eae JAMA Clinical Guidelines Synopsis Management of Sepsis and Septic Shock Micha! . Howe, MD, MP new MDa, MO. MPH “GubELINE TL Surviving Sepsis Campaign: International {Guidelines for Management of Sepsis and Seatie Shock: 2016 ‘bE vetoPEns Surviving Sepsis Campaign ($5), Society of Citic Care Medicina (SCH), and European Society of Intensive Care Medicine ESIC) RELEASE DATE January 18, 2017 PRJ0k VERSIONS 2012, 2008, 2004 ‘WAGET POPULATION Adults with sep or sptle shock SELECTED HALOR RECOMMENDATIONS Managing infection: » Antbotes: Administer broad spectrum intravenous atria fr al ihely pathogens win hour afer ‘sepsis recagniton (song recommendation; moderate ‘quay of evkdenceQ0eD. + Sourcecontrol- btn anatomic source control a apy asis practical (best practice statement [BPSD, Summary ofthe Cnieal Problem Sepsl results when the bodys response to infection causes fe threatening organ dysfunction. Sepieshockissapsisthatresultsin tissue hypoperfusion with vasopressorrequingiypotenson and ‘levtedlactazelovels! Sapte & . 2 leading cause of death, mor Vewnsntoage 807 bicty, and expense, contsibut Ingtoone-thicleohalf of eats Author Aone of hospitalized patients? de pending an dain tions2 Man- 2gernantofsepsisisacomplicatedclrical chalkrgereautingeary recogpitionandmnanaganentonvetio,bemedyransicisses, and ‘other organ dysfunctions, Characteristics ofthe Guideline Source ‘The guideline was developed bythe SSC, with funding and gover. ‘nance fromthe SCCM ane the ESICM (Table) (Veo 0 Guideline + Antibiotic stewardship: Assess patents day for deescaation of antimicrobials narow therapy based on cultures andr clinealimprovement (BPS) Managing resuscitation + Fuics For pales with sepsis cued typoperticon, provide 30 ml agfinrevancscrystafel within shor stongrecer ‘mandation; ow QE) with acluane! fue based on frequent reassessment (8P9),proferentlly using dame vaabies to assess uid responsiveness (weak acormendaton kw QCE), + Resuschation argos: For patients wih septic shock eauiing ‘vasopressors, target amaan arts presure (MAP) of G5 mm Hg {stongrecomvrendation moderate OOF}, + Vasopresots. Use norepinepiine asa fst choice ‘vasopressor (strong recommencation moderate QO). Mechanical veotfation inpatients with seps's-eated ARDS: * Target tidal volume of 6 mi hg of predicted body weight (strong recommendation: high QOE) ane plateau presse lof 30 emH,0 Gtrong recommendation: moderate QCE}, Formalimprovement rograms: + Hosplais and heat systems should implement programs to Improve sepis care thatincude sepsis screening (PS), ‘during the guideline development process tudes used fr ude line evidence uset ear definisons of sepstssyncromes, Benefits and Harms ‘The 2012 sepsis guidainesstrongly recommended protocalzedre- ‘sscation th quantatveand pins (ary goa rected therapy {EGOTD (vieo3).Rocommendatonsincudedspecgalfr cen tral vous presse (CV, MAP, an central venous oxen sata ration and formad the basis of national qualty and performance matics? Since the 200 guideline, substantia evolution has occrredin Lundestandingte value of EGDT. Three key randomized ial en ‘oll patients presenting to the emergency department who had ‘Tae Gtlne ote iting DG Goad committee members were from numerous specialties and i: yenestercafetctinerestinthegidsing and ‘dadec!methodsexpertsandapatentropresentative.Aforrnalcon- erent ror Sctel testrsmamernent poey wes olive. ‘dete deetesnont se compose ‘end Evidence Base Gina pace itelneontennicreven ire Good etstira eee oui seria eth rand ‘lf Bein amenaow ‘Thoguideline committee ese theGRADE method (Vieo-Popux —_Atluaion of cameras re lation intervention, control and outcomes questions wera con- —_Exerslevew ak structed: professonalibrriansassted with evidencereviews, + Uta fae rplayenain ue fi though the 2016 revision of defitions fr sepsis were published |avMh Fe.) 78 2007 lar 7, Nba Copyright 2017 American Medial Assocition, Al hts ressrved. Dowload From: htipsjamanctworkcomipalaccess.ashx?urldatajournahjama 36072! by a Ane Arundel Medial Center User on 031022017CiesRenen x eauetien AMACn akin yap Sepsis with stock orhypopartision.intePROCESS rl (r=I34pa- Lens from 31 USinsitutlons), protocol based approaches didnot recta 60-day mortalty vs usual care (18.5% 18.956 eatverise [RR], 1.04; 95%C1, 0.824131; 83), Thesimiay sized UK based PROMISE? andthe ARISE fom Aus-alaand NeWZeaind noth ‘compared EGDT and usual ear at 90 ays ad agin found no at- {erence inmnaralty (285% vs 28.25 RR, LOK 95860, 0.85:120, P90 and 8 5% ¥5 188% RR, 0.88; 5% CI, 080-121, P90, spectively, Token together these ls suggest tht while GOT Is safe it snotsuperiortousual nonpratocolzedeate, Usuol creas also evolved since these trials to include more agaressve fluid resusclatio.