SSC GUIDELINES 2015

Rizki A. Nawawi, S.Ked

Fakrocev C. Gulo, S.Ked
Lia Damayanti, S.Ked
Gebryza R. Utari, S.Ked

Advisor:
dr. H. Zulkifli, SpAn, KIC, M.Kes
Sepsis Severe sepsis Sepsis- induced
the presence sepsis + organ hypotension
(probable or dysfunction or SBP < 90 mm Hg
documented) of tissue or
infection together hypoperfusion (MAP) < 70 mmHg
with systemic or
manifestations of SBP decrease > 40
infection. mm Hg or
less than two SD
below normal for
age in the absence
of other causes.
PATHOGENESIS
 INITIAL RESUSCITATION OF SEVERE SEPSIS
1. During the first 6 hrs of
resuscitation, the goals (grade 2. Normalize
1C):
a) CVP 812 mm Hg
lactate level

b) MAP 65 mm Hg
c) Urine output 0.5 mLkghr
(grade 2C).
d) Superior vena cava oxygenation
saturation (Scvo2) or mixed venous
oxygen saturation (Svo 2) 70% or
65%

15.9% absolute
reduction in 28-day
mortality rate
 SCREENING FOR SEPSIS AND
PERFORMANCE IMPROVEMENT

1. Screening of potentially infected seriously ill patients for

severe sepsis (grade 1C).

early identification of sepsis improve outcomes and

decrease mortality.

2. Performance improvement efforts should be used to

improve patient outcomes (UG).
Sepsis management requires a multidisciplinary team
(physicians, nurses, pharmacy, respiratory, dieticians, and
administration) and multispecialty collaboration
(medicine, surgery, and emergency medicine).
 DIAGNOSIS
1. Obtain appropriate cultures before antimicrobial therapy is if
such cultures do not cause significant delay (> 45 minutes) (grade
1C).
To optimize identification two sets of blood cultures
(aerobic and anaerobic) before antimicrobial therapy,
Cultures of other sites (urine, cerebrospinal fluid, wounds,
respiratory secretions, or other body fluids that may be the
source of infection) should also be obtained if not causing
delay the administration of antimicrobial (grade 1C)

2. Imaging studies confirm a potential source of infection (UG).

May identify a source of infection that requires removal of a

foreign body or drainage
Clinicians must balancing risk and benefit
 ANTIMICROBIAL THERAPY

1. The administration antimicrobials IV within the

first hour of recognition goal of therapy.

First priorities:Vascular access and aggressive

fluid resuscitation
Each hour delay in achieving administration
of effective antibiotics increase in
mortality
 The most common pathogens that cause
septic shock in hospitalized patients are
2a. Initial empiric therapy Gram-positive, Gram-negative, and mixed
include one/more drugs bacterial microorganisms.
have activity against all likely
pathogens and can Candidemia antifungal therapy
penetrate into the tissues
presumed to be the source
of sepsis (grade 1B)

causative pathogen identified select

the most appropriate antimicrobial
2b. The antimicrobial
regimen reassessed daily
prevent the
development of resistance,
to reduce toxicity, and to
reduce costs (grade 1B).
3. the use of low
procalcitonin levels or
similar biomarkers to
discontinuation of empiric
antibiotics in patients who
appeared septic (grade
2C).
However, clinical experience with
this strategy is limited and the
potential for harm remains a
concern
 Combination empiric therapy:
neutropenic patients with severe sepsis (grade 2B)
multidrug-resistant bacterial pathogens such as
4a. Empiric Acinetobacter and Pseudomonas spp. (grade 2B).
Bacteremia P.aeruginosa beta-lactam and either an
therapy aminoglycoside or a fluoroquinolone (grade 2B).
antimicrobial Bacteremia Streptococcus pneumoniae beta-lactam and a
macrolide (grade 2B).
activity against
the most likely
pathogens.

