Summaryofthe2012SurvivingSepsisRecommendations

Dellingeretal.SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2012.CritCareMed.2013;41(2):580637

AnnotatedbyGeorgeChen,DOMPH(January25,2013)

TABLEOFCONTENTS

Definitions&DiagnosticTriggersforInitialResuscitationBundle

SepsisDiagnosticCriteria

INITIALRESUSCITATIONBUNDLE(mostimportantpage)

DetailedNotationoftheAdult2012Recommendations

DetailedNotationofthePediatric2012Recommendations

ARDSNET&ALVEOLITrialVentilatorManagementProtocols

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2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO1|P a g e

Summaryofthe2012SurvivingSepsisRecommendations
Delingeretal.SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2012.CritCareMed.2013;41(2):580637

AnnotatedbyGeorgeChen,DOMPH(January25,2013)

Definition&DiagnosticTriggersforstartingInitialResuscitationBundle(meetinganyofthe3boldeddefinitions)
(Sepsis=infection+systemicmanifestationsofinfection)
Severesepsis=sepsis+sepsisinducedorgandysfunctionortissuehypoperfusion(withanyofthebelowsigns)
1. Sepsisinducedhypotension=SBP<90mmHgorMAP<70mmHgorSBPdecrease>40mmHgorlessthan2
standarddeviationbelownormalforageintheabsenceofothercauseforhypotension
2. Lactateabovetheupperlimitofnormal
3. UoP<0.5mL/Kg/hrformorethan2hoursdespiteadequatefluidresuscitation
4. AcutelunginjurywithPaO2/FiO2<250intheabsenceofPNAasinfectionsource
5. AcutelunginjurywithPaO2/FiO2<200inthepresenceofPNAasinfectionsource
6. Cr>2mL/dL
7. TBili>2mg/dL
8. Platelet<100K
9. INR>1.5
Septicshock=persistentsepsisinducedhypotensiondespiteadequatefluidresuscitation.
Sepsisinducedtissuehypoperfusion=Sepsisinducedhypotensiondespitefluidchallenge,or,BloodLactate 4mmol/L
SepsisDiagnosticCriteria
1. Vitalsigns:
a. Temperature:Fever>38.3Corhypothermia<36C
b. HR:>90/min,ormorethan2standarddeviationabovenormalforage
c. Tachypnea
d. Alteredmentalstatus
e. Significantedemaorpositivefluidbalance>20mL/Kgover24hrs
f. Hyperglycemia>140mg/dLintheabsenceofdiabetesmellitus
2. Inflammatorymarkers:
a. WBC:>12Kor<4K
b. NormalWBCcountwith>10%immatureforms
c. CRP>2standarddeviationabovenormalvalue
d. Procalcitonin>2standarddeviationabovenormalvalue
3. Hemodynamic
a. SBP<90mmHg,MAP<70mmHgorSBPdecrease>40mmHginadultsorlessthan2standarddeviation
belownormalforage
4. Organdysfunction
a. Arterialhypoxemia(PaO2/FiO2<300)
b. AcuteOliguria(UoP<0.5mL/Kg/hrforatleast2hoursdespiteadequatefluidresuscitation)
c. Crincrease>0.5mg/dLor44.2mol/L
d. Coagulopathy:INR>1.5oraPTT>60sec
e. Ileus(nobowelsounds)
f. Thrombocytopenia:PLT<100K
g. Hyperbilirubinemia:TBili>4mg/dL
5. Tissueperfusion
a. Lactate>1mmol/L
b. Decreasecaprefillormottling
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO2|P a g e

2012INITIALRESUSCITATIONBUNDLE
1. Completedwithin3hoursofdiagnosis
a. DrawLactate
b. 2setsofBloodcultures(bestdonewithin45minutes)
c. Broadspectrumantimicrobials(bestdonewithin1hour)
d. Atleast30mL/Kgcrystalloidfluidchallenge
2. Completewithin6hoursofdiagnosis
a. VasopressortokeepMAP65mmHgifgoalsnotmetbyfluidchallenge,Norepinephrineisfirstchoice
b. Ifpersistenthypotensiondespitefluidresuscitationorinitiallactate4mmol/L:
i. CVP:goal812mmHg;1215mmHgforpatientswithmechanicallyventilationorintra
abdominalpressure(duetocardiacfillingimpediment)
ii. ScvO2:goal70%(or,SvO265%)
c. Remeasurelactate:goalisnormalizinglactate
d. (Othertargets:UoP0.5mL/Kg/hr,normalizinglactateasamarkerforimprovedtissuehypoperfusion)

