SURVIVING SEPSIS CAMPAIGN

INTERNATIONAL GUIDELINES FOR

MANAGEMENT OF SEPSIS AND SEPTIC
SHOCK 2021 .
A COMPARISON WITH 2016 GUIDELINES.

DR. MANISH JAGIA

(HOD, ANAESTHESIA AND CRITICAL CARE)
DR. CHHAVI TECKCHANDANI
(ATTENDING CONSULTANT,ANAESTHEISA)
 SEPSIS AND SEPTIC SHOCK
DEFINITIONS
• Sepsis is defined as Life threatening organ
dysfunction caused by dysregulated host response
to infection. (3rd international consensus definition )
• Septic shock is a subset of sepsis in which
underlying circulatory and cellular/ metabolic
abnormalities are profound enough to substantially
increase mortality.
• Critical imbalance between oxygen supply and
demand.
• Patients with septic shock can be generally
identified with a clinical construct of sepsis with
persisting hypotension requiring vasopressors to
maintain MAP >65 mmhg and having serum lactate
levels >2 mmol/l despite adequate volume
resuscitation .
• With these criteria, hospital mortality exceeds 40%
( NCBI, 3RD international consensus definition for
sepsis, septic shock. )
 GUIDELINES
• Screening and early treatment
• Screening tools for patients with sepsis and
septic shock
• Measurement of lactate levels
• Initial resuscitation
• Target mean arterial pressures
• Admission to ICU
• Infection control
 Antimicrobial therapy – antibacterial, antifungal,
antiviral therapy.
 to start antibiotics
 Patients with MRSA infection

• Hemodynamic measurement
• Ventilation
• Additional therapies
• Long term outcomes and goals of care
 TERMINOLOGIES
• RECOMMENDATION- strong, moderate, weak
• EVIDENCE QUALITY - High, moderate, low
• RECOMMENDATION- for, against
• SUGGESTION- for, against
 SCREENING AND EARLY
TREATMENT
2021 GUIDELINES 2016 GUIDELINES
It is RECOMMENDED that for acutely SEPSIS SCREENING (strong
ill, high risk patients , Performance recommendation, moderate quality
improvement programme for sepsis
evidence ) alone is
which includes both
RECOMMENDED as a
SEPSIS SCREENING (strong Performance improvement
recommendation, moderate quality programme for acutely ill, high risk
evidence )
patients
STANDARD OPERATING
PROCEDURES ( strong
recommendation, low quality
evidence )
Should be used for treatment.
SEPSIS SCREENING
TOOLS
• Screening tools are set of
screening parameters which
help to identify sepsis early.
• Sepsis screening, Education.
• In any locations of the
hospital- Emergency
department, wards, OTs,
ICUs.
STANDARD OPERTAING
PROCEDURE
• Set of practices that specify
a preferred response to
specific clinical
circumstances .
• Initially identified as GOAL
DIRECTED THERAPY,
now evolved to usual care
• Lactates, cultures,
antibiotics, fluids.
 SCREENING TOOLS FOR PATIENTS
WITH SEPSIS AND SEPTIC SHOCK
• RECOMMENDATION is AGAINST using SOFA
SCORE compared to SIRS, NEWS or MEWS as a
single screening tool for shock/septic shock.
 MEASUREMENT OF LACTATE
LEVELS
• It is SUGGESTED to measure blood lactate levels in
patients suspected for sepsis. (weak recommendation, low
quality evidence )

• Biomarker of tissue hypoxia and dysfunction, but not a direct

indicator of tissue perfusion.

• It is an evidence of cellular stress, also indicates refractory

hypotension.

• 1.6-2.5 mmol/L
 INITIAL RESUSCITATION
• It is RECOMMENDED that treatment and resuscitation should
begin IMMEDIATELY in view of sepsis being a medical
emergency .(best clinical practice statement)

• For sepsis induced hypotension, it is SUGGESTED that ATLEAST

30 ML/KG IV FLUID CRYSTALLOID should be given within FIRST
3 HOURS OF RESUSCITATION. (weak recommendation, low
quality evidence)

