R. Phillip Dellinger, MD, MCCM, FCCPActing Chair & Chief of Department of MedicineHead, Division of Critical Care MedicineCooper University Hospital Camden, New Jersey

Professor of Medicine Cooper Medical School of Rowan University

What’s new with the 2012 guidelines and

associated changes in the database

R. Phillip Dellinger MD, MCCMChrista A. Schorr RN, MSN, FCCM

Cooper Medical School Rowan UniversityCooper University Hospital

Camden, NJ

Potential Conflicts of Interest

• Neither has direct or indirect potential financial conflict of interest as to any material presented in this presentation

• As to potential intellectual conflict of interest both hold leadership positions in Surviving Sepsis Campaign

R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung,

Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus,

Clifford S. Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup.

Crit Care Med 2013; 41:580-637 Intensive Care Medicine 2013; ..

Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012

Currently Funded with a Gordon and Betty Moore Foundation Grant

No direct or indirect industry support for guidelines revision

Grading Quality of EvidenceGRADE System

• A- high quality

• B- intermediate

• C- low

• D- very low

– Case series or expert opinion

• Upgrade capability

• Ungraded (UG) recommendation

Grading Strength of RecommendationGRADE System

• 1- strong recommendation – We recommend

• 2- weak recommendation – We suggest

Early Screening and a Performance Improvement Program

Antibiotic Therapy

• We recommend that intravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (1C).(Best Practice versus Stand of Care)

Resuscitation of Sepsis Induced Tissue Hypoperfusion

• Recommend MAP 65 mm Hg

FLUID THERAPY

Fluid therapy

1. We recommend crystalloids be used in the initial fluid resuscitation of severe sepsis (Grade 1B).

Fluid therapy

1. We suggest the use of albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (Grade 2C).

Fluid challenge

Initial fluid challenge in sepsis-induced tissue hypoperfusion (hypotension or elevated

lactate) A minimum of 30ml/kg of crystalloids

(a portion of this may be albumin equivalent). (1B)

Vasopressors

Vasopressors

1. We recommend norepinephrine as the first choice vasopressor (Grade 1 B).

Vasopressors

2. We suggest epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain blood pressure (Grade 2B).

Vasopressors

3. Vasopressin .03 units/min can be added to norepinephrine with the intent of raising MAP to target or decreasing or decreasing norepinephrine dosage.

(UG)

Phenylephrine

Pure vasopressor and in general not recommended

Sepsis Induced Tissue Hypoperfusion(Recommend Quantitative

Resuscitation) Requirement for vasopressors after fluid

challenge

or

Lactate ≥ 4 mg/dL

Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion

Recommend Insertion central venous catheter• Central venous pressure: 8–12 mm Hg

• Higher with altered ventricular compliance or increased intrathoracic pressure

Grade 1C

Arterial Systolic Pressure Variation

Parry-Jones, et al. Int J Respir Crit Care Med 2003;2:67

Part

At

Effect on Stroke Volume

Effect on Stroke Volume

Effect on Cardiac Filling

Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion

Recommend Insertion central venous catheter• ScvO2 saturation (SVC) 70%Grade 1C

Lactate Clearance

In patients with elevated lactate levels as amarker of tissue hypoperfusion we suggesttargeting resuscitation to normalize lactate asrapidly as possible (grade 2C).