2012INITIALRESUSCITATIONBUNDLEPEDIATRICS

2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO3|P a g e

ADULT2012SurvivingSepsisRecommendationsDetailedNotations
Epidemiology
1. Newchangesmadeinthe2012recommendationsascomparedtothe2008SurvivingSepsisUpdateare:
a. DroppedICUManagementBundle&BrokeupInitialResuscitationBundleinto2parts
b. Pediatricsepsismanagementrecommendations
2. InitialResuscitationBundle(orwhatitwascalled,EarlyGoalDirectedTherapy),isasetofgoalstobemet
withinfirst6hoursafterdiagnosis.Thesestepsoftreatmentsneedtostartrightaway.Donotwaittostartit
whenthepatiententerstheICU.
3. Globalprevalenceofsepsispresentation:
a. Hypotensionwithlactate4mmol/L(16.6%),Hypotensiononly(49.5%),Lactate4mmol/L(5.4%)
b. Mortalityis46.1%,36.7%,30%,respectively
4. Meetingtheseinitialresuscitationsgoalswithinthefirst6hoursafterdiagnosisisassociatedwith15.9%
absolutereductionin28daymortality.(14)
5. NotAvailable:Xigris,or,fhAPCshowedasignificantreductioninmortalityof24.7%inthePROWESStrialin
2001.In2008itsusewasdowngradedtoonlyseverelyillpatientswithAPACHEIIscore25orMOF.In2011,
thePROWESSSHOCKtrialwith1,696patientsshowednomortalitybenefitsandthedrugwasw/dfrommarket.
InfectiousDisease
1. MostcommonbugsinsepticshockareGramPositive>GramNegative>mixedflora>>candida/toxicshock
2. 2setsofbloodculturesdrawnpriortoantimicrobialtherapyandgiveantimicrobialswithin1hourofdiagnosis.
(51)Get10mLperdraw.(53)Onesetofculturedrawnpercutaneouslyandonesetdrawnthrougheach
vascularaccessdevice,unlessifthedevicewasinsertedwithin48hours.
3. Ifthebloodculturedrawnfromthevascularaccessdeviceturnspositive2hoursbeforetheperipheralblood
culture,datasupportsthatthevascularaccessdeviceisthesourceoftheinfection.(36,51,52)
4. Initialempiricbroadspectrumantimicrobialtherapy(selectedtocoverallsuspectedorganism)within1hour
afterrecognitionofsepticshockandseveresepsiswithoutsepticshock(68,69)
5. Mortalityriseseveryhourwithoutantimicrobials(15,68,7072)
6. Combineempirialtherapyforneutopenicpatients,MDRDoublecoverP.aeruginosawithextendedspectrum
betalactamsandaminoglycosideorfluoroquinolone.ForStreppneumo,usebetalactamandmacrolide.
7. Antimicrobialregimentshouldbereassesseddailyfordeescalation.Empiriccombinationtherapyshouldnotbe
administeredfor>35days.Deescalatetomostappropriatesingletherapypendingsusceptibilityassoonas
possible.
8. Ifinvasivecandidiasissuspected,send1,3betaDglucanassay(2D),mannan&antimannanantibodyassay(2C)
9. Suspectviral,startantiviral.Testforseasonalvariations.CMVviremiaisabout1535%ofcriticallyillpatients,
andconnotesapoorprognosis.ConsiderHSV.
10. Useprocalcitoninlevelorothermarkerstoconsiderdiscontinuationofempiricantibioticforthosewhowas
initiallydiagnosedseptic,buthavenosubsequentevidenceofinfection.
11. Durationoftherapytypically710days.Longertherapyforpatientswithslowclinicalresponse,undrainablefoci
ofinfection,S.aureusbacteremia,somefungalorviralinfections,immunedeficiencies[negativebloodcultures,
VSS,afebrile,resolutionofsepsisandsepticshock,clinicalimprovement,sourcecontrol]
12. Noantimicrobialtherapyifpatientssevereinflammatorystateisnotduetoinfectiouscauses
SourceControl
1. Infectionsourcecontrolandpickappropriateantimicrobialchoicewithinfirst12hoursofdiagnosis
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO4|P a g e