• It is RECOMMENDED that DYNAMIC PARAMETERS -response to

passive leg raising or fluid bolus, SV, SVV, PPV, 2d echo, be used
as guide to resuscitation. (weak recommendation, low quality
evidence ) over physical examination/ static parameters alone.
• It is SUGGESTED to use DECREASING SERUM
LACTATE LEVELS in patients of sepsis/ septic shock as a
guide to resuscitation OVER NO SERUM LACTATE LEVEL
MONITORING. (weak recommendation, low quality
evidence )

• It is SUGGESTED to use CAPILLARY REFILL TIME as a

guide to PERFUSION AND RESUSCITATION as an adjunct
to other measures. (weak recommendation, low quality
evidence )
 TARGET MEAN ARTERIAL PRESSURE
• It is RECOMMENDED that an initial TARGET
MEAN ARTERIAL PRESSURE (MAP) OF 65
MMHG must be maintained in patients of sepsis/
septic shock OVER HIGHER MEAN TARGETS
( strong recommendation, moderate quality
evidence
 ADMISSION TO ICU
• It is SUGGESTED that patients with suspected
sepsis/ septic shock must be admitted to ICU
WITHIN INITIAL 6 HOURS.

• Outcomes of critically ill patients depend upon timely

application of critical care interventions in an appropriate
environment.
 INFECTION
• It is RECOMMENDED to CONTINUOUSLY
EVALUATE AND SEARCH FOR ALTERNATIVE
DIAGNOSIS and DISCONTINUE EMPERICAL
ANTIMICROBIALS if alternate cause of illness is
STRONGLY SUSPECTED/ DIAGNOSED.
(Best clinical practice statement )
 2021 GUIDELINES
• It is RECOMMENDED to
administer antibiotics
immediately, ideally within
1 HOUR OF
RECOGNITION, In
patients with possible
septic shock but NOT IN
SEPSIS WITHOUT
SHOCK. (strong
recommendation, low
quality evidence )
2016 GUIDELINES
• It is RECOMMENDED to
administer antibiotics
immediately, ideally within
1 hour of recognition, In
patients with BOTH
SEPSIS AND SEPTIC
SHOCK (strong
recommendation,
moderate quality evidence)
• In patients without septic shock, RAPID ASSESSMENT
of likelihood of INFECTIONS VERSUS NON
INFECTIOUS CAUSES of illness is RECOMMENDED.
(best clinical practice statement )

• In patients WITHOUT SEPTIC SHOCK, A time limited

course of RAPID INVESTIGATIONS (WITHIN 3
HOURS ) must be done, and if concern for infection
persists, then ADMINISTERING ANTIBIOTICS WITHIN
3 HOURS of first recognisisng sepsis is SUGGESTED.
(weak recommendation, very low quality of evidence)
 BIOMARKERS TO START
ANTIBIOTICS
• It is SUGGESTED AGAINST using
PROCALCITONIN + CLINICAL EVALUATION to
decide when to start antimicrobials AS COMPARED
TO CLINICAL EVALUATION ALONE.
 DECISION TO DEFER ANTIBIOTICS
2021 GUIDELINES
• For adults with LOW • It is RECOMMENDED to
LIKELIHOOD OF
INFECTION and
WITHOUT SHOCK, it is
SUGGESTED to DEFER
ANTIBIOTICS while
continuiung to closely
monitor the patient. (weak
recommendation, very low
quality evidence)
2016 GUIDELINES
INITIATE THE
ADMINISTRATION OF
ANTIMICROBIALS as
early as possible WITHIN
1 HOUR for patients in
both sepsis and septic
shock.
 PATIENTS WITH POSSIBLE MRSA
INFECTION
2021 GUIDELINES
It is RECOMMENDED to use
EMPERICAL ANTIMICROBIALS
WITH MRSA COVERAGE over
using those without MRSA
coverage in patients with HIGH
RISK OF MRSA INFECTION.
(best clinical practice statement )
Similarly , it is RECOMMENDED
AGAINST using emperical
antimicrobials with MRSA
coverage in patients with LOW
RISK OF MRSA.
2016 GUIDELINES
• It is RECOMMENDED to use
EMPERICAL BROAD
SPECTRUM THERAPY WITH
1 OR MORE
ANTIMICROBIALS TO COVER
ALL LIKELY PATHOGENS
( including bacterial and
potentially fungal or viral
coverage) in patients of sepsis/
septic shock . ( strong
recommendation, moderate
quality evidence )
 MULTI DRUG RESISTANCE
ORGANISMS
• It is SUGGESTED to use 2 ANTIMICROBIALS WITH
GRAM NEGATIVE COVERAGE FOR EMPERICAL
TREATMENT OVER 1, in patients of sepsis with HIGH
RISK OF INFECTION WITH MULTIDRUG RESISTANT
(MDR) ORGANISMS. Similarly, it IS SUGGESTED
AGAINST using 2 antimicrobials in patients with low risk of
infections with MDR organisms.

