Skip to main content

Table 1 Surviving Sepsis Campaign 2016 Recommendations [36]

From: Sepsis in the burn patient: a different problem than sepsis in the general population

A. Initial resuscitation
 1. Sepsis and septic shock are emergencies – treatment should start immediately
 2. Hypoperfusion – give 30 ml/kg IV crystalloid within 3 h
 3. After fluids, additional fluids depend on reassessment of hemodynamic status
 4. Further hemodynamic assessment (cardiac function) if clinical exam not helpful
 5. Prefer dynamic over static variables be used to assess hemodynamic status
 6. Target MAP 65 mmHg when using pressors
 7. Aim to lower lactate to normal levels
B. Screening for sepsis and performance improvement
 1. Hospitals should have a performance improvement program for sepsis – including sepsis screening
C. Diagnosis
 1. Appropriate cultures should be obtained before starting antimicrobial therapy
D. Antimicrobial therapy
 1. Start IV antimicrobials within one hour of diagnosis of sepsis and septic shock
 2. Start empiric broad-spectrum therapy to cover likely pathogens
 3. Narrow coverage once pathogens are identified and sensitivities are established, or clinical improvement
 4. Recommend against sustained antimicrobial prophylaxis in patients with severe inflammatory states (burns, pancreatitis)
 5. Optimize dosing based on pharmacokinetic and pharmacodynamic principles
 6. Start empiric combination therapy (at least two of different classes) aimed at likely organisms for septic shock
 7. Do not use combination therapy for other serious infections (sepsis, bacteremia)
 8. Do not use combination therapy for neutropenic sepsis
 9. De-escalate combination therapy within first few days in response to improvement for septic shock
 10. Treatment for 7–10 days is adequate for most infections causing sepsis/septic shock
 11. Longer courses are appropriate in patients with slow response, undrainable foci of infection, bacteremia with S. aureus, some fungi or viruses, or immunologic deficiencies
 12. Shorter courses are appropriate for patients with rapid resolution following source control
 13. Daily assessment for de-escalation
 14. Procalcitonin can be used to shorten therapy
 15. Procalcitonin can be used to support discontinuation of antibiotics
E. Source control
 1. Search for a diagnosis that can be treated with source control (i.e., abscess, infected wound)
 2. Remove intravascular access devices that could be a cause of sepsis as soon as possible (change lines)
F. Vasoactive medications
 1. Norepinephrine is the first choice for vasopressor
 2. Add vasopressin (up to 0.03 units/min) or epinephrine to norepinephrine next
 3. Use dopamine only in highly selected patients (low risk for tachyarrhythmias and bradycardia)
 4. Do not use dopamine for renal protection
 5. Use dobutamine in patients with persistent hypoperfusion despite adequate volume status and use of vasopressors
 6. Arterial lines should be placed if on vasopressors
G. Fluid therapy
 1. Continue fluid challenges as long as hemodynamic factors improve
 2. Use crystalloids as fluid of choice for initial resuscitation and subsequent volume replacement
 3. Use balanced crystalloids or saline for fluids
 4. Add albumin to crystalloids when patients require large volumes
 5. Do not use hydroxyethyl starches
 6. Crystalloids are preferred over gelatins
H. Corticosteroids
 1. Do not use steroids if fluids and vasopressors are effective. If not, IV hydrocortisone at 200 mg/day
I. Blood products
 1. Transfuse blood only when hemoglobin <7.0 mg/dL (except in extenuating circumstances – myocardial ischemia, severe hypoxemia, acute hemorrhage)
 2. Do not use erythropoietin for anemia
 3. Do not use fresh frozen plasma to correct clotting abnormalities in the absence of bleeding or planned invasive procedure
 4. Transfuse platelets when <10,000/mm3, and when <20,000 mm3 if at risk for bleeding, ≥50,000 mm3 for active bleeding, surgery or invasive procedures
J. Immunoglobulins
 1. Do not use IV immunoglobulins for sepsis/septic shock
K. Blood purification
 1. No recommendation about blood purification
L. Anticoagulants
 1. Do not use antithrombin for sepsis/septic shock
M. Mechanical Ventilation (for sepsis-induced ARDS in adults)
 1. Target tidal volume of 6 mL/kg predicted body weight (not 12 mL/kg)
 2. Use upper limit goal for plateau pressures of 30 cm H2O
 3. Use higher PEEP over lower PEEP
 4. Use recruitment maneuvers
 5. Use prone position over supine if P/F <150
 6. Do not use high-frequency oscillatory ventilation
 7. No recommendation about noninvasive ventilation
 8. Use neuromuscular blocking agents for ≤48 h if P/F < 150
 9. Use a conservative fluid strategy if no hypoperfusion
 10. Do not use β-2agonists if no bronchospasm
 11. Do not use a pulmonary artery catheter for sepsis-induced ARDS in adults
 12. Use lower tidal volumes in sepsis-induced respiratory failure without ARDS
 13. Elevate the head of bed to 30°–45° in ventilated patients
 14. Use spontaneous breathing trials in ventilated patients
 15. Use weaning protocols in patients who can tolerate weaning
N. Sedation and Analgesia
 1. Minimize continuous or intermittent sedation in ventilated patients
O. Glucose control
 1. Use a protocol for glucose control when two consecutive glucoses >180 mg/dL (not 110)
 2. Monitor glucoses every 1–2 h until stable, then every 4 h if on insulin infusion
 3. Interpret point-of-care glucoses with caution
 4. Use arterial over capillary blood if arterial line present
P. Renal replacement therapy
 1. Use either continuous or intermittent renal replacement therapy
 2. Use continuous renal replacement therapy if hemodynamically unstable
 3. Do not use renal replacement therapy just for increased creatinine or oliguria without other definitive indications for dialysis
Q. Bicarbonate therapy
 1. Do not use sodium bicarbonate with lactic acidemia with pH ≥ 7.15
R. Venous thromboembolism prophylaxis
 1. Use pharmacologic prophylaxis (UFH or LMWH) in the absence of contraindications
 2. Use LMWH rather than UFH
 3. Combine pharmacologic prophylaxis and mechanical prophylaxis whenever possible
 4. Use mechanical prophylaxis when pharmacologic prophylaxis is contraindicated
S. Stress ulcer prophylaxis
 1. Give stress ulcer prophylaxis to patients at risk for GI bleeding
 2. Use either proton pump inhibitors or histamine-2 receptor antagonists
 3. Do not use stress ulcer prophylaxis in patients without risk factors for GI bleeding
T. Nutrition
 1. Do not use parenteral feedings if enteral feedings possible
 2. Do not provide parenteral nutrition for the first 7 days if enteral feedings not possible (advance enteral feedings as tolerated)
 3. Start early enteral feedings if possible
 4. Start early trophic/hypocaloric or early full feedings (advance as tolerated)
 5. Do not use omega-3 fatty acids
 6. Do not check routine gastric residual volumes (but check if feeding intolerance or high risk for aspiration – applies to nonsurgical patients)
U. Setting goals of care
 1. Goals of care and prognosis should be discussed with the patient and families
 2. Goals of care should be incorporated into treatment and end-of-life planning, using palliative care principles when appropriate
 3. Address goals of care as early as feasible, but no later than 72 h after ICU admission
  1. IV Intravenous, MAP Mean arterial pressure, S. aureus Staphylococcus aureus, dl deciliter, ARDS acute respiratory distress syndrome, PEEP positive end expirato ry pressure, P/F PaO2/FIO, UFH unfractionated heparin, LMWH Low molecular weight heparin, GI gastrointestin al, ICU intensive care unit