SSG 2016 Flashcards
sepsis definition:
life-threatening organ dysfunction caused by a dysregulated host response to infection
Septic shock definition:
subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality
A. INITIAL RESUSCITATION
- Sepsis and septic shock are
- sepsis-induced hypoperfusion, at least ——– of IV crystalloid fluid be given within the first ——- h (strong recommendation, low quality of evidence).
- following initial fluid resuscitation, additional fluids be guided by
- further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock if the clinical examination does not lead to a clear diagnosis (BPS).
medical emergencies, and treatment and resuscitation begin immediately (BPS).
30 mL/kg of IV crystalloid fluid
3 h
frequent reassessment of hemodynamic status (BPS)
- further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock if the clinical examination does not lead to a clear diagnosis (BPS).
- We suggest that —– over ——- variables be used to predict fluid responsiveness, where available (weak recommendation, low quality of evidence).
- We recommend an initial target mean arterial pressure (MAP) of
- We suggest guiding resuscitation to normalize
dynamic over static variables
65 mm Hg in patients with septic shock requiring vasopressors (strong recommendation, moderate quality of evidence).
lactate levels as a marker of tissue hypoperfusion (weak recommendation, low quality of evidence)
EGDT was challenged following
challenged following the failure to show a mortality reduction in three subsequent large multicenter RCTs [17–19].
No harm was associated with the interventional strategies; thus, the use of the previous targets is still safe and may be considered.
use of CVP alone to guide fluid resuscitation…
Dynamic measures of assessing whether a patient requires additional fluid have been proposed in an effort to improve fluid management and have demonstrated
These techniques encompass
can no longer be justified bc the ability to predict a response to a fluid challenge when the CVP is within a relatively normal range (8–12 mm Hg) is limited
better diagnostic accuracy at predicting those patients who are likely to respond to a fluid challenge by increasing stroke volume
passive leg raises
fluid challenges against stroke volume measurements
MV variations in systolic pressure
pulse pressure
stroke volume to changes in intrathoracic pressure induced by mechanical ventilation
review of five studies of the use of pulse pressure variation to predict fluid responsiveness in patients with sepsis or septic shock demonstrated a sensitivity
sensitivity of 0.72 (95% CI 0.61–0.81)
specificity of 0.91 (95% CI 0.83–0.95)
the quality of evidence was low due to imprecision and risk of bias (ESM 3) [24]. A recent multicenter study demonstrated limited use of cardiac function monitors during fluid administration in the ICUs.
sum of studies comparing MAP of 85 vs 65 concluded:
desirable consequences of targeting MAP of 65 mm Hg (lower risk of atrial fibrillation, lower doses of vasopressors, and similar mortality) led to a strong recommendation favoring an initial MAP target of 65 mm Hg over higher MAP targets
When a better understanding of any patient’s condition is obtained, this target should be individualized to the pertaining circumstances.
Is serum lactate a direct measure of tissue perfusion:
No
Increases in the serum lactate level may represent tissue hypoxia, accelerated aerobic glycolysis driven by excess beta-adrenergic stimulation, or other causes (e.g., liver failure)
Regardless of the source, increased lactate levels are associated with worse outcomes
Five randomized controlled trials evaluated lactate-guided resuscitation of patients with septic shock:
sum of results:
significant reduction in mortality was seen in lactate-guided resuscitation
no evidence for difference in ICU length of stay
Two other meta-analyses of the 647 patients who were enrolled in these trials demonstrate moderate evidence for reduction in mortality when an early lactate clearance strategy was used, compared with either usual care (nonspecified) or with a Scvo2 normalization strategy
We recommend screening program for sepsis:
We recommend Sepsis performance improvement programs:
sepsis screening has been associated with decreased mortality
implementation of a core set of recommendations (bundle) has been a cornerstone of sepsis performance improvement programs
SSC bundles have been developed separately from the guidelines in conjunction Institute for Healthcare
A study of 1794 patients from 62 countries with severe sepsis (now termed “sepsis” after the Sepsis-3 definition [1] or septic shock demonstrated a 36–40% reduction of the odds of dying in the hospital with compliance with either the 3- or 6-h SSC bundles
Dx:
We recommend that appropriate routine microbiologic cultures (including blood) be obtained before starting antimicrobial therapy in patients with suspected sepsis or septic shock if doing so
results in no substantial delay in the start of antimicrobials (BPS).