• It is SUGGESTED AGAINST using double gram negative

coverage antibiotics ONCE THE CAUSATIVE AGENT IS
KNOWN.
 ANTIFUNGAL THERAPY
2021 GUIDELINES
• It is SUGGESTED to USE • It is RECOMMENDED to
EMPERICAL
ANTIFUNGAL THERAPY
OVER NO ANTIFUNGAL
THERAPY in patients of
sepsis/ septic shock with
HIGH RISK OF FUNGAL
INFECTIONS. ( weak
recommendation, low
quality evidence )
2016 GUIDELINES
use EMPERICAL BROAD
SPECTRUM THERAPY
WITH 1 OR MORE
ANTIMICROBIALS TO
COVER ALL LIKELY
PATHOGENS
( INCLUDING BACTERIAL
AND POTENTIALLY
FUNGAL OR VIRAL
COVERAGE)
CONT. CONT.
• It is SUGGESTED • patients of sepsis/ septic
AGAINST the use of shock .
antifungals in LOW RISK (strong recommendation,
OF FUNGAL INFECTION. moderate quality evidence)
(weak recommendation, low
quality evidence)
• No recommendation on use of ANTIVIRAL AGENTS.

• Prolonged INFUSION OF BETA LACTAMS FOR

MAINTAINENCE (AFTER INITIAL BOLUS ) OVER
CONVENTIONAL BOLUS INFUSION is SUGGESTED.
(strong recommendation, moderate quality evidence)

• OPTIMISING DOSING STRATEGIES of antimicrobials based

on ACCEPTED PHARMACOKINETIC/ PHARMACODYNAMIC
PRINCIPLES and specific drug properties is
RECOMMENDED. ( best clinical practice statement )
• It is RECOMMENDED to RAPIDLY IDENTIFY OR
EXCLUDE A SPECIFIC ANATOMICAL DIAGNOSIS OF
INFECTION THAT REQUIRES EMERGENT SOURCE
CONTROL and implementing any required SOURCE
CONTROL INTERVENTION as soon as medically and
logistically practical.( best clinical practice statement)

• PROMPT REMOVAL OF INTRAVASCULAR ACCESS

DEVICES that can be possible sources of infection after
other vascular access has been established is
RECOMMENDED . ( best clinical practice statement)
• DAILY ASSESSMENT FOR DE ESCALATION OF
ANTIMICROBIALS over using fixed durations of therapy
without daily assessment is SUGGESTED. (weak
recommendation, very low quality evidence)

• For patients with initial diagnosis of septic shock and

ADEQUATE SOURCE CONTROL, it is SUGGESTED to
use SHORTER DURATION OF ANTIMICROBIAL
THERAPY OVER LONGER.(weak recommendation, very
low quality evidence )
• It is SUGGESTED to use PROCALCITONIN
+CLINICAL EVALUATION to decide when to
DISCONTINUE ANTIMICROBIALS over CLINICAL
EVALUATION ALONE when optimal DURATION OF
THERAPY IS UNCLEAR.
(weak recommendation, low quality evidence )
 HEMODYNAMIC MANAGEMENT
2021 GUIDELINES 2016 GUIDELINES
• It is RECOMMENDED to • It Is SUGGESTED to use
use BALANCED EITHER BALANCED
CRYSTALLOIDS for CRYSTALLOIDS OR
resuscitation OVER NORMAL SALINE FOR
NORMAL SALINE. RESUSCITATION.
(weak recommendation, low (weak recommendation, low
quality evidence ) quality evidence )
 2021 GUIDELINES 2016 GUIDELINES
• It is SUGGESTED • It is SUGGESTED to use
AGAINST GELATIN USE CRYSTALLOIDS OVER
FOR RESUSCITATION OF GELATIN FOR
PATIENTS with RESUSCITATION of
sepsis/septic shock. (weak patients with sepsis/ septic
recommendation, shock. (weak
moderate quality evidence) recommendation, low
quality evidence )
• CRYSTALLOIDS to be used as 1ST LINE FLUID for
resuscitation is RECOMMENDED. (strong
recommendation, high quality evidence )