2. Wheninfectedperipancreaticnecrosisisidentifiedaspotentialsourceofinfection,definitiveinterventionis
bestdelayeduntiladequatedemarcationofviableandnonviabletissueshasoccurred.(111,RCTshowed
betteroutcomewithdelayedapproach)
3. Chooseleastphysiologicinsultinginterventionpossibleduringacutephase
4. Removeintravascularaccessdevicespromptlyifitissuspectedtobethesourceofinfection.
Fluids
1. Initialfluidresuscitationwithcrystalloid,minimumof30mL/Kginadultsand20mL/Kginchildren.Consider
additionofalbumininpatientsrequiringsubstantialamountsofcrystalloidstomaintainadequateMAP.
a. Recommendagainsthetastarch.Artificialcolloidshasnoprovensurvivalbenefitsbutshowanincrease
inriskofacutekidneyinjury(126128)
b. CRYSTMAStrial:nodifferenceinmortalitybetweenHESvsNS.(Underpoweredtodetectthe6%
differenceinabsolutemortalityobserved)(122)
c. 6STrialGroup:6%increaseinmortalitybetweenHESvsLR(SickerpatientsinScandinavianstudy)(123)
d. CHESTtrial:7,000criticallyillpatients.Nodifferencein90daymortalitybetweenHESvsNS,butthe
needforrenalreplacementtherapywashigherintheHESgroup.(124)
e. Metaanalysisof56RCTs:nodifferenceinmortalitybetweencrystalloidsvsartificialcolloids.(126)
f. SAFEtrial:albuminwassafeandequallyaseffectiveasNS.(129)
g. RCT:albuminisassociatedwith2.2%absolutereductionin28daymortality,butdidntachieve
statisticalsignificance.(130)
2. Continuefluidchallengetechniqueaslongashemodynamicimprovement:basedondynamicvariables(change
inpulsepressure,strokevolume)orstaticvariables(arterialpressure,HR)
Vasopressor
1. NorepinepherineisthefirstchoicevasopressortokeepMAP65mmHg.
2. Epinephrineisthesecondadditionalagent,orsubstituteforNE,ifneededtomaintainMAP.Somestudies
suggestthatitdecreasessplanchniccirculationandcausehyperlactatemia,butthereisnoclinicalevidence
supportingthis.4RCTshownodifferenceinNEorEinmortality(142,147,154,155)
3. Vasopressin(0.03U/min)canbeaddedtonorepinephrinetoeitherraiseMAPtotarget,ortodecreaseNEdose.
But,donotuseitastheinitialvasopressor.Dosehigherthan0.04U/minisonlyusedwhenconsideredas
salvagetherapy.VASSTtrial,RCT,shownodifferenceinoutcomebetweenNEvsNE+V.Highdosevasopressin
hasbeenassociatedwithcardiac,digital,andsplanchnicischemia,soshouldonlybeusedassalvage.(166,167)
4. Phenylephrineisnotrecommendedinsepticshockexcept:1.WhenNEisassociatedwithseriousarrhythmias,
2.COishigh,BPpersistentlylow,3.Assalvagetherapy(156)
5. Dopamineisnotrecommended,withgoodevidence,exceptinhighlyselectivecases.Itcausesmore
tachycardiaandismorearrythmogenicthanNE.(153)Itmayaffectthehypothalamicpituitaryaxisandhave
immunosuppressiveeffects.(148)Hasnoclinicallysignificantrenalbenefitorsurvivalbenefits,ICU/hospital
lengthofstay,arrhythmiascomparetoNE(171,172)
6. Dobutamine20mcg/Kg/mincanbeaddedtovasopressorinthepresenceofmyocardialdysfunction(suggested
byincreasedcardiacfillingpressureandlowcardiacoutput)orongoingsignsofhypoperfusion(cardiacindex
andScvO2)despiteachievingadequateintravascularvolumeandgoalMAP(173,174)
7. Allpatientswithvasopressorsneedanarterialcatheter.
8. SuperiorvenacavaO2sat(ScvO2>70%)orMixedvenousoxygensaturation(SvO2>65%).Ifcannotachieveby
6hours,adddobutamineinfusiontomax20mcg/Kg/minorPRBCtransfusiontoahematocrit30%to
maximizeoxygencarryingcapacity.
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO5|P a g e

