Approach to sepsis- a primary physician perspective

APPROACH TO SEPSIS MANAGEMENT

Thursday, September 17, 2015 1

WHAT THE PRIMARY PHYSICIAN SHOULD DO

Dr. A.P.Naveen Kumar

Chief Specialist (Gen. Med. )Visakha Steel General Hospital

Clinical impact of Severe Sepsis

†National Center for Health Statistics, 2001. §American Cancer Society, 2001. *American Heart Association. 2000. ‡Angus DC et al. Crit Care Med. 2001 (In Press).

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Polymicrobial sepsis shows higher risk for complication, length of stay and mortality than unimicrobial.

Thursday, September 17, 2015 3N Abed et al. Outcome of unimicrobial versus polymicrobial sepsis. Critical Care 2010, 14(Suppl 1):P62

(n=101) Unimicrobial infection Polymicrobial infection P value

Positive sputum 66% 71% 0.6

+ve blood culture 14% 51% 0.0001

UTI 6.3% 49.7% 0.0001

Wound infection 2.1% 20.7% 0.004

Acinetobacter/Candida/ E. coli

0.032

Mean hospital stay 17.4(+/- ) 9.3 days 26.9(+/- )15.4 days 0.001

Guide to Recommendations’ Strengths and Supporting Evidence: 1 = strong recommendation;1 = strong recommendation;

2 = weak recommendation or suggestion;2 = weak recommendation or suggestion;

A = good evidence from randomized trials;A = good evidence from randomized trials;

B = moderate strength evidence from small randomized trial(s) or B = moderate strength evidence from small randomized trial(s) or

multiple good observational trials;multiple good observational trials;

C = weak or absent evidence, mostly driven by consensus opinion.C = weak or absent evidence, mostly driven by consensus opinion.

Thursday, September 17, 2015 5Dellinger R P et al. Critical Care Medicine. 2013;41(2):580-637

Infection either

Bacteraemia (or viraemia/fungaemia/protozoan)is the presence of bacteria within the bloodstream

Septic focus (abscess / cavity / tissue mass)

SIRS –Systemic Inflammatory Response Syndrome

2/4 ofTemp >38 or <36

HR >90

Respiratory Rate >24 / mt.

WCC >12 or <4 or >10% bands (immature forms)

Definitions

SepsisSepsis is defined as the presence (probable or documented) of

infection together with systemic manifestations of infection(SIRS).


Definit ions

Severe sepsisSevere sepsis is defined as sepsis plus sepsis-induced

organ dysfunction or tissue hypoperfusion.


Organ System Involvement Circulation

Hypotension, increases in microvascular permeability Shock

Lung Pulmonary Edema, hypoxemia, ARDS

Hematologic DIC, coagulopathy (DVT)

Organ System Involvement GI tract

stress ulcer Translocation of bacteria, Liver Failure, Gastroparesis and ileus, Cholestasis

►Kidney Acute tubular necrosis, Renal Failure

Organ System Involvement Nervous System Encephalopathy

►Skeletal Muscle Rhabdomyolysis

Endocrine Adrenal insufficiency

1. Cardiovascular: Arterial systolic blood pressure < 90 mmHg or mean arterial pressure < 70 mmHg that responds to administration of intravenous fluid

2. Renal: Urine output <0.5 mL/kg per hour for 1 h despite adequate fluid resuscitation

3. Respiratory: PaO2/FIO2 < 250 or, if the lung is the

only dysfunctional organ < 200


OXYGEN DELIVERY

FiO2 PaO2/FiO2

Room air 0.21 476

1 Litre / mt. 0.24 416

2 Litre/ mt. 0.28 357

3 Litre/ mt. 0.32 312

4 Litre/ mt. 0.36 277

5 Litre/ mt. 0.40 250

6 Litre/ mt. 0.44 227

7 Litre / mt. 0.48 208

8 Litre / mt. 0.52 192

4. Hematologic: Platelet count <80,000/L or 50% decrease in platelet count from highest value recorded over previous 3 days