• It is RECOMMENDED to use ALBUMIN in patients who

have received LARGE VOLUMES OF CRYSTALLOIDS.
(weak recommendation, moderate quality evidence )

• RECOMMENDATION against using STARCHES FOR

RESUSCITATION. (strong recommendation, high quality
evidence )
• It is RECOMMENDED to use NOREPINEPHRINE as 1ST LINE
AGENT over other VASOPRESSORS. ( strong
recommendation, high quality evidence).
• Strong recommendations after norepinephrine in the order,
follow -
1. Dopamine ( high quality evidence ‘’)
2. Vasopressin (moderate ‘’)
3. Epinephrine (low ‘’ )
4. Selepressin (low’’ )
5. Angiotensin 2 (very low ‘’ )
• It is SUGGESTED to ADD VASOPRESSIN INSTEAD OF
ESCALATING NOR EPINEPHRINE dose in patients with
inadequate MAP. (weak recommendation ,moderate quality
evidence )

• It is SUGGESTED to add EPINEPHRINE OVER

VASOPRESSIN AND NOR EPINEPHRINE in patients not
maintaining MAP. (weak recommendation, low quality
evidence)

• It is SUGGESTED AGAINST use of TERLIPRESSIN.

(weak recommendation ,low quality of evidence )
• In patients with septic shock and CARDIAC
DYSFUNCTION, with PERSISTANT HYPOPERFUSION,
despite adequate volume status and arterial blood
pressure, It is SUGGESTED to add DOBUTAMINE to
norepinephrine or using epinephrine alone and
SUGGESTED AGAINST using LEVOSIMENDAN. (weak
recommendation ,low quality evidence )

• INVASIVE MONITORING of ARTERIAL BLOOD

PRESSURE over non invasive monitoring if feasable, is
SUGGESTED. (weak recommendation, very low quality
evidence )
• It is SUGGESTED to START VASOPRESSORS
PERIPHERALLY to restore mean arterial pressure
RATHER THAN DELAYING INITIATION until a central
venous access is restored. (weak recommendation, very
low quality evidence )

• There is INSUFFICIENT EVIDENCE to make a

recommendation on the use of restrictive versus liberal fluid
fluid strategies in the first 24 hours of resuscitation in
patients who still have signs of hypoperfusion and volume
depletion after initial resuscitation.
 VENTILATION
• There is INSUFFICIENT EVIDENCE to make a
recommendation on use of conservative oxygen targets in
adults with sepsis induced hypoxemic respiratory failure.

• HIGH FLOW NASAL OXYGEN over non invasive

ventilation is SUGGESTED. (weak recommendation, low
quality evidence )

