Surviving Sepsis 2012 Guidelines

Question 1

Goals of initial resuscitation of sepsis-induced hypoperfusion (Early Goal Directed Therapy or EGDT)

Answer 1

CVP 8-12
MAP ≥65
Urine output >0.5 mL/kg/hr
SVCO2: 70% or SVO2 75%

Question 2

Blood Culture Guidelines

Answer 2

• BEFORE broad-spectrum abx administration
• Two sets, different sites, both aerobic & anaerobic
• At least one percutaneous, one from each lumen of any access device unless it was very recently placed (< 48hr)

Question 3

Rationale for imaging studies in sepsis

Answer 3

May identify a source of infection that requires removal of foreign body or drainage to maximize likelihood of satisfactory response to treatment

Question 4

Rationale for IV antimicrobials in sepsis

Answer 4

Failure to provide therapy correlates with increased morbidity & mortality in patients with severe sepsis or septic shock

Question 5

Most common pathogens causing septic shock in hospitalized patients:

Answer 5

1) Gram + bacteria

2) Gram - and mixed bacterials

Question 6

Antimicrobial regimen should be reassessed daily for de-escalation because…

Answer 6

$ To prevent development of resistance
$ To reduce toxicity
$ To reduce cost

Question 7

Combination therapy should be used for how many days?

Answer 7

3-5

Question 8

Specific/targeted therapy should be used for how many days?

Answer 8

7-10

Question 9

Diagnosis & intervention of an infection source (such as soft-tissue necrosis, peritonitis, intestinal infarction, etc) should be undertaken within how many hours of initial sepsis diagnosis?

Answer 9

12

Question 10

What form of oral decontamination is suggested in the guidelines?

Answer 10

Chlorhexidine gluconate (CHG)

Question 11

For fluid therapy, do the guidelines recommend crystalloid or colloid IV fluids?

Answer 11

Crystalloid

Question 12

Rationale for crystalloid instead of colloid?

Answer 12

$ Absence of any clear benefit to colloids compared to crystalloids
$ Expense of colloid solutions

Question 13

Recommendation for initial fluid challenge in patients with suspected hypovolemia

Answer 13

Minimum of 30 mL/kg of crystalloids

Question 14

Fluid challenge technique should continue to be applied until…

Answer 14

No further improvement in these variables:

$ Dynamic (pulse pressure, stroke volume)
$ Static (heart rate, arterial pressure)

Question 15

Vaspressor therapy should target a MAP of…

Answer 15

65 mm Hg

Question 16

The guidelines recommend which vasopressor as the first choice?

Answer 16

Norepinephrine

Question 17

The guidelines recommend which vasopressor as the second choice?

Answer 17

Epinephrine

Question 18

Dopamine is not recommended except in the following circumstances:

Answer 18

Patients with low risk of tachyarrhythmia, or with absolute or relative bradycardia

Question 19

Phenylephrine is not recommended except in the following circumstances:

Answer 19

$ Norepinephrine is associated with serious arrhythmia
$ Cardiac output is known to be high & BP persistently low
$ Salvage therapy when combined inotrope/vasopressor drugs & low-dose vasopressin have failed to achieve MAP target

Question 20

Vasopressin may be added to therapy when…

Answer 20

…combination of norepinephrine & epinephrine have failed to achieve target MAP

Question 21

What are the benefits of norepinephrine that make it the first-line vasopressor choice?

Answer 21

$ Increases MAP due to vasoconstriction
$ Little change in heart rate
$ Less increase in stroke volume

Question 22

What effect might epinephrine have on lactate levels?

Answer 22

May increase them, preventing the use of lactate clearance to guide resuscitation

Question 23

What do the guidelines recommend re: blood pressure monitoring while a patient is on vasopressors?

Answer 23

Arterial cannula instead of blood pressure cuff. More accurate, continuous analysis.

Question 24

What is the inotrope of choice in the guidelines?

Answer 24

Dobutamine

Question 25

Inotropic therapy is recommended when...

Answer 25

...evidence of tissue hypoperfusion persists despite adequate intravascular volume & adequate MAP.

Question 26

True or false: the guidelines recommend use of IV hydrocortisone in all circumstances.

