Professional Documents
Culture Documents
2008 Pocket Guides
2008 Pocket Guides
I n i t i al r e s u s c i t a t i o n ( f i r s t 6 h o u rs )
N Begin resuscitation immediately in patients with hypotension or elevated
Sou r c e i d e n ti fi c a ti on a n d c on tr ol
N A specific anatomic site of infection should be established as rapidly as
serum lactate 4mmol/L; do not delay pending ICU admission. (1C) N Resuscitation goals: (1C)
Central venous pressure (CVP) 812 mm Hg* Mean arterial pressure 65 mm Hg Urine output 0.5 mL.kg-1.hr-1 Central venous (superior vena cava) oxygen saturation 70%,
and/or dobutamine infusion max 20 g.kg-1.min-1 * A higher target CVP of 12-15 mmHg is recommended in the presence of mechanical ventilation or pre-existing decreased ventricular compliance.
F l u i d t h e r a py
N Fluid-resuscitate using crystalloids or colloids. (1B) N Target a CVP of 8mmHg (12mmHg if mechanically ventilated). (1C) N Use a fluid challenge technique while associated with a hemodynamic
Dia gn osis
N Obtain appropriate cultures before starting antibiotics provided this does
improvement. (1D)
N Give fluid challenges of 1000 mL of crystalloids or 300500 mL of col-
loids over 30 minutes. More rapid and larger volumes may be required in sepsis-induced tissue hypoperfusion. (1D)
N Rate of fluid administration should be reduced if cardiac filling pressures
A n t i b i o t i c t h e r ap y
N Begin intravenous antibiotics as early as possible, and always within the
V as o pr e s s o r s
N Maintain MAP 65mmHg. (1C) N Norepinephrine or dopamine centrally administered are the initial
first hour of recognizing severe sepsis (1D) and septic shock. (1B)
N Broad-spectrum: one or more agents active against likely bacterial/fungal
susceptibilities. (2D)
N Duration of therapy typically limited to 710 days; longer if response slow,
as practical. (1D)
I n o t r o pi c t h e ra p y
N Use dobutamine in patients with myocardial dysfunction as supported
January 2008
Ste r oids
N Consider intravenous hydrocortisone for adult septic shock when
M e c h an i c a l v e nt i l at i o n o f s e p s i s - i n d u c e d a c u t e l u ng i n j u r y ( A LI )/ A R D S
N Target a tidal volume of 6mL/kg (predicted) body weight in patients with
Gl uc o s e c o nt r o l
N Use IV insulin to control hyperglycemia in patients with severe sepsis
ALI/ARDS. (1B)
N Target an initial upper limit plateau pressure 30cmH2O.
tive to hydrocortisone is being used which lacks significant mineralocorticoid activity. Fludrocortisone is optional if hydrocortisone is used. (2C)
N Steroid therapy may be weaned once vasopressors are no longer
every 1-2 hours (4 hours when stable) in patients receiving intravenous insulin. (1C)
N Interpret with caution low glucose levels obtained with point of care
testing, as these techniques may overestimate arterial blood or plasma glucose values. (1B)
required. (2D)
N Hydrocortisone dose should be 300mg/day. (1A) N Do not use corticosteroids to treat sepsis in the absence of shock
injurious levels of FiO2 or plateau pressure, provided they are not put at risk from positional changes. (2C)
N Maintain mechanically ventilated patients in a semi-recumbent position
R e na l r e pl ac e m e n t
N Intermittent hemodialysis and continuous veno-venous hemofiltration
unless contraindicated.(1B)
N Suggested target elevation 30 - 45 degrees.(2C)
R e c o m b i n a nt h u m a n a c t i v a t e d p r o t e i n C ( r h A P C )
N Consider rhAPC in adult patients with sepsis-induced organ dysfunction
patients. (2D)
with clinical assessment of high risk of death (typically APACHE II 25 or multiple organ failure) if there are no contraindications. (2B; 2C for postoperative patients)
patients with mild-moderate hypoxemic respiratory failure. The patients need to be hemodynamically stable, comfortable, easily arousable, able to protect/clear their airway, and expected to recover rapidly. (2B)
N Use a weaning protocol and a spontaneous breathing trial (SBT) regularly
B i c a r b o n at e t h e r a p y
N Do not use bicarbonate therapy for the purpose of improving
hemodynamics or reducing vasopressor requirements when treating hypoperfusion-induced lactic acidemia with pH 7.15. (1B)
N Adult patients with severe sepsis and low risk of death (eg: APACHE II 20 or one organ failure) should not receive rhAPC. (1A)
D e e p v e i n t h r o m b o s i s ( D V T ) p r o ph y l a x i s
N Use either low-dose unfractionated heparin (UFH) or low-molecular
B l o o d p r o d u c t a d m i n i s t ra t i o n
N Give red blood cells when hemoglobin decreases to 7.0 g/dL ( 70 g/L) to target a hemoglobin of 7.0 9.0 g/dL in adults. (1B) A higher hemoglobin level may be required in special circumstances (eg: myocardial ischemia, severe hypoxemia, acute hemorrhage, cyanotic heart disease, or lactic acidosis) N Do not use erythropoietin to treat sepsis-related anemia.
for patients who are at very high risk for DVT. (2C)
N In patients at very high risk LMWH should be used rather than UFH. (2C)
S e d a t i o n , a na l g e s i a , a n d n eu r o m u s c u l a r b l o c k a d e i n s e p s i s
N Use sedation protocols with a sedation goal for critically ill mechanically
S t re s s u l c e r p r o p h y l a x i s
N Provide stress ulcer prophylaxis using H2 blocker (1A) or proton pump
inhibitor (1B). Benefits of prevention of upper GI bleed must be weighed against the potential for development of ventilator-acquired pneumonia.
to predetermined end points (sedation scales), with daily interruption/ lightening to produce awakening. Re-titrate if necessary. (1B)
N Avoid neuromuscular blockers where possible. Monitor depth of block
C o n s i d e r at i o n f o r l i m i t a t i o n o f s u p po rt
N Discuss advance care planning with patients and families.
Prepared on behalf of the SSC by Dr Jeremy Willson & Professor Julian Bion