* response, the 206 guideline has removed san- iar DT resuscitation targets, instead recommending that sepsis induced hypoperfusion be treated with atleast 30 ml fof intra venous estas given in 3hourso less (Video 2). In theabeence ‘ofthe former static EGDT targets (eg CVP), te guideline empha sizes frequent clnialeassessment and the use of dynamic me ‘sutesof lid responsiveness (eg areal pusepressuevariaton, sve evidence that dymamlc measures predic Mud responsive essbetterthanstaticmessuresdo, Because infection causes sepsis, managing infection is per: haps the most tcl component of sepsis therapy. Mortal i- ‘ceases even with very short delays of antiicrobias To opting ‘here beneftprofi thestrategyofntlatbroadspecrumthesapy requices meticulous attention to antinreblalstewatdship, ilu Ingealyappropianacuttaresand ly revew to recuce or top a Uimicobials Additional, anstomc source contol (eg, entity ‘nfecied central ines, pylonepirts with ureteral obstruction In ‘testinal perforation) should occu 8 soon ass practical Discussion ‘The ROCESS," PROMISE.” and ARISE* ashavecreatad substan. {luncertantyinhowtogukdacnicansianaging patents withsep Sis and soptic shock? when usual eareisequivsent to EGDT, what Isacinkiantodo? Themostsigiicantupdate to the gudelnere fctsthisshiftinevence:remevingmestscedic GOT and pints ‘and emphasing frequentreevaliation sndpatient specter Ingothemodyrarc therapy Even vith ackangeiaconsensuscef tions for epsis the guideline provdesstrongrecommendations {ora number of elements of standardized care, suchas atimico AgncLeHFORUATION nerunences| ‘Auth Aton Coro Meath Deiery 1 Sige Daun C8, SeyraurC oa fae Coneeeteleteet the testo Mtn le 24ST S383, Seance asinpraton Unvesty age, bial tnerapy initia ud volume, blood pressure goals, and vaso: pressor choice Reflecting substantial consensusamengeroars ct Ingwas by 75% of panel members with atleast 80% agreement. ‘Te qudalne also provdesa BPS for hospitals ane health sys: tems to develop formal zepss performance improvement pro ‘gras, gvena suggestion of mertalty bene, Tools suchas order sa, checklists, posters reminder cards andelecronicmedicalrec: ‘rel decsion support may asst cians in early recognition and ‘sapropiate treatment of sepsis. Peciatic sepsis guidelines willbe published separately. witha specific guideline for ventlation in ARDS expactedin 2017 Areas in Need of Future Study at Ongoing Research ‘The best appreach for hemodynamic therapy for sepals has be ame more uncertain as evidence has accumulated, This axtenss leven tothe degree to which eliniians shoul! usa intravenous Fr lds. foundation for resuscitation n oun patint groups. The idle correctly dentists asa ay areaor further research The best way to improve public health related to sepsis re: mainsunsette For example, post UShospitalsreraquted tore ar sepsis process mesures, Collection of thse data may be re Sourcaintense ancmay distract rom other Imravesment effets? ‘nadvertentlypreamoteoverteatmentor unnecessary testing ore ‘ay nonsepsis diagnoses * At present, the ntamaloral eansensus clfinkion of sepsis the rew guides arc CMS's core measure equterentsareunsynchrenizn. Thoughtulsignment wouller sure mi2aringl reporting and improve patiea outcomes, Rekted Guides and Other Resources ‘crore for Heath an Cae Ecalee (NCE) Sugano oct andes kos Society ef Ai (aera teens) Infections isaases Soci of American Amica Tha Soci (entistareacit puro) Sepia Video 4) 6 Yen oM etary A ‘noted aot potct bees 39 Gaga Hoi Von Pony andcrtea) —SepipandSepe Shock (Sese) IA 201.67 May PR, Orn, Pt Ge Tt Gre therwsiyoF age Cig @escis0, (owe Genet Mocha Universiyof Yer etna Hosp dbatisinpstent whet 2eepedent 8, Pek, DebneyA Bly Me ins, (Geshretd eset ates aly 3. Rhee cons Kurpet lh Ragaony ‘motes sep carer fr cation "gid 240 TS 4. tesé burst, hana Nth Survieng 10, Dun, Dona A, Sante Ge Leto Confit ees Dicieven Theatinchave _SeisCampin rst gains snonsgeret fs ceed Co re Met etiovoacanovonenooeasans 5. Wot Howe Mo. 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AB ght eserved. pslfamanetworkcomipaiaccessashx?4rlsatajournalejam36073 bya An Arandel Medical Ceaer User oo 63022017arabe aches MD Dement Hoss, Jnvesie Libre ets | ee dae Dasutmertat ‘oestidogy and Graeacaretedene, Joinslonene Ne Beer Nor & Robtedarie paae su? corresponding ‘at oecoxma, namo, “he ines espa Dearie faneshesbey Ghiatcretatene, "ue 20 nd taker, HO 2052198 (orensteice), (Soman Surviving Sepsis Guidelines A Continuous Move Toward Better Care of Patients With Sepsis Sepsis a life-threatening condition that affects ‘nore than Iilicn patients a year inthe United States and even more patients arn the lobe ands ane of. tive leading causes of death. Since the Declaration of Barcel n 2002, te European Society of Intensive Cre Medicineand the Society of ital Cie Medicine (SCCM have launched sever! initiatives to decrease ‘hemortaity