4b. Combination
Avoid antimicrobial resistance
therapy not be
administered >
3-5 days (grade
2B).
 slow clinical
response

undrainable
foci of
infection

5. Duration of
therapy: 7-10
days.
immunologic
deficiencies,
bacteremia
including
with S. aureus
neutropenia
(grade 2C).
some fungal
and viral
infections,
 confirmed
influenza among
persons with
severe influenza

Antiviral initiated as
early as possible

severe primary persons at

or generalized higher risk for
varicella zoster influenza
virus infections complications
7. antimicrobial agents not be used in patients
with severe inflammatory with noninfectious
cause (UG)

to minimize the likelihood that the patient will become

infected with an antimicrobial-resistant pathogen or will
develop a drug-related adverse effect.
SOURCE CONTROL
1. specific anatomical diagnosis of infection requiring consideration for
emergent source control (eg, necrotizing soft tissue infection, peritonitis,
cholangitis, intestinal infarction) be sought and diagnosed or excluded as
rapidly as possible, and intervention be undertaken for source control
within the first 12 hr after the diagnosis is made. (grade 1C)
The principles of source control
rapid diagnosis of the specific site of
infection
identification of a focus of infection
amenable to source control measures
 3. Use albumin when
substantial amounts
of crystalloids (grade
2C)
2. Dontuse of 4. Fluid challenge:
hydroxyethyl minimum of 30 mL/
starches (HES) kg of crystalloids
(grade 1B). (grade 1C).

5. fluid challenge
1. crystalloids as the
initial fluid (grade
Fluid technique be applied
continued as long as
1B). Therapy there is
hemodynamic
improvement

CRYSTMAS no
difference in mortality with
HES vs. 0.9% normal saline
(31% vs. 25.3%, p = 0.37)
Scandinavian multicenter
study increased
mortality rates with 6%
HES 130/0.42 compared to
Ringers acetate (51% vs.
43% p = 0.03)

The CHEST study no

difference in 90-day
mortality between
resuscitation with 6% HES
and isotonic saline (18% vs.
17%, p = 0.26)
 Target MAP 65
mmHg

Dopamine:
1st choice
alternation of
norepinephrin
vasopressor

Vasopressor

Low dose
vasopressin and Additional
phenylephrine agent
not epinephrin
recommended

Vasopressin
(0,03 U/m) can
be added
Dopamine

increases MAP and cardiac output, primarily due

to an increase in stroke volume and heart rate.

Norepinephrine

increases MAP due to its vasoconstrictive effects,

with little change in heart rate and less increase
in stroke volume compared with dopamine.
Five randomized trials comparing norepinephrine
to dopamine does not support the routine
use of dopamine in the management of septic
shock
8. Low-dose dopamine not be used for renal protection

A large randomized trial and meta-analysis: low-dose

dopamine vs placebo no difference in either primary
outcomes (peak serum creatinine, need for renal
replacement, urine output, time to recovery of normal renal
function) or secondary outcomes (survival to either ICU or
hospital discharge, ICU stay, hospital stay, arrhythmias)

9. All patients requiring vasopressors have an arterial

catheter placed (UG).

In shock states, use of an arterial cannula provides a more

appropriate and reproducible measurement of arterial
pressure.
 INOTROPIC THERAPY

a) myocardial dysfunction:
elevated cardiac filling
pressures and low cardiac
Dobutamine infusion up to output
20 g/kg/min be
administered or added to
vasopressor (if in use) in b) ongoing signs of
the presence of: hypoperfusion, despite
achieving adequate
intravascular volume and
MAP (grade 1C).
CORTICOSTEROID
1.Not using intravenous hydrocortisone as a treatment if hemodynamic is stable
after the resuscitation.
If not hydrocortisone IV single 200 mg per day (grade 2C).

2. Not using the ACTH stimulation test to identify who should receive
hydrocortisone (grade 2B).

In one study, the observation of a potential interaction between steroid use and
ACTH test was not statistically significant.

3. Taper the steroid

when vasopressors are no longer required (grade 2D).

4. Corticosteroids not be administered

in the absence of shock (grade 1D).