5. Unexplained metabolic acidosis: A pH < 7.30 or a base deficit 5.0 mEq/L and a plasma lactate level >1.5 times upper limit of normal for reporting lab

6. Adequate fluid resuscitation: Pulmonary artery

wedge pressure < 12 mmHg or central venous pressure < 8 mmHg


Definit ions

Sepsis-induced tissue hypoperfusion Sepsis-induced tissue hypoperfusion is

defined as infection-induced hypotension, elevated lactate, or

oliguria.


Definit ions

Septic shockSeptic shock is defined as sepsis-induced hypotension

persisting despite adequate fluid resuscitation.


Sepsis - SIRS + Infection

Severe Sepsis- Sepsis+ Organ dysfunction

Septic shock– Sepsis+ Hypotension despite fluid resuscitation

Critical illness–related corticosteroid insufficiency (CIRCI)

Inadequate corticosteroid activity for the patient's severity of illness; should be suspected when hypotension is not relieved by fluid administration


Multiple organ dysfunction syndrome Dysfunction of more than one organ,requiring

intervention to maintain hemostasis

Refractory Septic Shock

Septic shock that lasts for > 1 hr. and does not respond to fluids or pressor administration


Case -1

51 year old male Presented with fever, cough and breathlessness h/o streaky hemoptysis h/o orthopnea+ Known case of COPD Ethanolic Non DM /non smoker

Examination

Conscious and coherent Febrile, HR- 140/mt.,RR – 40/mt ,BP 100/70 Lungs – Bil. Rhonchi and crepts. CVS – Tachycardia CNS- no deficit

Investigations Hb.-13.6 ,TC – 24100 , DC – P94 L04 , Pl. -2.1 FBS – 225 mgs /dl ,Sr. Crea. – 1.8 mgs/dl , Urea –

49 mgs/dl LFT – 1.8 / 53 / 48 /93 ECG – sinus tachycardia CXR – Lt.basal consolidation SPo2 – 66

CAP with Sepsis

Case -2

54 year old female Fever with breathlessness Dysuria and decreased urination DM , HTN Febrile , HR- 112/mt. ,BP – 80/60 Lungs –clear ,CVS -NAD

Hb.- 10.2 , TC -18600 , DC-P88 L10 E2 FBS – 224 ,PPBS -336 ,Crea. – 1.8 Urine –plenty of pus cells CXR –NAD ECG –WNL

UROSEPSIS

CASE 3

64 year old male HTN ,CAD ,DM, LV Dysfunction Presented with breathlessness –PND + Cough ,low grade fever Afebrile ,HR-122/mt. ,RR -32/mt. ,BP- 70/50 Lungs – bil. Crepts ,CVS – LVS3+ tach.,JVP -↑

Hb. -12.6 ,TC- 12400 ,DC –P72 L22 E6 ,Pl. -2.3 FBS- 168 ,PPBS -224 ,Crea. – 1.2 ,LFT –N ECG - T L1, Avl , V 2-6↓ CXR – s/o CCF SPo2 - 86

Case 4

70 yrs male Fever, chills ,altered sensorium HR 108 / mt. , RR – 28 /mt. ,BP – 90/ 50 Tc -12200 , FBS -144, Crea. – 2.2 Na – 118 , K -2.9

Metabolic encephalopathy


Severe Sepsis: The Final Common Pathway

Endothelial Dysfunction and Microvascular Thrombosis

Hypoperfusion/Ischemia

Acute Organ Dysfunction (Severe Sepsis)

Death

High Risk Patients For Sepsis

Middle-aged, elderly Post op / post trauma Post splenectomy Transplant immune supressed Alcoholic / Malnourished Genetic predisposition Delayed appropriate antibiotics Comorbidities : AIDS, renal or liver failure, neoplasms

