Surviving Sepsis Campaign: International guidelines formanagement of severe sepsis and septic shock: 2008
R. Phillip Dellinger, MD; Mitchell M. Levy, MD; Jean M. Carlet, MD; Julian Bion, MD; Margaret M. Parker, MD; Roman Jaeschke, MD;Konrad Reinhart, MD; Derek C. Angus, MD, MPH; Christian Brun-Buisson, MD; Richard Beale, MD; Thierry Calandra, MD, PhD;Jean-Francois Dhainaut, MD; Herwig Gerlach, MD; Maurene Harvey, RN; John J. Marini, MD; John Marshall, MD; Marco Ranieri, MD;Graham Ramsay, MD; Jonathan Sevransky, MD; B. Taylor Thompson, MD; Sean Townsend, MD; Jeffrey S. Vender, MD;Janice L. Zimmerman, MD; Jean-Louis Vincent, MD, PhD; for the International Surviving Sepsis Campaign Guidelines Committee
*The correct citation for this article is as follows.Dellinger RP, Levy MM, Carlet, JM, et al: SurvivingSepsis Campaign: International guidelines for manage-ment of severe sepsis and septic shock: 2008 [pub-lished correction appears in
Crit Care Med
Crit Care Med
2008; 36:296–327.From Cooper University Hospital, Camden, NJ (RPD);Rhode Island Hospital, Providence, RI (MML); Hospital Saint-Joseph, Paris, France (JMC); Birmingham University, Bir-mingham, UK (JB); SUNY at Stony Brook, Stony Brook, NY(MMP);McMasterUniversity,Hamilton,Ontario,Canada(RJ);Friedrich-Schiller-University of Jena, Jena, Germany (KR);University of Pittsburgh, Pittsburgh, PA (DCA); Hopital HenriMondor, Créteil, France (CBB); Guy’s and St Thomas’ Hos-pital Trust, London, UK (RB); Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (TC); French Agency forEvaluation of Research and Higher Education, Paris, France(JFD); Vivantes-Klinikum Neukoelin, Berlin, Germany (HG);Consultants in Critical Care, Inc, Glenbrook, NV (MH); Univer-sity of Minnesota, St. Paul, MN (JJM); St. Michael’s Hospital,Toronto, Ontario, Canada (JM); Università di Torino, Torino,Italy (MR); West Hertfordshire Health Trust, Hemel Hemp-stead, UK (GR); The Johns Hopkins University School ofMedicine, Baltimore, MD (JS); Massachusetts General Hos-pital,Boston,MA(BTT);RhodeIslandHospital,Providence,RI(ST); Evanston Northwestern Healthcare, Evanston, IL (JSV);TheMethodistHospital,Houston,TX(JLZ);ErasmeUniversityHospital, Brussels, Belgium (JLV).Sponsoring organizations: American Association ofCritical-Care Nurses,* American College of Chest Physi-cians,* American College of Emergency Physicians,* Ca-nadian Critical Care Society, European Society of ClinicalMicrobiology and Infectious Diseases,* European Societyof Intensive Care Medicine,* European Respiratory Soci-ety,* Indian Society of Critical Care Medicine,** Interna-tional Sepsis Forum,* Japanese Association for AcuteMedicine, Japanese Society of Intensive Care Medicine;Society of Critical Care Medicine,* Society of HospitalMedicine,** Surgical Infection Society,* World Federationof Critical Care Nurses,** World Federation of Societies ofIntensive and Critical Care Medicine.** Participation andendorsement by the German Sepsis Society and the Latin American Sepsis Institute. *Sponsor of 2004 guidelines.**Sponsors of 2008 guidelines who did not participateformally in revision process. Members of the 2008 SSCGuidelines Committee are listed in Appendix I. Appendix Jprovides author disclosure information. Also published in
Intensive Care Medicine
(January2008).For information regarding this article, E-mail:Dellinger-Phil@CooperHealth.eduCopyright © 2007 by the Society of Critical CareMedicine
To provide an update to the original Surviving Sepsis Campaignclinical management guidelines, “Surviving Sepsis Campaign Guidelines for Man-agement of Severe Sepsis and Septic Shock,” published in 2004.