patients with sepsis The Surviving Sep sis Campaign (SSC) was launches! i 2002 and has 3 point aged: building avareness of sepsis, improw- Ing agnosis and recgriton, defining and increasing ‘the use of appropate treatment and cre, eeucating tealt care professionals improving postintensive cae unit cara, develaing gudelines of ear, and imple menting apsformancelmrovement progam, ‘The morta of natients with sepsis improved ‘ver time. n an observational study that included 23.470 patents in sepsis worldwide, every quarter of participation inch SSCintlave we associated with ‘siniicant decrease inthe odds of hespital mortality {odds rato, 036, 95% CI, 0.95-097; « 001)? ‘The Surviving Sepsis Gudalines were fist pub- lished in 2004, with revisions in 2008 and 2012, 1n January 2017, the fourth rovslon ofthe Surviving Sepsis Guidelines was presented at the 46th annua’ SCCM meeting and published anne oity in Critical Care Madice ae intensive Care Medina & sep: ‘is of the audalines ako hasbeen published.” “The update guideline mas generated by 35 ter national experts representing 25 international organ _zatonsinvolvectin the cae of patents wth sepsis and providing 93 recommendations on ealy management of sepals and septic shock, Tare are rumerous major ‘advances in the revision ofthe guieies, Ameng the various topics covered, inital resusctation and antibie oc therazy ave the domains in wen the mos irpor tant changes and advances were made. Foc intial cesusetation, previous guidelines were ‘mostly base on early goatdirected therapy, wich Mas ‘been changed! by recent tas and this approach ‘no longer recommended, Of pate, no harm Was dem= “onstrate those tr, so there va net arecomme dation to avoid early goal-trected therapy targets ‘The gudalines recommend (mostly a best practice ‘tatements) the use of hemodynamic assessment for further fu acinstration after te inital uid bots ((ncluding valle physiologcal variables but alzo rnirvasve or ina hernadyiamle menting) anc Ipemodynamic assessment to determine the type of ‘shock ifthe clinica diagnosis doesnot lead to clear lognoss (this is particularly important in comalex cases: for example, thse with ahistory of eardiac dys furtion who develop pneumoeia, when the nature of ircuatory flues not always obvious), ‘nother important advance is thatthe new epide- lines recommend the use of dynamic (ie, pulse ot stroke volume varlatlons induces by mechanical venti tio or passive lg ase ts) over static variables Gn lravascular pressuras or volumes) to predict fluid ‘esponsivenas. This isasignficant charge 2s previous _uldesins recommended that clinicians shoul target specific vols of central venous pressure, Subsequent data have shown that central venous pressure has i ed value forthe prediction of te resparse to ids.” Important, the gusdnas recommend that when fic ‘ximistationis inated, elieians shoulduse te fit ‘hullenge technique to evaluate the effect (and safety) ‘of tui administration. When hemosiynamic ferors coatnue to inprove i response tofu futher Mud administration can be considered, However, Fuld administration should be giscontioued when the response to fui ino longer beneficial a step often neglected in nia practice” This partodariy impor tant because multe stucies have shown that exces sive net fuld status is associated with a poorer out- ‘come, including an increase in mortality. Hence, the suidelines moved from a protocoized, quantitative resuscitation strategy to a more patlnt-centared resuscitation approach guided by hemodynarnic assessment including dynamic variables for fluid ‘esponsiveness and ongoing reevaluation of the ‘response to treatment lnfection source control (g, retrial of eatheter device suspectadtobelnfected suricalprocedure) and eatlyantibiote therapy remaln mainstays of treat ‘ment. Source contal should aiwaysbeebtainedasrap- ‘yas poss. Thenew guidelines recommenelthatan- ‘biotiesshouldbeadministeradas soon as posible and within thourmadmum. This rocommendatenisbased ‘camultipechsenational uses showingthat any de lay inantitiotacminisration sassociated wth an n- ‘creased rik of death Inaction to the ning of at biotics Ibis important to ensure the adequacy of anlbotcsinteonsofboth doses andekugselection, The ‘ew guidelines state thatbest practceincludesthe use (of dosing strategies based on pharmacokinetics? pharmacodynamics principles in patients with sepsis ‘when such tests are avaFabe. Ths statement is based. on the observation tat recommended ntl doses of antibioticsareoften nsufkient because ofanincraase invohmeofdstroutionandals, some patients aug mented rena clearance mn, Fen 2,2017 Vie Namba Copia 2017 American Medial Assotiaton Al ight eservad ownlorded From: htp:/jamanetworkcemiplueessashx?urinjournasjama/¥36072/ bya Anne Arad Meal Ceater User on 9942/2017 | | : |