to the Surviving Sepsis study?

Surviving Sepsis Campaign Guidelines: Key Findings and Recommendations

Immediate Recognition and Initial Resuscitation

Sepsis and septic shock are medical emergencies requiring immediate treatment and resuscitation. 1

First 3 Hours - Aggressive Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion (hypotension persisting after initial fluid challenge or lactate ≥4 mmol/L). 1
• Use crystalloids as the fluid of choice for initial resuscitation and subsequent volume replacement. 1
• Avoid hydroxyethyl starches for intravascular volume replacement. 1
• Consider balanced crystalloids or saline for fluid resuscitation. 2

Hemodynamic Monitoring and Targets

• Target mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors. 1
• Following initial fluid resuscitation, guide additional fluids by frequent reassessment of hemodynamic status through thorough clinical examination (heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, urine output). 1
• Use dynamic variables over static variables to predict fluid responsiveness when available. 1
• Target lactate normalization in patients with elevated lactate levels as a marker of tissue hypoperfusion. 1

Critical Evolution from 2012 to 2016 Guidelines

The 2016 guidelines represent a major shift away from the original protocolized early goal-directed therapy (EGDT):

• Eliminated central venous pressure (CVP) targets (previously 8-12 mmHg). 1
• Eliminated central venous oxygen saturation (ScvO2) targets (previously 70%). 1
• Eliminated urine output targets (previously ≥0.5 mL/kg/hr). 1
• Moved toward individualized, dynamic assessment rather than rigid numerical targets. 1

Antimicrobial Therapy

Timing and Selection

• Administer IV antimicrobials within 1 hour of recognition of septic shock and severe sepsis. 1
• Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, fungal, viral as appropriate). 1
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before antibiotics, but never delay antimicrobials beyond 45 minutes if cultures cannot be obtained. 1

De-escalation Strategy

• Reassess antimicrobial therapy daily for potential narrowing once pathogen identification and sensitivities are available. 1
• Typical duration is 7-10 days guided by clinical response. 1

Vasopressor Therapy

• Norepinephrine is the first-choice vasopressor to maintain MAP ≥65 mmHg. 1
• Epinephrine should be added when an additional agent is needed to maintain adequate blood pressure. 1
• Vasopressin (0.03 U/min) can be added to norepinephrine to either raise MAP to target or decrease norepinephrine dose, but should not be used as the initial vasopressor. 1
• Dopamine is not recommended except in highly selected circumstances. 1
• Dobutamine should be administered or added to vasopressor in the presence of myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite adequate intravascular volume and MAP. 1

Source Control

• Identify the specific anatomic diagnosis of infection requiring source control as rapidly as possible. 2
• Implement required source control intervention as soon as medically and logistically practical after diagnosis, ideally within 12 hours. 3
• Perform imaging studies promptly to confirm potential sources of infection. 1
• Use the least invasive effective approach for source control. 2

Corticosteroid Therapy

• Consider IV hydrocortisone only for patients with septic shock unresponsive to fluid resuscitation and vasopressor therapy. 2, 3
• Avoid corticosteroids for sepsis without shock. 2
• This represents a more conservative approach compared to earlier guidelines. 1

Blood Product Management

• Transfuse red blood cells only when hemoglobin decreases to <7.0 g/dL in the absence of extenuating circumstances (tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage). 2, 3
• Target hemoglobin of 7-9 g/dL. 1
• Avoid erythropoietin for treating sepsis-associated anemia. 2

Mechanical Ventilation for Sepsis-Induced ARDS

• Use low tidal volume ventilation (6 mL/kg predicted body weight) for patients with sepsis-induced ARDS. 2, 3
• Limit plateau pressures to ≤30 cm H₂O in patients with ARDS. 2, 3
• Apply higher PEEP in patients with moderate to severe ARDS. 2
• Position patients semi-recumbent (head of bed 30-45°) unless contraindicated. 3

Nutritional Support

Enteral Feeding Strategy

• Initiate early enteral feeding rather than complete fasting or IV glucose alone in critically ill patients with sepsis or septic shock who can be fed enterally. 1
• Consider either early trophic/hypocaloric or early full enteral feeding; if trophic/hypocaloric feeding is the initial strategy, advance feeds according to patient tolerance. 1

Feeding Intolerance Management

• Avoid routinely monitoring gastric residual volumes, but measure gastric residuals in patients with feeding intolerance or who are at high risk of aspiration. 1
• Use prokinetic agents in patients with feeding intolerance. 1
• Consider placement of post-pyloric feeding tubes in patients with feeding intolerance or who are at high risk of aspiration. 1

Supplements to Avoid

• Do not use omega-3 fatty acids as an immune supplement. 1
• Do not use IV selenium to treat sepsis and septic shock. 1
• Do not use glutamine to treat sepsis and septic shock. 1
• Avoid arginine to treat sepsis and septic shock. 1

Metabolic Management

• Target blood glucose ≤180 mg/dL using a protocolized approach after initial stabilization. 3
• This represents a less aggressive target compared to earlier recommendations of <150 mg/dL. 1

Performance Improvement and Screening

• Hospitals should implement a performance improvement program for sepsis, including sepsis screening protocols for acutely ill, high-risk patients. 1, 2
• Establish multidisciplinary teams including physicians, nurses, pharmacy, and respiratory therapy. 3
• Use sepsis bundles and protocols with regular education and performance feedback. 3

Goals of Care and Palliative Care Integration

• Discuss goals of care and prognosis with patients and families as early as feasible, but no later than within 72 hours of ICU admission. 1, 3
• Incorporate goals of care into treatment and end-of-life care planning, utilizing palliative care principles where appropriate. 1, 3

Common Pitfalls to Avoid

• Failing to obtain appropriate cultures before starting antibiotics while simultaneously avoiding delays beyond 45 minutes. 1, 2
• Inadequate initial fluid resuscitation (less than 30 mL/kg in first 3 hours) or excessive fluid administration without proper reassessment. 2
• Delayed source control for infections requiring intervention beyond 12 hours. 2
• Failure to de-escalate antibiotics when appropriate after pathogen identification. 2
• Inappropriate use of vasopressors without adequate fluid resuscitation first. 2
• Overlooking the importance of early enteral nutrition and continuing complete fasting. 2
• Neglecting to discuss goals of care with patients and families within 72 hours. 2
• Using static variables alone (like CVP) to guide fluid resuscitation rather than dynamic assessment. 1