Remarks Appropriate routine microbiologic cultures always include at least two sets of blood cultures (aerobic and anaerobic)
which sites:
Pan culture?
all sites considered to be potential sources of infection if it results in no substantial delay in the start of antimicrobials
including blood, CSF, urine, wounds, respiratory secretions, and other body fluids
Not bronchoscopy or open surgery
discouraged (unless the source of sepsis is not clinically apparent), because this practice can lead to inappropriate antimicrobial use
specific anatomic site of infection, cultures of other sites (apart from blood) + BLOOD
45 min i.e. be no substantial delay
How many samples and what type:
Catheter and blood - if concerned about catheter related infection?
Two or more sets
aerobic and anaerobic of blood cultures
Data are inconsistent regarding the utility of differential time to blood culture positivity (i.e., equivalent volume blood culture from the vascular access device positive more than 2 h before the peripheral blood culture) in suggesting that the vascular access device is the source of the infection
ANTIBIOTICS:
We recommend that administration of IV antimicrobials be initiated
as soon as possible after recognition
and within 1 h for both sepsis and septic shock (strong recommendation, moderate quality of evidence; grade applies to both conditions)
- We recommend empiric ______ with ______ antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens (including bacterial and potentially fungal or viral coverage) (strong recommendation, moderate quality of evidence).
- We recommend that antimicrobial therapy be narrowed once
empiric broad-spectrum
one or more antimicrobials
sensitivities are established and/or adequate clinical improvement is noted (BPS)
Several factors in determining the appropriate antimicrobial regimen (a) (b) (c) (d) (e)
(a) The anatomic site of infection with respect to the typical pathogen profile and to the properties of individual antimicrobials to penetrate that site
(b) Prevalent pathogens within the community, hospital, and even hospital ward
(c) The resistance patterns of those prevalent pathogens. (d) The presence of specific immune defects such as neutropenia, splenectomy, poorly controlled HIV infection and acquired or congenital defects of immunoglobulin, complement or leukocyte function or production
(e) Age and patient comorbidities including chronic illness (e.g., diabetes) and chronic organ dysfunction (e.g., liver or renal failure), the presence of invasive devices (e.g., central venous lines or urinary catheter) that compromise the defense to infection.
prophylaxis Ab in severe inflammatory states of noninfectious origin (e.g., severe pancreatitis, burn injury) (BPS).
We recommend against sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of noninfectious origin (e.g., severe pancreatitis, burn injury) (BPS).
distinctions with Ab dosing in sepsis:
most importantly with respect to initial empiric antimicrobial dosing
frequency of hepatic and renal dysfunction
high prevalence of unrecognized immune dysfunction predisposition to infection resistant organisms
increased volume of distribution for most antimicrobials, in part due to the rapid expansion of extracellular volume as a consequence of aggressive fluid resuscitation. This results in an unexpectedly high frequency of suboptimal drug levels with a variety of antimicrobials in patients with sepsis and septic shock
β-lactams, the key pharmacodynamics correlate to microbiologic and clinical response is the time that the plasma concentration of the drug is above the pathogen MIC relative to the dosing interval (T > MIC)
A minimum T > MIC of 60% is generally sufficient to allow a good clinical response to
T > MIC of 100% for
simplest way to increase T > MIC is to:
mild to moderate illness
severe
use increased frequency of dosing
some meta-analyses suggest that extended/continuous infusion of β-lactams may be more effective than intermittent rapid infusion, particularly for relatively resistant organisms and in critically ill
recent individual patient data meta-analysis of randomized controlled trials comparing continuous versus intermittent infusion of β-lactam antibiotics in critically ill patients with severe sepsis demonstrated an independent protective effect of continuous therapy after adjustment for other correlates of outcome
How many Ab. septic shock
empiric combination therapy (using at least two antibiotics of different antimicrobial classes) aimed at the most likely bacterial pathogen(s) (weak recommendation, low quality of evidence).
combination therapy for bacteremia and sepsis without shock?
not be routinely used for ongoing treatment of most other serious infections, including bacteremia and sepsis without shock (weak recommendation, low quality of evidence).
combination therapy for the routine treatment of neutropenic sepsis/bacteremia?
against combination therapy for the routine treatment of neutropenic sepsis/bacteremia (strong recommendation, moderate quality of evid
If combination therapy is initially used for septic shock, we recommend
de-escalation with discontinuation of combination therapy within the first few days in response to clinical improvement and/C&S