5. Low-dose hydrocortisone infusion (grade 2D).

A small prospective study: repetitive bolus application increase in blood
glucose
SUPPORTIVE THERAPY FOR SEVERE SEPSIS
1. Tissue hypoperfusion resolved, RBC transfusion: Hb < 7.0 g/dL (grade 1B).
Transfusion Requirements in Critical Care: Hb 7 -9 g/dL vs 10-12 g/dL was not
associated with increased mortality

2. Not using erythropoietin as a specific treatment of anemia (grade 1B).

Clinical trials decrease in RBC transfusion requirement with no effect on
clinical outcome

3. FFP not be used to correct laboratory clotting abnormalities (grade 2D).

deficiency of coagulation factors (increased PT, INR, or PTT) and the presence of
active bleeding or before surgical or invasive procedures

4. Not administer antithrombin (grade 1B).

No beneficial effect on 28-day mortality in adults

5. Platelets be administered prophylactically

10,000/ mm3 in the absence of apparent bleeding
20,000/mm3 if the patient has a significant risk of bleeding. (grade 2D).
Severe sepsis limitation of platelet production and increased platelet
consumption.
 One larger multicenter
RCT in adult patients and
Dont give IV
one large multinational
immunoglobulins (grade
RCT in infants with
2B)
neonatal sepsis no
benefit.
Dont use IV selenium
(grade 2C). Although some RCTs are
Selenium was administered to available, the evidence on
correct the known reduction of the use of intravenous
selenium concentration
provide antioxidant defense.
selenium is still very weak.
HISTORY OF RECOMMENDATIONS
REGARDING USE OF
RECOMBINANT ACTIVATED PROTEIN C
2001: Approved for use in adult
patients (PROWESS: in mortality)

2004: SSC recommended use of

rhAPC, grade B quality of evidence

2008: SSC suggested only in adult

patients with APACHE II score 25

2011: PROWESS SHOCK: No benefit

in severe sepsis & septic shock

Product withdrawn from market (no

need for recommendation)
 Target a tidal
volume of 6
mL/kg PBW

Recruitment
Measure plateau
maneuvers in
Mechanical
severe refractory
pressures (30
cmH2O)
hypoxemia
Ventilation of
Sepsis-Induced
ARDS
Apply PEEP to
Base strategy on
avoid alveolar
higher PEEP
collapse
 Prone positioning in
patients with PaO2/FiO2
100 mmHg in
experienced facilities

Maintain ventilated
Spontaneous breathing
trials regularly Mechanical patient with head
elevated 30-45

Ventilation of
Sepsis-Induced
ARDS

Noninvasive mask
A weaning protocol ventilation in some
needs to be in place patients where benefits >
risks
 no new potentially
serious conditions

low ventilatory and

hemodynamically
end-expiratory
stable (without
pressure
vasopressor agents)
requirements

Evaluate the ability low Fio2

to discontinue requirements which
arousable can be met safely
mechanical delivered with a face
ventilation mask or nasal cannula
 Against routine use
of pulmonary artery
catheter

Mechanical
Ventilation of
Sepsis-Induced
Not using 2-
ARDS Conservative fluid
agonists unless strategy if no sign of
indicated hypoperfusion
SEDATION, ANALGESIA, AND
NEUROMUSCULAR BLOCKADE

Continuous or intermittent sedation be minimized in

mechanically ventilated patients

NMBAs be avoided if possible in the septic patient without

ARDS
If must be maintained, either intermittent bolus as required or
continuous infusion with train-of-four monitoring of the depth of
blockade

Short course of NMBA ( 48 hrs) for patients with early

sepsis-induced ARDS and PaO2/FiO2 < 150 mm Hg
 Glucose Control
Commence insulin
Monitor blood
dosing if 2 Interpret glucose
every 12 hrs until
consecutive blood levels obtained with
glucose values and
glucose point-of-care testing
insulin infusion rates
measurement >180 of capillary blood
stable afterwards
mg/dL (target 180 with caution
every 4 hrs
mg/dL)
 Renal Replacement Therapy
Continuous renal replacement
therapies and intermittent
hemodialysis are equivalent in
patients with severe sepsis and
acute renal failure
Use continuous therapies to
facilitate fluid balance
management in
hemodynamically unstable
septic patients

Na-bicarbonate therapy is not used for improving

hemodynamics or reducing vasopressor requirements in
patients with hypoperfusion-induced lactic acidemia (pH 7.15)