SYMPTOMS normo- or hypothermic,Hyperventilation

Disorientation, confusion, encephalopathy

Hypotension and DIC predispose to acrocyanosis and ischemic necrosis of peripheral tissues, most commonly the digits

Cellulitis, pustules, bullae, or hemorrhagic lesions may develop when hematogenous bacteria or fungi seed the skin or underlying soft tissue

vomiting, diarrhea, and ileus ,Stress ulceration , Cholestatic jaundice, acute hepatic injury or ischemic bowel necrosis


Init ial Resuscitation, Diagnosis, and Antibiotic Therapy

Recommend early goal-directed therapy:Recommend early goal-directed therapy:

Give early appropriate antibioticsGive early appropriate antibiotics

Give early appropriate fluidsGive early appropriate fluids

Give appropriate inotropic supportGive appropriate inotropic support

Take early culturesTake early cultures

Take early lactate levelTake early lactate level

Take early central venous oxygen saturation(SVO2) – pending the Take early central venous oxygen saturation(SVO2) – pending the

results of numerous ongoing trials.results of numerous ongoing trials.


The Bundles To be completed within 3 hrs

Measure lactate level

Obtain blood culture samples prior to administration of antibiotics.

Administer broad spectrum antibiotics.

Administer 30mL/Kg crystalloids for hypotension or lactate >/= 4

mmol/L.

Thursday, September 17, 2015v 36Dellinger R P et al. Critical Care Medicine. 2013;41(2):580-637

The Bundles

To be completed within 6 hrs Apply vasopressors (for hypotension that does not respond to

initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65 mm Hg.

In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/L (36 mg/dL):Measure central venous pressure (CVP)Measure central venous oxygen saturation (ScvO2)

Remeasure lactate if initial lactate was elevated

Targets for quantitative resuscitation included in the guidelines are CVP of 8 mm Hg, ScvO2 of 70%, and normalization of lactate


Screening for and Diagnosis of Sepsis

• Routine screening is recommended of potentially infected seriously ill

patients for severe sepsis to increase the early identification of sepsis

and allow implementation of early sepsis therapy (grade 1C).

• Obtaining appropriate cultures before antimicrobial therapy is

initiated if such cultures do not cause significant delay (> 45

minutes) in the start of antimicrobial(s) administration (grade 1C).


Currently available Biomarkers

WBC Lactate levels C-Reactive protein (CRP) Procalcitonin Cytokines New markers


LACTATE LEVELS

0.5-1 mmol/l – normal > 4 mmol/l - lactic acidosis Useful for monitoring response of septic patients Higher the lactate clearance better the prognosis


PROCALCITONIN LEVELS

Rises within 2-4 hrs. – peak - 8-24 hrs. Short half life of 24 hrs. independent of renal

function Normal - < 0.05 ng /l Tend to be low in viral infections Guidelines advocate PCT levels for

starting,continuing or stopping antibiotics


PCT LEVELS


NEWER MARKERS

Soluble CD 14 subtype ( Presepsin )

Heparin binding protein

Pentraxin

Macrophage migration inhibitory factor ( MIF )

Cytokine / Chemokine Biomarkers



No recommendation given for the use of procalcitonin

levels or other biomarkers (such as C-reactive protein) to

distinguish between severe infection and other acute inflammatory

states.

When no infection can be found during empiric antibiotic

therapy, consider using a low procalcitonin level as a supportive

tool for the decision to stop antibiotics (Grade 2C).



For patients at risk for fungal infection as a source for severe

sepsis, checking one of the newer tests for IFIs such as 1,3-

beta-D-glucan, galactomannan, or anti-mannan ELISA antibody

testing (Grade 2B/C).

Imaging studies be performed promptly in attempts to

confirm a potential source of infection(UG).


I.V. antibiotics Initiated as soon as cultures are drawn

Severe sepsis should receive broadspectrum antibiotic.