9. CVPusageismostreadilyavailable,thatswhyweuseit.However,itisconfoundedbypulmonaryHTN,
limitationofstaticventricularfillingpressuremeasurementassurrogateofresuscitation
10. IfScvO2isnotavailable,itsoktouselactatetrendtonormalasasurrogateofresolutionoftissue
hypoperfusion.(Noninferiorityin2RCT)20%decreaseinlactateandScvO270%withinfirst2hoursof
diagnosisisassociatedwith9.6%absolutereductioninmortality.(35,36)
Steroids
1. AvoidIVhydrocortisoneinadultsepticshockifIVFandvasopressorcanrestorehymodynamicstability.
a. CORTICUStrial:LargeEuropeanRCT,nomortalitybenefitsofsteroids.(178)
b. FrenchRCTwithverysickpatients:Steroidshowsignificantshockreversalandmortalityreductionin
patientswithrelativeadrenalinsufficiencybasedonACTHstimtest.(175)
c. Annaneetal,metaanalysisshowedsignificantmortalityreductionwithlowdosesteroid(179,180)
d. Sligletal,metaanalysisshowednodifferenceinmortality,butdoesshowimprovedshockreversalwith
lowdosesteroid.(181)Thesestudiesincludeddisproportionalamountoflowriskpatients.
2. DontuseACTHstimtesttoidentifywhoneedshydrocortisone.Noclearunderstandingofresponderandnon
responders.Thereareprobablyotherconfoundingvariablespresent.Weknowthatetomidatesignificantly
suppressesthehypothalamicpituitaryadrenalaxis.(185,186)anditsignificantlyincreasethe28daymortality
whenusedpriortolowdosesteroid.(187)
3. Taperhydrocortisonewhenvasopressorsarenotneeded
4. Recommendusecontinuousinfusionofhydrocortisoneat200mg/ddose,ratherthanbolusinjectionstolimit
hyperglycemiaandhypernatremiasecondarytothepeakeffect,whichisnotseenwiththecontinuousinfusion.
(175,192)
BloodProducts
1. Hgbtarget79g/dLintheabsenceofhypoperfusion,ischemicCAD,oracutehemorrhage.(193)PRBC
transfusionincreasesO2delivery,butdoesntincreaseO2consumption.ThenewchangestatesthattheHgb
thresholdof7ratherthanusingtargetHct30%withptswithlowScvo2<70%duringthefirst6hoursof
resuscitation.(13)
2. RecommendedagainstusingEPOtotreatsepsisrelatedanemia.(198,199)
3. RecommendedagainstusingFFPtocorrectcoagulopathyintheabsenceofbleedingorplannedinvasive
procedure.(200203)
4. Recommendedagainstuseofantithrombin.PhaseIIIclinicaltrialshownobenefitsonmortality,butincreased
riskofbleedingwhenadministrationwithheparin.(206)
5. Platelettransfusion:prophylacticallywhen10Kwithoutbleeding,20Kwithhighriskofbleed,50Kifactive
bleedorplannedsurgery.
6. Recommendedagainstuseofimmunoglobulins.Needmorestudiesinsepsispatients.
7. Recommendedagainstseleniumuse.Itisusedasanantioxidant.Thereisaconcentrationdependentreduction
inmortality,butthereisnosignificantdifferenceinoutcome/mortality/antibioticuse/lengthofstay.(221)
MechanicalVentilation,ARDS,VAP
1. UpdatedBerlinDefinition:ARDS:mild,moderate,severeisPaO2/FiO2300,200,100.(previouslylabeledALIor
ARDS)(233)
2. ARDS:targettidalvolumeof6mL/Kgpredictedbodyweight(9%decreaseinallcausemortalitywhenventilate
with6mL/Kgvs12mL/KginARDS);andtargetpassiveinspiratoryplateaupressureof30cmH2O.Lower
plateaupressureisassociatedwithlowermortality.(245)
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3. ARDSnet:goaltoreduceTvover12hoursfrominitialvalue,onceachieved6mL/Kgandplateaupressureisstill
>30cmH2O,itsoktoreducetidalvolumetoaslowas4mL/Kg.Needtomaintainminuteventilation
4. Permissivehypercapneawithvolumeassistedorventilationassistedventilationok,aslongasthereareno
contraindications,suchasincreasedICP.Bicarbortromethaineinfusionmaybeusefultofacilitatepermissive
hypercapneawithparticularventilatorstrategy.
5. HightidalvolumesandplateaupressuresmaycauseARDS.Nosinglemodeofventilationhasconsistentlyshow
advantageascomparedtoanyothermodeswhenrespectingtheprinciplesoflungprotectiveventilation.
6. UseatleastminimalPEEPtopreventatelectotrauma(failuretokeeprecruitedalveoliopen).(233)Usually
PEEP>5cmH2Oisneeded.Minimizingendexpiratoryalveolarcollapsehelpminimizeventilatorinducedlung
injurywhenhighplateaupressuresareinuse.
7. HigherratherthanlowerlevelsofPEEPforsepsisinducedmoderateorsevereARDS,PaO2/FiO2200mmHg
haddecreasedmortalitywithhigherPEEP.(258)
8. RecruitmentmaneuversinsepticpatientswithsevererefractoryhypoxemiaduetoARDS.Pronepositioningin
sepsisinducedARDSpatientwithPaO2/FiO2100mmHg.(263266)Othertechniquesarehighfrequency
oscillatoryventilation,APRV,extracorporealmembraneoxygenation.(271)
9. ConservativefluidstrategyforwithARDSwhodoesnothavetissuehypoperfusion.Studyshowedthatthey
usedCVP<4mmHgreducedICUstay,butnochangeonmortality.(299)
10. RecommendedagainstbronchodilatorsinpatientwithARDSandnobronchospasm.Rateofdeathbefore
dischargeis23%inINHalbuterolgroupvs17.7%inplacebogroup.(301)BALTI2trial,patientwithIV
salbutamoltreatedpatienthadincreased28daymortality.Earlyterminationoftrial.(302)
11. HOBelevation3045degreesinmechanicallyventilatedpatients,decreaseriskofaspirationandVAP.50%of
intubatedpatientinsupinepositiondevelopesVAP,versus9%insemirecumbentposition.(276)
12. Selectiveoral(chlorhexidine)andGIdecontaminationshouldbeusedtoreduceVAP
13. RecommendedagainstSwanGanzCatheter
Sedation,NeuromuscularBlockade
1. Sedationandventilationweaningprotocols.SpontaneousBreathingTrialcriteria:arousable,hemodynamically
stable,novasopressors,nonewpotentiallyseriouscondition,lowventilatorandPEEPrequirement,lowFiO2
requirementwhichcanbemetwithfacemaskorNC,[offsedation,RSBI<105(Tv/RR),(+)cuffleak,onminimal
ventsettings(CPAP:PS8,FiO230%,goodTv),lowsecretions,resolutionofthereasonforintubation]
2. Minimizeuseofeitherintermittentbolussedationorcontinuousinfusionsedationtargetspecifictitration
endpoint.Benefitofeitherintermittentversuscontinuousinfusionofsedationisnotestablished.Less
sedation,intermittentboluseshaveassociateddecreaseinventilatordays.(281,305,308,309)
3. AvoidneuromuscularblockerwithoutARDSduetoincreasedriskofprolongedblockade
4. Shortcourse(lessthan48hrs)ofneuromuscularblockerforpatientswithearlyARDSandPaO2/FiO2<150
mmHg.Usetrainoffourmonitoringfordepthdecreasesoverparalysis.
Insulin
1. Startinsulindripprotocolwhen2consecutiveBG>180mg/dL.Glucosegoal180mg/dL,not110mg/dL.BG
monitoringevery12houruntilstablethenq4hrsafter.CapillaryBGmaynotbeasaccurateasbloodBG.NICE
SUGARtrialshowincreasemortalitywithtightBGcontrol.(331)
RenalReplacementTherapy
2. Equivocal:continuousvenovenoushemofiltrationversusintermittenthemodialysis
3. Usecontinuousmethodstomanagefluidbalanceinhemodynamicallyunstablesepticpatients
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO7|P a g e