No evidence supports its use in sepsis patients with such

condition
DVT PROPHYLAXIS
Daily
pharmacoprophylaxis Subcutaneous LMWH daily
against venous If creatinine clearance is <30 mL/min, use
dalteparin/other LMWH minimally metabolised
thromboembolism renally/UFH
(VTE)

Combine pharmacologic therapy and intermittent pneumatic compression

devices whenever possible

If heparin is Use mechanical prophylactic treatment (such as

contraindicated, graduated compression stockings or intermittent
pharmacoprophylaxis compression devices) unless contraindicated
is not given When risk decreases, start pharmacoprophylaxis
STRESS ULCER PROPHYLAXIS

Prophylaxis using H2 inhibitor

or PPI is given to septic
patients with risk for bleeding

If prophylaxis used:
PPI > H2 inhibitor

If no risk factors patients do

not receive prophylaxis
NUTRITION
Administer oral or enteral (if necessary) feedings
as tolerated

Avoid mandatory full caloric feeding in the first

week suggest low dose feeding (eg, up to 500
calories per day), advancing only as tolerated

Use IV glucose and enteral nutrition in the first 7

days after a diagnosis of severe sepsis/septic
shock

Use nutrition with no specific immunomodulating

supplementation
 Discuss goals
of care and
prognosis with
patients and
families

Setting
Goals
of Care
Incorporate Address goals of
goals of care care as early as
feasible, but no
into treatment later than 72
and end-of-life hours of ICU
care planning admission
THE 2015 UPDATE
Rationale: 3 trials do not demonstrate superiority of required use of a
central venous catheter (CVC) to monitor central venous pressure
(CVP) and central venous oxygen saturation (ScvO2) in all patients with
septic shock who have received timely antibiotics and fluid resuscitation
compared with controls or in all patients with lactate >4 mmol/L
BUNDLES
Within 3 hours of time of
presentation
Within 6 hours of time of
presentation

Measure lactate level Apply vasopressors (for hypotension that

does not respond to initial fluid
resuscitation) maintain MAP 65mmHg

Obtain blood cultures prior to

administration of antibiotics
If MAP <65 mmHg after initial fluid
administration or initial lactate was 4
mmol/L re-assess volume status and
tissue perfusion and document findings

Administer broad spectrum antibiotics

Re-measure lactate if initial lactate

elevated
Administer 30ml/kg crystalloid for
hypotension or lactate 4mmol/L
CONCLUSIONS

Sepsis: a systemic inflammatory response towards infection

Pathophysiology begins with host response activation of
inflammatory and coagulation cascades collateral damage
in normal tissues
Management of sepsis incorporates initial management,
handling basic problems, and strategies to maintain organ
function
Management, general or specific, needs to be given as fast
and efficient as possible to gain better prognosis
CONCLUSIONS
Antibiotics must be appropriately chosen in order to be effective
in the eradication of causative pathogen from systemic
circulation.
Suspect sepsis if there are toxic appearance, fever, shivering,
tachycardia, tachypnea, decreased level of consciousness and
oliguria. Septic shock is marked by the clinical characteristics of
sepsis with signs of shock.
While guidelines like SSC are static, optimal treatment of severe
sepsis and septic shock is a dynamic and developing process. New
interventions will be proven and preexisting interventions may
need to be modified.
THANK YOU FOR YOUR KIND ATTENTION
DISCUSSION
Kevin
How to assess antimicrobial regimens daily?
Assess responses: clinical improvement with AB administration

If culture results (+) switch to ABs specific to causative agents

Laboratoric values need to be reassessed as well

How to deliver continuous fluid therapy in septic shock after this issue has been
resolved?
Resuscitation guidelines only, no such guideline in SSC-

CVP 8-12 mmHg, MAP >= 65 mmHg

Leo
Combined ABs 5-7 days only, avoid resistance. 7-10 days also for combi therapy?
What do we fear with continuous sedation?
Can still be given to prevent ARDS...
Sedative agents only used for <48 hrs due to its metabolites

Excessive use also interferes with hemodynamics other than arousability and longer days