Empiric antifungal drug; Neutropenic patients, DM, chronic steroids.

Antibiotics

• Abx within 1 hr hypotension: 79.9% survival

• Survival decreased 7.6% with each hour of delay

• Mortality increased by 2nd hour post hypotension

• Time to initiation of Antibiotics was the single strongest predictor of outcome

Dosage for IV administration (N renal function)

Imipenem-cilastin 0.5g q 6h Meropenem 1.0g q 8h Piperacillin-tazobactam 3.375gq 4h or 4.5 g q 6h Cefepime 2 gms. 12 hr

Patients allergic to B lactums

Gatifloxacin 400mg iv q d Levofloxacin 500-750 mg 12 hrly.

plus clindamycin (600 mg q8h).Vancomycin (15 mg/kg q 12 hrly ) added to each of the

above regimes

Neutropenia (<500 neut./ L)

imipenem-cilastatin (0.5 g q6h) meropenem (1 g q8h) cefepime (2 g q8h);

piperacillin/tazobactam (3.375 g q4h) plus tobramycin (5–7 mg/kg q24h).

Vancomycin (15 mg/kg q 12 hrly ) added to each of the above regimes

Empirical anti fungal therapy 51

Splenectomy Cefotaxime (2 g q6–8h) or ceftriaxone (2 g q12h) B- lactum allergy - vancomycin (15 mg/kg q12h)

plus either moxifloxacin (400 mg q24h) or levofloxacin (750 mg q24h) or aztreonam (2 g q8h) should be used

IV drug user Vancomycin (15 mg/kg q12h)

AIDSCefepime (2 g q8h) or piperacillin-tazobactam

(3.375 g q4h) plus tobramycin (5–7 mg/kg q24h)Thursday, September 17, 2015 52

For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B).

A combination of beta-lactam and macrolide for patients with septic shock from bacteremic

Streptococcus pneumoniae infections (grade 2B).


Antimicrobial Therapy

The administration of effective intravenous antimicrobials within

the first hour of recognition of septic shock and severe sepsis

without septic shock (grade 1B/ 1C) should be the goal of therapy.

The initial empiric anti-infective therapy include one or more

drugs that have activity against all likely pathogens and that

penetrate in adequate concentrations into the tissues

presumed to be the source of sepsis (grade 1B).


Mortality associated with Sensitive vs Resistant GNB*

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Sensitive Resistant

Bochem PY, Intensive Care Med 2001

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*GNB-gram-negative bacilli

Enterobacteriacae

Pseudomonas

Anaerobes

Renal/hepatic function

Patient

condition

Co-existing medical illness

So many factors to consider

?Abscess

Resistance

patterns

Community vs hospital acquired infection

Monotherapy vs Combination

?Candida

Solomkin JS, Mazuski JE, et al. Clinical Infectious Diseases 2003 Mazuski JE, Sawyer RG et al. Surgical Infections 2002

% patients of sepsis with renal failure

Thursday, September 17, 2015 57Singh M et al. Pharmacologyonline . 2009;3: 597-605

Higher doses warranted in critical patients

Recent evidence states beta-lactam antibiotics should be above the MIC for > 70% dosing interval in serious infections


The antimicrobial regimen should be reassessed daily for

potential de-escalation to prevent the development of

resistance, to reduce toxicity, and to reduce costs (grade 1B).

Low procalcitonin levels or similar biomarkers should be used

to assist the clinician in the discontinuation of empiric

antibiotics in patients who appeared septic, but have no

subsequent evidence of infection (grade 2C).



Combination therapy, when used empirically in patients with severe

sepsis, should not be administered for longer than 3 to 5 days.

De-escalation to the most appropriate single-agent therapy should be

performed as soon as the susceptibility profile is known (grade 2B).

Exceptions would include aminoglycoside monotherapy, which

should be generally avoided, particularly for P. aeruginosa sepsis,

and for selected forms of endocarditis, where prolonged courses of

combinations of antibiotics are warranted.



the duration of therapy typically be 7 to 10 days if clinically

indicated.

