April 08, 2014

Surviving Sepsis Guidelines 2013

Dr. Bharat Awsare, Assistant Professor of Medicine, Medical Director, MRICU at Thomas Jefferson University highlights of changes in the 2013 version of the Surviving Sepsis Guidelines.

The Surviving Sepsis Campaign is an international collaboration between the Society of Critical Care Medicine, European Society of Intensive Care Medicine, and the International Sepsis Forum. The campaign was devised in 2002 in an effort to reduce the mortality of sepsis through educational programs and performance improvement initiatives. The 2008 iteration of the guidelines were recently revised and presented at the Society of Critical Care Medicine, American College of Emergency Physicians, and in Critical Care Medicine (Crit Care Med 2013;41:580-637). The quality of evidence was presented using the Grading of Recommendations Assessment, Development, and Evaluation system (GRADE) from high (A) to very low (D). The strength of the recommendations was presented as strong (1) or weak (2). The following is a summary of important changes of the guidelines from the 2008 version.

With regards to fluids, the authors strongly recommended the use of crystalloids (normal saline) for initial fluid resuscitation in severe sepsis (1B). When excessive amounts of fluids are needed for resuscitation, albumin was a weak recommendation (2C). Hydroxyethyl starches (HES) was not recommended (1B). The lack of clear benefit of alternate solutions to crystalloids and the increased cost of colloids was the rationale for the recommendations. The initial fluid bolus has been increased from 15-20 ml/kg to 30 ml/kg and at least 1 liter is recommended in the first 6 hours (1C).

In addition, the guidelines have fallen out of favor for dopamine as an initial pressor in severe sepsis due to its arhythmogenicity ; norepinephrine (NE) remains the pressor of choice (1C). The guidelines now say that dopamine should be only used as an alternative only in selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia (2C). Epinephrine now has been added as a pressor in addition to and possible instead of norepinephrine (2B). Vasopressin can be added to NE at a dose of 0.03 units/minute to increase blood pressure or decrease NE use. Phenylephrine should not be used unless NE is associated with serious arrhythmias, cardiac output is high and blood pressure low, or as salvage vasopressor therapy (1C).

Another important change is the recommendation of using lactate clearance as a substitute to central venous oxygen saturation monitoring (2C) when the latter is unavailable; central venous oxygen saturation is still a 1C recommendation (strong recommendation with low evidence). Of note, three separate trials (ARISE in Australia, PROCESS in US, and PROMISE in the UK) are currently ongoing to answer the question of whether lactate clearance is as effective.

The panel recommend against the routine use of corticosteroids for patients in whom fluids and vasopressors can restore an adequate mean arterial pressure (2C). Furthermore, an ACTH stimulation test to identify adrenal insufficiency was not recommended (2B). Finally, when hydrocortisone is given, there was a weak recommendation to give continuous infusion (2D).

Interestingly, the panel addressed the concerns of the delicate balance between early liberal use of antibiotics and the overuse of antibiotics in patients without infection. One such recommendation was the use of the biomarker procalcitonin to terminate antibiotics in low risk patients (2C).

Suggested additional resources include the surviving sepsis website.

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