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 |