Longer courses may be appropriate in patients who have a slow

clinical response, undrainable foci of infection, bacteremia with S.

aureus; some fungal and viral infections, or immunologic

deficiencies, including neutropenia (grade 2C).


Fluid Resuscitation Recommendations

Strong 1A recommendation for the use of crystalloids like

normal saline as the initial fluid resuscitation for people with severe

sepsis.

The initial fluid challenge should be 1L or more of crystalloid,

and a minimum of 30 mL/kg of crystalloid (2.1 L in a 70 kg or 154-

pound person) in the first 4-6 hours.



Incremental fluid boluses should be continued as long as

patients continue to improve hemodynamically (Grade 1C).

Weak recommendation adding albumin to initial fluid

resuscitation with crystalloid for severe sepsis and septic shock

(Grade 2B).



Authors strongly recommended not using hetastarches/

hydroxyethyl starches greater than 200 kDa in molecular

weight (Grade 1B).

They did not comment on the use of lower molecular

weight hetastarches or the use of gelatins; trials are ongoing

to evaluate these resuscitative agents.


Sepsis-induced hypotensionsystolic less than 90 mm Hg

or a reduction of more than 40 mm Hg from baseline in the absence of other causes of hypotension.”

1.A loss of plasma volume into the interstitial space,

2. Decreases in vascular tone, 3. myocardial depression.

Goals for initial resuscitation

Central venous pressure 8 to 12 mmHg.

Mean arterial pressure > 65 mmHg.

Urine output 0.5 mL per kg per hr.

Pulmonary capillary wedge pressure exceeds 18 mmHg

Treatment of Hypotension Intravenous fluids : Crystalloids vs. Colloids. need more than ‘maintenance’ + replace losses

Fluid Therapy

No mortality difference between;

colloid vs. crystalloid

Vasopressors and Inotrophic Therapy

The researchers recommend using norepinephrine as the first

choice vasopressor (Grade 1B)

Adding or substituting epinephrine when an additional drug is needed

to maintain adequate blood pressure (Grade 2B).

Vasopressin 0.03 units per minute may be added or

substituted for norepinephrine (Grade 2A).


Vasopressors and Inotrophic Therapy Dopamine was suggested as an alternative vasopressor, but only

in highly selected patients at very low risk of arrhythmias and with a low

cardiac output and/or low heart rate (Grade 2C).

Dobutamine infusion be started or added to a vasopressor in

myocardial dysfunction (elevated cardiac filling pressure and low cardiac

output) or ongoing signs of hypoperfusion, even after adequate

intravascular volume and mean arterial pressure are achieved (Grade 1C).

Low dose dopamine should not be used for renal protection

(grade 1A).


Source Control

A specific anatomical diagnosis of infection requiring

consideration for emergent source control should be sought and

diagnosed or excluded as rapidly as possible, and intervention

be undertaken for source control within the first 12 hr after

the diagnosis is made, if feasible (grade 1C).

In infected peripancreatic necrosis, definitive intervention is

best delayed until adequate demarcation of viable and

nonviable tissues has occurred (grade 2B).


Source Control

When source control in a severely septic patient is required, the

effective intervention associated with the least physiologic

insult should be used (eg, percutaneous rather than surgical

drainage of an abscess) (UG).

If intravascular access devices are a possible source of severe

sepsis or septic shock, they should be removed promptly

after other vascular access has been established (UG).


Infection Prevention

Selective oral decontamination (SOD) and selective digestive

decontamination (SDD) should be introduced and investigated as a

method to reduce the incidence of ventilator-associated pneumonia

(VAP); this infection control measure can then be instituted in

healthcare settings and regions where this methodology is found to

be effective (grade 2B).

