2012 Sepsis Guidelines Overview

1. Wes Theurer, DO 2012 Sepsis GuidelinesOverview

2. Objectives • Recognize sepsis early • Understand therapeutic principles • Cultures before antibiotics • Crystalloid fluid resuscitation • Antimicrobials • Vasopressor agents • Role of imaging and other cultures

3. Recognition • Sepsis: • suspected infection + systemic manifestations • See Table 1

4. Severe Sepsis Defintion • Severe Sepsis: acute organ dysfunction secondary to documented or suspected infection • Septic Shock: severe sepsis not reversed with fluid resuscitation

5. More definitions • Sepsis-induced hypotension • systolic blood pressure (SBP) < 90 mm Hg or mean arterial pressure (MAP) < 70 mm Hg or a SBP decrease > 40mm Hg or less than two standard deviations below normal for age in the absence of other causes of hypotension. • Sepsis-induced tissue hypoperfusion • infection-induced hypotension that persists after fluid challenge, elevated lactate, or oliguria.

8. Cultures • How many? • Two (1 or 2 percutaneous, one from every pre-existing line) • Do it before IV Antimicrobials • Draw a lactate while you’re at it

9. Crystalloid • Crystalloid (1B) – 30mL/kg (or more) (1C) • Albumin for those who continue to require lots of crystalloid (2C) • DON’T use hetastarch (1C) • If not responsive to fluids  vasopressors

10. Kill the Bugs • Antimicrobials within one hour! • Which ones? • Many options – probably need combination

11. Most common organisms • Gram positive bacteria • Gram negative bacteria • Mixed bacterial organisms Viral and fungal are not as common but should be considered.

12. Antibiotics • Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrug- resistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B). • 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).?

13. Abx stuff continued • Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B). • Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, un-drainable foci of infection, bacteremia with S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia (grade 2C). • Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C). • Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause (UG).

14. Vasopressor Agents • Norepinephrine – 1st choice vasopressor (to MAP >65 mm HG) (1B) • Epinephrine – 2nd line/additional agent (2B) • Vasopressin (0.03 U/min) can be added (UB)

15. Vasopressor agents continued • Dopamine is not recommended (highly select circumstances) (2C) • Dobutamine if myocardial dysfunction (low filling pressures/ cardiac output) (1C) • IV Hydrocortisone – don’t use if fluids and vasopressor therapy work (2C)

16. Imaging & other cultures • Prompt imaging studies (to confirm source) • Cultures of other sites if doing so does not cause significant delay in antibiotic administration (grade 1C).

18. Sim Day Suggestion • Rapid Recognition • Treatment • ABC’s • IV, O2, Monitor • Crystalloid resuscitation • Blood Cultures, Lactate • Broad spectrum antimicrobials • Imaging and other cultures judiciously • Vasopressors if not responsive to crystalloid • Early consultation

19. Summary • Recognize sepsis early • Understand therapeutic principles • Cultures before antibiotics • Crystalloid fluid resuscitation (30mL/kg) • Broad spectrum antimicrobials within 1 hour • Vasopressor agents when crystalloid not enough • Image to confirm infection source • Other cultures if no delay for antibiotics

20. Key Recommendations • Early quantitative resuscitation within 6 hrs of recognition • Blood cultures before antibiotics (1C) • Prompt imaging studies (to confirm source) • Broad spectrum antibiotics within 1 hour of recognition(1B) • Goal: severe sepsis without septic shock • Crystalloid (initial fluid) (1B) – 30mL/kg (or more) (1C) • Albumin for those who continue to require lots of crystalloid (2C) • DON’T use hetastarch (1C) • Norepinephrine – 1st choice vasopressor (to MAP >65 mm HG) (1B) • Epinephrine – 2nd line/additional agent (2B) • Vasopressin (0.03 U/min) can be added last (UB) • Dopamine is not recommended (highly select circumstances) (2C) • Dobutamine if myocardial dysfunction (low filling pressures/ cardiac output) (1C) • IV Hyxrocortisone – don’t use if fluids and vasopressor therapy work (2C) • Hemoglobin goal: 7-9 g/dL (unless other complication (1B)

21. Reference • Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 • Critical Care Medicine • February 2013. Vol. 41. No.2