4. Typicaldoseofcontinuousrenalreplacementis2025mL/Kg/hrofeffluentgeneration.
IVSodiumBicarbonate
1. RecommendedagainstusingBicarbtoimprovehemodynamics,reducingvasopressorrequirementinpatient
withhypoperfusioninducedlacticacidosispH7.15.
DVTProphylaxis
2. DVTprophylaxisrecommended.CrCl<30mL/min,usedalteparinorUFH.AlsouseBilatSCD.9RCTandmeta
analysisshowbenefitofreductioninDVTandPE.(390,391)
3. CCCtrial:nodifferenceinasymptomaticDVTbetweenheparin5000IUBIDvsLMWHdalteparin5000IUqDay.
But,LMWHisassociatedwithsignificantlylowerdiagnosedPE.(392)MetaanalysisshowthatUFHTIDis
betterthanBIDtopreventVTE,butBIDisassociatedwithlowerbleedingrisk.
4. ConcurrentuseofSCDsandLMWHorUFHissuperiortoanythingalone.(398)
StressUlcerProphylaxis
1. GIprophylaxisrecommendedtopreventUGIBfromstressulcers,onlyforthosewithbleedingrisks.PPI>H2RA.
NoPPIifnobleedingrisks.(415417)
Nutrition
2. POorenteralfeedrecommendedovercompletefastingorsoloIVglucosewithinfirst48hoursafterdiagnosis.
Thoughnomortalitybenefitswereseeninstudies,butmanybenefitsinsecondaryoutcomesinreductionof
infectiouscomplications,reducelengthofmechanicalventilation,reducedICUandhospitalstay.
3. Avoidmandatoryfullcaloricfeedingwithinfirstweek.Startwithlowdosefeedingof500caloriesperdayand
advanceastolerated.Thisispermissiveunderfeedingortrophicfeedingisagoodstrategy.(433,434)
4. First7days,useIVglucoseplusenteralnutritionratherthanTPNaloneorparenteralnutritionwithenteral
feeding.Severalstudiessuggestparenteralnutritionisassociatedwithincreaseriskforinfectioncomparedto
enteralnutritionorIVglucose.
ImmunemodulatingSupplements
1. Recommededagainstuseofimmunomodulatingsupplementation,arginine,glutamine,omega3,antioxidants.
Nobenefitandcancauseharm.(445448)
2. Arginineisthoughttobereducedinsepsis,leadtoreducenitricoxidesynthesisandenhancesuperoxideand
peroxynitriteproduction.Butitcanleadtovasodilationandhyptension.Nogooddataforbenefit.
3. Glutamineisreducedincriticalillness.Supplementationcanreducegutatrophyandpermeabilityandpossibly
reducebacterialtranslocation.Itcanalsoenhanceimmunecellfunction,decreaseproinflammatorycytokine
productionandhigherlevelsofglutathioneandantioxidativecapacity.(452,453)6trialsfailtoshowmortality
benefit.But,sometrialshowreductionininfectiousmorbidities.(461,462,465)Nosolidbenefitorharm.
4. Omega3:reduceproinflammatoryprostaglandins,leukotrienes,andthromboxanes.Nodatawithsolidbenefit
orrisk.
GoalofCare
1. Recommendedtoaddressgoalofcare,prognosis,andendoflifeplanningasearlyaspossible,necessarywithin
72hoursofICUadmission