Oral chlorhexidine gluconate (CHG) should be used as a form of

oropharyngeal decontamination to reduce the risk of VAP in ICU

patients with severe sepsis (grade 2B).


Blood Product Administration

Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration decreases to <7.0 g/dL to target a hemoglobin concentration of 7.0 –9.0 g/dL in adults (grade 1B).


Not using erythropoietin as a specific treatment of anemia associated with severe sepsis (grade 1B).

Fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).

• Not using antithrombin for the treatment of severe sepsis and septic shock (grade 1B).


Platelets

In patients with severe sepsis, administer platelets prophylactically when counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding.

We suggest prophylactic platelet transfusion when counts are < 20,000/mm3 (20 x 109/L) if the patient has a significant risk of bleeding. Higher platelet counts (≥50,000/mm3 [50 x 109/L]) are advised for active bleeding, surgery, or invasive procedures (grade 2D).


Supportive therapy for severe sepsis


Sedation, Analgesia, and neuromuscular Blockade

Either continuous or intermittent sedation should be minimized

in mechanically ventilated sepsis patients, targeting specific

titration endpoints (grade 1B).

NMBAs should be avoided if possible in the septic patient without

ARDS due to the risk of prolonged neuromuscular blockade

following discontinuation.

If NMBAs must be maintained, either intermittent bolus as

required or continuous infusion with monitoring of the depth of

blockade should be used (grade 1C).

A short course of an NMBA (≤ 48 hours) for patients with early,

sepsis-induced ARDS and Pao2/Fio2 < 150 mm Hg (grade 2C).Thursday, September 17, 2015 80

Steroids in Sepsis and Sepsis-Induced ARDS

In adult septic shock patients, it is suggested not to use IV

corticosteroids if fluid resuscitation or vasopressor therapy is able to

restore the patient to hemodynamic stability.

When hemodynamic stability cannot be achieved, the researchers

recommend IV hydrocortisone 200 mg daily given with

continuous infusion (Grade 2C).


Steroids in Sepsis and Sepsis-Induced ARDS ACTH stimulation test should not be used to identify adults with septic

shock who should receive hydrocortisone (grade 2B).

In treated patients hydrocortisone should be tapered when vasopressors

are no longer required (grade 2D).

Corticosteroids not to be administered for the treatment of sepsis in the

absence of shock (grade 1D).

When HC is given, continuous flow should be used(grade 2D).Thursday, September 17, 2015 82Dellinger R P et al. Critical Care Medicine. 2013;41(2):580-637

Mechanical Ventilation of Sepsis-Induced ARDS It is Suggested that clinicians target a tidal volume of 6 mL/kg predicted

body weight in pt with sepsis induced ARDS(grade1A) vs. 12 mL/kg.

Higher levels of PEEP in patients with severe ARDS (grade 2C).

The researchers suggest recruitment maneuvers in patients with severe

refractory hypoxemia (Grade 2C).

They also suggest prone positioning for patients with severe ARDS whose

PaO2 /FiO2 rates are less than 100 despite such maneuvers (Grade 2C).


Mechanical Ventilation of Sepsis-Induced ARDS It is suggested that noninvasive mask ventilation (NIV) be

used in that minority of sepsis-induced ARDS patients in whom the

benefits of NIV have been carefully considered and are thought to

outweigh the risks (grade 2B).

That a weaning protocol be in place.

Against the routine use of the pulmonary artery catheter

for patients with sepsis-induced ARDS (grade 1A).


Glucose Control

A protocolized approach when 2 consecutive blood glucose

levels are >180 mg/dL.

Should target an upper blood glucose ≤180 mg/dL rather

than an upper target blood glucose ≤ 110 mg/dL (grade 1A).

Blood glucose values be monitored every 1–2 hrs until

glucose values and insulin infusion rates are stable and then

every 4 hrs thereafter (grade 1C).