Modiﬁed Delphi method with a consensus conference of 55 interna-tional experts, several subsequent meetings of subgroups and key individuals,teleconferences, and electronic-based discussion among subgroups and amongthe entire committee. This process was conducted independently of any industryfunding.
We used the Grades of Recommendation, Assessment, Developmentand Evaluation (GRADE) system to guide assessment of quality of evidence fromhigh (A) to very low (D) and to determine the strength of recommendations. Astrong recommendation (1) indicates that an intervention’s desirable effectsclearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirableeffects is less clear. The grade of strong or weak is considered of greater clinicalimportance than a difference in letter level of quality of evidence. In areas withoutcomplete agreement, a formal process of resolution was developed and applied.Recommendations are grouped into those directly targeting severe sepsis, rec-ommendations targeting general care of the critically ill patient that are consid-ered high priority in severe sepsis, and pediatric considerations.
Key recommendations, listed by category, include early goal-directedresuscitation of the septic patient during the ﬁrst 6 hrs after recognition (1C);blood cultures before antibiotic therapy (1C); imaging studies performed promptlyto conﬁrm potential source of infection (1C); administration of broad-spectrumantibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsiswithout septic shock (1D); reassessment of antibiotic therapy with microbiologyand clinical data to narrow coverage, when appropriate (1C); a usual 7–10 daysof antibiotic therapy guided by clinical response (1D); source control with atten-tion to the balance of risks and beneﬁts of the chosen method (1C); administrationof either crystalloid or colloid ﬂuid resuscitation (1B); ﬂuid challenge to restoremean circulating ﬁlling pressure (1C); reduction in rate of ﬂuid administration withrising ﬁling pressures and no improvement in tissue perfusion (1D); vasopressorpreference for norepinephrine or dopamine to maintain an initial target of meanarterial pressure
65 mm Hg (1C); dobutamine inotropic therapy when cardiacoutput remains low despite ﬂuid resuscitation and combined inotropic/vasopres-sortherapy(1C);stress-dosesteroidtherapygivenonlyinsepticshockafterbloodpressure is identiﬁed to be poorly responsive to ﬂuid and vasopressor therapy(2C); recombinant activated protein C in patients with severe sepsis and clinicalassessment of high risk for death (2B except 2C for postoperative patients). In theabsence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage,target a hemoglobin of 7–9 g/dL (1B); a low tidal volume (1B) and limitation ofinspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respi-ratory distress syndrome (ARDS); application of at least a minimal amount ofpositive end-expiratory pressure in acute lung injury (1C); head of bed elevation inmechanically ventilated patients unless contraindicated (1B); avoiding routine useof pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanicalventilation and ICU length of stay, a conservative ﬂuid strategy for patients withestablished ALI/ARDS who are not in shock (1C); protocols for weaning andsedation/analgesia (1B); using either intermittent bolus sedation or continuousinfusion sedation with daily interruptions or lightening (1B); avoidance of neuro-muscular blockers, if at all possible (1B); institution of glycemic control (1B),targeting a blood glucose
150 mg/dL after initial stabilization (2C); equivalencyof continuous veno-veno hemoﬁltration or intermittent hemodialysis (2B); prophy-laxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to preventupper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors(1B); and consideration of limitation of support where appropriate (1D). Recom-mendations speciﬁc to pediatric severe sepsis include greater use of physicalexamination therapeutic end points (2C); dopamine as the ﬁrst drug of choice forhypotension (2C); steroids only in children with suspected or proven adrenalinsufﬁciency (2C); and a recommendation against the use of recombinant acti-vated protein C in children (1B).
There was strong agreement among a large cohort of interna-tional experts regarding many level 1 recommendations for the best current careof patients with severe sepsis. Evidenced-based recommendations regarding theacute management of sepsis and septic shock are the ﬁrst step toward improvedoutcomes for this important group of critically ill patients.K
: sepsis; severe sepsis; septic shock; sepsis syndrome; infection;Grades of Recommendation, Assessment, Development and Evaluation criteria;GRADE; guidelines; evidence-based medicine; Surviving Sepsis Campaign; sepsisbundles
1Crit Care Med 2008 Reprint