Sepsis and Septic Shock: Updated Management Guidelines

Researchers have updated the 2012 sepsis and septic shock management guidelines based on the results of recent clinical trials.
Researchers have updated the 2012 sepsis and septic shock management guidelines based on the results of recent clinical trials.

In a joint effort involving the Surviving Sepsis Campaign (SSC), the Society of Critical Care Medicine,  and the European Society of Intensive Care Medicine,  a 2016 guideline update for the management of sepsis and septic shock was recently released and published in JAMA.1    

Using the GRADE (grading of recommendations, assessment, development, and evaluations) method for evidence-based medicine, members of the guideline committee—including 55 clinician experts from 25 international organizations—reviewed the previous guidelines and associated evidence to create the 2016 guideline update, which includes 93 recommendations on the early management of sepsis and septic shock.

Since 2012, there has been “substantial evolution” in the understanding of early goal-directed therapy (EGDT) in sepsis management. Multiple clinical trials2-4 found that although EGDT is safe, it is “not superior to usual, nonprotocolized care,” noted guideline synopsis authors Michael D. Howell, MD, MPH, and Andrew M. Davis, MD, MPH, both of the University of Chicago department of medicine.

“Because infection causes sepsis, managing infection is perhaps the most critical component of sepsis therapy,” they explained. “Mortality increases even with very short delays of antimicrobials. To optimize the risk-benefit profile, the strategy of initial broad-spectrum therapy requires meticulous attention to antimicrobial stewardship, including early appropriate cultures and daily review to reduce or stop antimicrobials.”

In an accompanying viewpoint article,5 Daniel De Backer, MD, from the department of intensive care at the Universite Libre de Bruxelles in Brussels, Belgium, and Todd Dorman, MD, PhD, of the department of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, covered additional developments penned by the SSC, such as the Sepsis in Resource Limited Nations initiative, aimed at improving the quality and reliability of patient-centered care in developing nations.

“This fourth revision of the SSC guidelines…should prove helpful for clinicians to continue to improve the care of patients with sepsis and improve the outcome of critically ill patients,” Drs De Backer and Dorman wrote.

Selected major recommendations from the updated guidelines are listed below: 

Managing Infection
Antibiotics: Initiation of broad-spectrum intravenous antimicrobial pharmacotherapy covering all likely pathogens within 1 hour of sepsis diagnosis (strong recommendation; moderate quality of evidence [QOE]).
Source control: Achieve effective anatomic source control in a timely manner (best practice statement [BPS]).
Antibiotic stewardship: Repeat assessments for possible antimicrobial de-escalation on a daily basis; tailor antimicrobial therapy using results from cultures and tracking patient response to treatment (BPS).
Managing Resuscitation
Administer 30 mL/kg of intravenous crystalloid solution within 3 hours of diagnosing sepsis-induced hypoperfusion (strong recommendation; low QOE), administering additional fluid after reassessing patient‘s hemodynamic status (BPS), ideally guided by dynamic variable measurements (weak recommendation; low QOE).
Resuscitation targets: An MAP of 65 mm Hg should be targeted in patients with septic shock necessitating vasopressor treatment (strong recommendation; moderate QOE).
Vasopressors: Norepinephrine should be used as the first-line vasopressor of choice (strong recommendation; moderate QOE).
Mechanical Ventilation in Patients With Sepsis-Related Acute Respiratory Distress Syndrome
A tidal volume of 6 mL/kg of predicted body weight (strong recommendation; high QOE) with a maximum plateau pressure of ≤30 cm H2O (strong recommendation, moderate QOE) should be used in patients with sepsis-related acute respiratory distress syndrome requiring mechanical ventilation.
Formal Improvement Programs
Hospitals and health systems should implement programs to improve sepsis care that include sepsis screening (BPS).

References

  1. Howell MD, Davis AM. Management of sepsis and septic shock [published online January 19, 2017]. JAMA. doi: 10.1001/jama.2017.0131
  2. Yealy DM, Kellum JA, Huang DT, et al; for the ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. doi: 10.1056/NEJMoa1401602
  3. Mouncey PR, Osborn TM, Power S, et al; for the ProMISe Investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301-1311. doi: 10.1056/NEJMoa1500896
  4. Peake SL, Delaney A, Bailey M, et al; for the ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496-1506. doi: 10.1056/NEJMoa1404380
  5. De Backer D, Dorman T. Surviving sepsis guidelines. A continuous move toward better care of patients with sepsis [published online January 19, 2017]. JAMA. doi: 10.1001/jama.2017.0059
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