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PEDIATRICS2012SurvivingSepsisRecommendationsDetailedNotations
1. Background,newbornandchildrenarenotsmalleradults:
a. Incidenceismuchlowerthanadult.Mortalityis2%inhealthychildren,8%inchildrenwithchronic
illness(497).BPisnotagoodmarker.ChildrentendtovasoconstrictandincreaseHRtomaintainBP.
Oncehypotensionhappens,childrencrashfast.Fluidresuscitationinhypovolemicshockiskeyforboth
normotensiveandhypotensivechildren.Fluidoverloadinchildrenshowsupashepatomegalyandrales.
Ifthesesignsareabsent,therecouldbealargefluiddeficit;theinitialfluidresuscitationcanbe4060
mL/Kgormore.Ifthesesignsarepresent,thenusediuretics.
2. Initialresuscitation:
a. Respiratorydistressorhypoxemia:usefacemaskO2,highflownasalcannula,nasopharyngealCPAP.
b. Initialtreatmentendpoint:caprefill<2sec,normalBPforage,normalHRwithnodifferentialbetween
peripheralandcentralpulses,warmextremities,UoP>1mg/Kg/hr,normalmentalstate,ScvO270%,
Cardiacindexbetween3.36.0L/min/m2.Lactateisnothelpfulinchildren,theyareusuallynormal
eveninseveresepsisandsepticshock.
c. Evaluateforreversiblecauses:pneumothorax,pericardialtamponade,endocrineemergencies
3. Antibioticsandsourcecontrol
a. Obtainbloodculturespriortoantimicrobial.Startantimicrobialswithin1hourofdiagnosis.Consider
MDR,andotherrisk.Duetosmallveins,oktogiveIMorPOfirstpriortovenousorIOaccess.
b. Clindamycinandantitoxintherapyfortoxicshocksyndromewithrefractoryhypotension.Childrenare
morepronetotoxicshockbecauseoftheirlackofcirculatingantibodiestotoxins.Signsoftoxicshockin
childrencanberefractoryhypotensionwithdiffusederythroderma.
c. Earlyaggressivesourcecontrol
d. C.diffcolitistreatedwithenteralantibiotics.POvancomycinforseveredisease.
4. Initialfluidchallenge:
a. 20mL/Kgincrystalloidoralbuminover510minutes.Ifhepatomegalyorralesexist,theninotropic
supportshouldbestarted,notfluids.Innonhypotensivechildrenwithseverehemolyticanemia(severe
malariaorsicklecellcrises)bloodtransfusionissuperiortocrystalloidsoralbumin.
5. RefractoryHypotension:
a. StartperipheralinotropicsupportuntilCVCobtainedforfluidunresponsivepatients.Patientwithlow
cardiacoutputandelevatedSVRandnormalBPshouldbegivenvasodilatorinadditiontoinotropic
agents.Thiscanreverseshock.TypeIIIphosphodiesteraseinhibitors(amrinone,milrinon,enoximone)
andcalciumsensitizerlevosimendancanbehelpfulinovercomingreceptordesensitization.Other
vasodilatorscanhelp:nitrosovasodilators,prostacyclin,fenoldopam.Pentoxifyllinehasbeenusedin2
RCTinnewbornstoreducemortalityinseveresepsis.
6. ConsiderECMOforrefractoryshockandrespiratoryfailure.73%survivalbenefitfornewbornsand39%for
olderchildren.(572)
7. TimelyIVhydrocortisoneif:fluidrefractory,catecholamineresistantshockandsuspectedorprovenabsolute
adrenalinsufficiency.25%childrenwithsepticshockhaveabsoluteadrenalinsufficiency.Initialinfusionis
stressdoseat50mg/m2/24hr,but50mg/Kg/daymayneedtobeusedtoreverseshock.Deathfromabsolute
adrenalinsufficiencyandsepticshockoccurswithin8hoursofpresentation.(578583)
8. Duringresuscitation,keepHgbgoal>10g/dLforthosechildrenwithScvO2<70%inthefirst72hrsofPICU
admissionshowsurvivalbenefits.(511)WhenstableandstillhypoxemicthenHgbgoal>7g/dL.Same
platelet/FFP/Cryotransfusiongoalasadults.
9. Lungprotectivemechanicalventilation,considermethodssimilartoadults
10. Sedation,needclearlyestablishedgoalsandprotocols
11. Hyperglycemia:
2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO9|P a g e

