New Surviving Sepsis Guidelines – What’s new? St.Emlyn’s

severe sepsis definitionAfter much anticipation the new surviving sepsis guidelines have been published in critical care medicine.

There will no doubt be much conversation, debate and discussion about this in the coming weeks and I’ll bet Scott Weingart will be all over it already. I’m really looking forward to the inevitable podcasts on this from my expert ICU colleagues.

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This post is really just a quick heads up on what’s happening. If you are an ED/Intensivist you really should be going through all 58 pages yourself. This is important stuff which will probably influence practice for years to come. If 58 pages is too much for you then there are some more accessible guides here at the surviving sepsis website. What I would like to see is a nice diagram though – I like pictures!

So what about the ED docs? What’s new for us in the first read through? Here are a few notable points from the document –

  1. Definitions of severe sepsis are clear and defined across a range of clinical and laboratory investigations (see the table above).
  2. Outcomes for initial resuscitation within 6 hours mandate
  • CVP 8-12
  • MAP >65mmHg
  • Urine output >o.5ml/Kg
  • ScVO2 or mixed venous O2 of 70% or 65% respectively.
  • Normalisation of lactate as a resuscitation goal.

3. Dobutamine and/or Red cells for patients with persistently low venous O2 s

4. Priority to antibiotics within first hour, 2 sets of cultures so long as antibiotics not delayed by more than 45 mins.

5. Priority to search for source of infection – early imaging helpful (my thoughts)

So, no reduction in the number of central lines that need placing in the ED then and a re-iteration of the need for early antibiotics. CVP is still advocated to guide resuscitation which is interesting (though the limitations of this are mentioned in the full article). Starch has gone (as we have been saying for a while here at St.Emlyn’s).

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The guideline has been put into two bundles. One to be delivered within three hours and one within 6 hours. Cynically I notice that this straddles the 4-hour target in the UK (but perhaps that is too cynical).

Bundle  
1. Complete within 3 hours
  • Measure lactate
  • Get blood cultures before antibiotics
  • Give broad spectrum antibiotics
  • Give 30ml/Kg crystalloid for hypotension or lactate >4mmol/L
2. Complete within 6 hours
  • Give vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) _ 65 mm Hg
  • In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/L (36 mg/dL):

–       Measure central venous pressure (CVP)*

–       Measure central venous oxygen saturation (ScVO2)

  • Remeasure lactate if initial lactate was elevated

 

*Targets for quantitative resuscitation included in the guidelines are CVP of _8 mm Hg, ScvO2 of 70%, and normalization of lactate.

 

So what do you think? My initial thoughts are that the guideline is pretty conservative and may arguably be behind the current thinking in some units.

What do you think?

[author] [author_image timthumb=’on’]http://stemlynsblog.org/wp-content/uploads/2012/07/Simon-Carley.jpeg[/author_image] [author_info]Simon Carley[/author_info] [/author]

 

 

4 Comments

  1. Kirsty Challen (@KirstyChallen)

    Thoughts:

    1. This will leave PROMISE in a mess as arguing for equipoise will be hard.

    2. Mandatory CVP? Really? Has no-one heard of IVC US for fluid responsiveness (oh, sorry, Prof C, you taught it to me!). Cue Weingart I think – it makes me very uncomfortable that there is no recognition of alternatives in a patient set where IJ/SC placement may be contraindicated/ difficult/ dangerous/ all 3. They do acknowledge in the whole guideline that SCVO2 might be replaced or augmented by lactate clearance but not a nod to alternatives to CVP.

    3. Crystalloids and norepi – woohoo, at last!

    4. Clearly we should aim to culture to target abx therapy. However I wonder what the pickup rate is of blood cultures in the hypothermic patient? (Genuine question, any microbiologists out there?)

    Reply
    1. drgdh

      Wasn’t PROMISE a bit of a mess anyway? Anyone have equipoise before this update? Saying that, interesting to note that apart from Rivers, the only RCT found to support EGDT is a 314 patient study published in Chinese….

      Reply
  2. emcrit

    podcast will be out on Thursday. Love to hear your thoughts fater.

    Scott

    Reply
    1. Simon Carley (Post author)

      Fantastic – I’ll add a link to it in the post when it’s out. I really want to hear your thoughts on the fluid management and assesment parts of the guidelines.

      Is this the end (or just the beginning) of using USS to evaluate fluid tolerance/responsiveness?

      CVP as an target for resuscitation.

      I’ll be listening (as will the world).

      S

      Reply

Thanks so much for following. Viva la #FOAMed

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