R.

Phillip Dellinger, MD,

MCCM, FCCP
Acting Chair & Chief of Department of
Medicine
Head, Division of Critical Care Medicine
Cooper University Hospital
Camden, New Jersey

Professor of Medicine Cooper Medical

School of Rowan University
Whats new with the 2012
guidelines and
associated changes in the
database

R. Phillip Dellinger MD, MCCM

Christa A. Schorr RN, MSN, FCCM
Cooper Medical School Rowan
University
Cooper University Hospital
Camden, NJ
 Potential Conflicts of Interest
Neither has direct or indirect potential financial
conflict of interest as to any material presented in
this presentation

As to potential intellectual conflict of interest both

hold leadership positions in Surviving Sepsis
Campaign
Surviving Sepsis Campaign: International
guidelines for
management of severe sepsis and septic shock:
2012

R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali

Annane, Herwig Gerlach, Steven M. Opal, Jonathan E.
Sevransky, Charles L. Sprung, Ivor S. Douglas, Roman
Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R.
Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C.
Angus, Clifford S. Deutschman, Flavia R. Machado,Gordon D.
Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis
Vincent, Rui Moreno, and the Surviving Sepsis Campaign
Guidelines Committee including the Pediatric Subgroup.
Crit Care Med 2013; 41:580-637
Intensive Care Medicine 2013; ..
 Currently Funded with a
Gordon and Betty Moore
Foundation Grant

No direct or indirect industry support

for guidelines revision
Grading Quality of Evidence
GRADE System
A- high quality
B- intermediate
C- low
D- very low
Case series or expert opinion

Upgrade capability
Ungraded (UG) recommendation
Grading Strength of
Recommendation
GRADE System

1- strong recommendation
We recommend
2- weak recommendation
We suggest
Early Screening and a Performance
Improvement Program
 Antibiotic Therapy

We recommend that intravenous

antibiotic therapy be started as early as
possible and within the first hour of
recognition of septic shock (1B) and
severe sepsis without septic shock (1C).
(Best Practice versus Stand of Care)
Resuscitation of Sepsis
Induced Tissue
Hypoperfusion

Recommend MAP 65 mm Hg
FLUID THERAPY
 Fluid therapy

1. We recommend crystalloids be used

in the initial fluid resuscitation of
severe sepsis (Grade 1B).
 Fluid therapy

1. We suggest the use of albumin in

the fluid resuscitation of severe
sepsis and septic shock when
patients require substantial amounts
of crystalloids (Grade 2C).
 Fluid challenge

Initial fluid challenge in sepsis-

induced tissue
hypoperfusion (hypotension or
elevated lactate)
A minimum of 30ml/kg of crystalloids
(a portion of this may be albumin
equivalent). (1B)
Vasopressors
 Vasopressors

1. We recommend norepinephrine as
the first choice vasopressor (Grade 1
B).
 Vasopressors

2. We suggest epinephrine (added to

and potentially substituted for
norepinephrine) when an
additional agent is needed to
maintain blood pressure (Grade
2B).
 Vasopressors

3. Vasopressin .03 units/min can be

added to norepinephrine with the
intent of raising MAP to target or
decreasing or decreasing
norepinephrine dosage.
(UG)
Phenylephrine

Pure vasopressor and in general not recommended

 Sepsis Induced Tissue
Hypoperfusion
(Recommend Quantitative
Resuscitation)
Requirement for vasopressors after
fluid challenge

or

Lactate 4 mg/dL
 Initial Resuscitation of Sepsis
Induced Tissue Hypoperfusion

Recommend
Insertion central venous catheter
Central venous pressure: 812 mm Hg
Higher with altered ventricular
compliance or increased
intrathoracic pressure
Grade 1C
Arterial Systolic Pressure
Variation

Parry-Jones, et al. Int J Respir Crit Care Med 2003;2:6

 Effect on Stroke Volume

Part

A
t
Effect on Stroke Volume
Effect on Cardiac Filling
 Initial Resuscitation of Sepsis
Induced Tissue Hypoperfusion

Recommend
Insertion central venous catheter
ScvO2 saturation (SVC) 70%
Grade 1C
 Lactate Clearance
In patients with elevated lactate levels
as a
marker of tissue hypoperfusion we
suggest
targeting resuscitation to normalize
lactate as
rapidly as possible (grade 2C).