12.

13.

14.

15.

a. GoalBG180mg/dL.Glucoseinfusionshouldaccompanyinsulininfusioninnewbornsandchildren
becausesomehyperglycemicchildrenmakenoinsulinatallandsomeareinsulinresistant.Infantstend
todevelophypoglycemiawhentheyareonIVF.TheyneedIVglucoseof46mg/Kg/minorD10NS.
Newbornmayneed68mg/Kg/minofglucose.
Fluidoverload:
a. Usediureticstoreversefluidoverloadwhenshockhasresolved.Ifnotsuccessful,thenusecontinuous
venovenoushemofiltration(CVVH)orintermittentdialysistoprevent>10%totalbodyweightfluid
overload.
DVTProphylaxis:
a. NorecommendationofDVTprophylaxisinprepubertalchildren.MostDVTsinchildrenareassociated
withcentralvenouscatheters.
StressUlcerProphylaxis:
a. NorecommendationofStressUlcerprophylaxis.StudyshownclinicallysignificantGIBsoccuratsame
rateasadults.PPIorH2RAarecommoninmechanicallyventilatedpatients.
Nutrition:
a. Enteralnutritionastolerated,otherwise,parenteralisok.D10NSprovidestheglucoserequirementfor
newbornsandchildren.

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2012SurvivingSepsisCampaignUpdate.SummarizedbyGeorgeChen,DO11|P a g e