Tight Glycemic control

Continuous insulin infusion

Maintaining serum glucose levels between 120 and 180 mg/dl

Decreased mortality development of renal failure

Renal Replacement Therapy

Continuous renal replacement therapies and intermittent

hemodialysis are equivalent in patients with severe sepsis and

acute renal failure (grade 2B).

Use continuous therapies to facilitate management of fluid

balance in hemodynamically unstable septic patients (grade

2D).


Bicarbonate Therapy

Not using sodium bicarbonate therapy for the purpose of

improving hemodynamics or reducing vasopressor requirements in

patients with hypoperfusion-induced lactic acidemia with pH ≥7.15

(grade 2B).


Deep Vein Thrombosis Prophylaxis Patients with severe sepsis receive daily pharmacoprophylaxis

against venous thromboembolism (VTE) (grade 1B).

This should be accomplished with daily subcutaneous low-

molecular weight heparin (LMWH).

If creatinine clearance is <30 mL/min, use Dalteparin (grade

1A) or another form of LMWH that has a low degree of renal

metabolism (grade 2C) or UFH (grade 1A).


Deep Vein Thrombosis Prophylaxis Patients with severe sepsis be treated with a combination of

pharmacologic therapy and intermittent pneumatic

compression devices whenever possible (grade 2C).

Septic patients who have a contraindication for heparin use not

receive pharmacoprophylaxis (grade 1B), but receive mechanical

prophylactic treatment, (grade 2C), unless contraindicated.

When the risk decreases start pharmacoprophylaxis

(grade 2C).


Stress Ulcer Prophylaxis

Stress ulcer prophylaxis using H2 blocker or proton pump

inhibitor be given to patients with severe sepsis/septic shock who

have bleeding risk factors (grade 1B).

When stress ulcer prophylaxis is used, proton pump inhibitors

rather than H2RA (grade 2D)

Patients without risk factors do not receive prophylaxis (grade 2B).


Nutrit ion

Administer oral or enteral (if necessary) feedings, as

tolerated, rather than either complete fasting or provision of only

intravenous glucose within the first 48 hours after a diagnosis of

severe sepsis/septic shock (grade 2C).

Avoid mandatory full caloric feeding in the first week but

rather suggest low dose feeding (eg, up to 500 calories per day),

advancing only as tolerated (grade 2B).


Nutrit ion

Use intravenous glucose and enteral nutrition rather than total parenteral

nutrition (TPN) alone or parenteral nutrition in conjunction with enteral

feeding in the first 7 days after a diagnosis of severe sepsis/septic shock

(grade 2B).

Use nutrition with no specific immunomodulating

supplementation rather than nutrition providing specific

immunomodulating supplementation in patients with severe sepsis (grade

2C).


Setting Goals of Care

It is recommended that the goals of care and prognosis be

discussed with patients and families (grade 1B).

The goals of care be incorporated into treatment and end-of-

life care planning, utilizing palliative care principles where

appropriate (grade 1B).

The goals of care be addressed as early as feasible, but no

later than within 72 hrs of ICU admission (grade 2C).


SurgeryGet the pus out ofabscesses or foci of infection should be drained

Early definitive care ;e,.g; ruptured appendix, cholecystitis

Mortality

Sepsis: 30% - 50%

Septic Shock: 50% - 60%

SUMMARY AND FUTURE DIRECTIONS Though this document is static, the optimum treatment of severe

sepsis and septic shock is a dynamic and evolving process.

Additional evidence that has appeared since the publication of the 2008 guidelines allows more certainty in making severe sepsis recommendations; however, further programmatic clinical research in sepsis is essential to optimize these evidence-based medicine recommendations.

New interventions will be proven and established interventions may need modification.

This publication represents an ongoing process.

The Surviving Sepsis Campaign and the consensus committee members are committed to updating the guidelines regularly as new interventions are tested and results published.


Approach to sepsis- a primary physician perspective

Health & Medicine

Transcript of Approach to sepsis- a primary physician perspective