• INSUFFICIENT EVIDENCE to make a recommendation on

use of non invasive ventilation over invasive ventilation.
 FOR PATIENTS WITH SEPSIS
INDUCED ARDS
• LOW TIDAL VOLUME (6ML/KG) ventilation strategy is recommended
over higher volumes(10ml/kg).
• Upper limit goal for PLATEAU PRESSURE is recommended to BE 30
CM H2O.
• It is suggested to use HIGHER PEEP OVER LOWER PEEP.
• TRADITIONAL RECRUITMENT MANEOUVERS are suggested.
• Recommendation against using INCREMENTAL PEEP STRATEGY.
• Prone ventilation for GREATER THAN 12 HOURS DAILY is
recommended.
• INTERMITTANT NMBA BOLUSES are suggested than using NMBA
CONTINUOUS INFUSION
• It is suggested to use VENO-VENOUS ECMO when
 ADDITIONAL THERAPIES
2021 GUIDELINES
• It is SUGGESTED to use • It is SUGGESTED against
IV CORTICOSTEROIDS in
patients of sepsis/ septic
shock requiring
vasopressor therapy.
(strong recommendation,
moderate quality
evidence )
2016 GUIDELINES
using INTRAVENOUS
HYDROCORTISONE to
treat septic shock patients
if adequate fluid
resuscitation and
vasopressor therapy are
able to restore
hemodynamic stability.
 2021 GUIDELINES 2016 GUIDELINES
• It is SUGGESTED against • If not achievable, then iv
using POLYMYXIN B HYDROCORTISONE
HEMOPERFUSION. 200MG/DAY is
( weak recommendation, RECOMMENDED.
low quality evidence ) • NO RECOMMENDATION
• INSUFFICIENT regarding use of BLOOD
EVIDENCE to make a PURIFICATION
recommendation on the TECHNIQUES
use of BLOOD
PURIFICATION
TECHNIQUES.
• RESTRICTIVE OVER LIBERAL TRANSFUSION strategy is
RECOMMENDED. (strong recommendation , moderate
quality evidence )
• It is SUGGESTED AGAINST using INTRAVENOUS
IMMUNOGLOBULINS. ( weak recommendation, low quality
evidence)
• It is SUGGESTED to use STRESS ULCER PROPHYLAXIS
in patients with RISK FACTORS FOR GIT BLEEDING.
(weak recommendation, moderate quality evidence )
• It is RECOMMENDED to USE PHARMACOLOGICAL
VENOUS THROMBOEMBOLISM PROPHYLAXIS unless a
contraindication to such therapy exists. (strong
recommendation, moderate quality evidence )
• It is RECOMMENDED to USE LOW MOLECULAR
WEIGHT HEPARIN OVER UNFRACTIONATED HEPARIN
for VTE prophylaxis. (strong recommendation, moderate
quality evidence )
• It is SUGGESTED AGAINST using MECHANICAL
THROMBOPROPHLAXIS + PHARMACOLOGICAL
THROMBOPROPHYLAXIS over pharmacological
thromboprophylaxis alone. (weak recommendation, low
quality evidence)
• It is SUGGESTED using RENAL REPLACEMENT THERAPY
(EITHER CONTINUOUS OR INTERMITTANT ) in patients of
sepsis/ septic shock with AKI . (weak recommendation, low
quality evidence )

• It is RECOMMENDED to initiate INSULIN THERAPY at a

glucose level of >180 MG/DL (10mmol/L) (strong
recommendation, moderate quality evidence )

• It is SUGGESTED AGAINST using INTRAVENOUS

VITAMIN C (weak recommendation, low quality evidence )
• For patients with septic shock and hypoperfusion induced lactic
acidemia, it is SUGGESTED AGAINST using SODIUM
BICARBONATE THERAPY TO IMPROVE HEMODYNAMICS or
to REDUCE VASOPRESSOR REQUIREMENTS (weak
recommendation ,low quality evidence)

• For patients with septic shock and SEVERE METABOLIC

ACIDEMIA PH<7.2 AND ACUTE KIDNEY INJURY use of
SODIUM BICARBONATE therapy is SUGGESTED. (weak
recommendation, low quality evidence )

• For patients with sepsis or septic shock who can be FED

ENTERALLY, EARLY INITIATION ( WITHIN 72 HOURS ) OF
ENTERAL NUTRITION is SUGGESTED. ( weak
recommendation, vey low quality evidence )
 LONG TERM OUTCOMES AND
GOALS OF CARE
• DISCUSSING GOALS OF CARE EARLY (WITIN 72
HOURS ) AND PROGNOSIS with patients and families
over no such discussions/ late discussion is
RECOMMENDED. (best clinical practice statement)
• It is RECOMMENDED that PRINCIPLES OF PALLIATIVE
CARE should be incorporated into treatment plan. (best
clinical practice statement)
• SCREENING OF ECONOMIC AND SOCIAL SUPPORT
(housing, nutritional, financial, spiritual support) is
RECOMMENDED. (best clinical practice statement)
 ,
• RECONCILING MEDICATIONS at both ICU AND HOSPITAL
DISCHARGE is RECOMMENDED. (best clinical practice statement)

• INCLUSION OF INFORMATION ABOUT ICU STAY, SEPSIS,

RELATED DIAGNOSIS, TREATMENTS, AND COMMON
IMPAIRMENTS AFTER SEPSIS IN WRITEN AND VERBAL
HOSPITAL DISCHARGE SUMMARY are RECOMMENDED. (best
clinical practice statement)

• Patients who develped new impairments, it is RECOMMENDED

that HOSPITAL DISCHARGE PLANS INCLUDE FOLLOW UP WITH
CLINICIANS in order to support and manage new and long term
sequelae. (best clinical practice statement)
THANK
YOU