Answer 26

False. Guidelines recommend the use of IV hydrocortisone ONLY if adequate fluid resuscitation & vasopressor therapy are not enough to achieve hemodynamic stability.

Question 27

True or false: corticosteroids should be administered for the treatment of sepsis in the absence of shock.

Answer 27

False.

Question 28

When should steroid therapy be weaned?

Answer 28

When vasopressors are no longer required.

Question 29

The guidelines recommend which type of administration: continuous infusion or repetitive bolus injections?

Answer 29

Continuous infusion, because there were fewer peaks of blood glucose.

Question 30

The guidelines recommend red blood cell transfusion at what hemoglobin level?

Answer 30

< 7.0 g/dL

Question 31

Do the guidelines recommend the use of erythropoetin for treatment of anemia associated with sepsis?

Answer 31

No. The guidelines state that patients given erythropoetin show "some decrease in red cell transfusion requirement, with no effect on clinical outcome".

Question 32

Do the guidelines recommend for or against antithrombin therapy in sepsis?

Answer 32

Against. They were unable to recommend until further clinical trials are performed.

Question 33

What do the guidelines recommend regarding platelet administration?

Answer 33

$ Prophylactically when counts ≤ 10 without bleeding $ ≤ 20 in presence of significant bleeding risk $ ≤ 50 for active bleeding, surgery, or invasive procedures

Question 34

Do the guidelines recommend administration of immunoglobulin?

Answer 34

No. They found no clinical benefit.

Question 35

What are the recommendations on IV selenium?

Answer 35

Recommend against, based on insufficient evidence.

Question 36

What is the recommended tidal volume for a mechanically ventilated sepsis patient?

Answer 36

6 mL/kg

Question 37

What is the recommended upper limit plateau pressure goal for a mechanically ventilated sepsis patient?

Answer 37

≤ 30 cm H20

Question 38

What is the rationale for the prone position in a sepsis patient with ARDS?

Answer 38

Improved oxygenation

Question 39

What are the risks for the prone position in a sepsis patient with ARDS?

Answer 39

Greater risk of dislodging endotracheal or chest tubes.

Question 40

Mechanical ventilation should be assessed frequently & discontinued on the following findings:

Answer 40

$ arousable $ hemodynamically stable without vasopressors $ no new, potentially serious conditions $ low ventilatory & end-expiratory pressure requirements $ low FiO2, deliverable by mask or cannula

Question 41

Do the guidelines recommend for ß-agonists (albuterol)? Why or why not?

Answer 41

No; two different studies were ended early for futility comparing ß-agonists with placebo. In one, a trend was noted toward decreased days off ventilator, & in the other, an increase in mortality.

Question 42

What do the guidelines say about the use of sedation?

Answer 42

Minimize use of sedation; decreased days in ICU, decreased length of stays were noted for patients in whom sedation was minimized.

Question 43

What do the guidelines say about neuromuscular blocking agents?

Answer 43

$ That NMBA be avoided if possible in the patient WITHOUT ARDS due to the risk of prolonged neuromuscular blockade following discontinuation. $ Recommend a short course (≤ 48 hrs) for patients with early, sepsis-induced ARDS.

Question 44

The guidelines recommend a glucose control protocol when 2 consecutive blood glucose levels are...

Answer 44

≥ 180 mg/dL

Question 45

What is the upper target blood glucose?

Answer 45

≤ 180 mg/dL

Question 46

Do the guidelines recommend point-of-care capillary blood testing?

Answer 46

They recommend POC glucose be interpreted with caution, because of the many issues during sepsis that may affect the measurements (i.e. anemia causing a false high).

Question 47

What do the guidelines say about CRRT vs intermittent hemodialysis ?

Answer 47

$ In sepsis patients, they achieve similar short-term survival rates & the guidelines suggest they are equivalent. $ The guidelines recommend CRRT in cases of hemodynamically unstable patients.

Question 48

What do the guidelines recommend regarding sodium bicarbonate?

Answer 48

They recommend against the use of sodium bicarb therapy for the purpose of improving hemodynamics or reducing vasopressor requirements in patients with lactic acidemia with pH > 7.15. There is no evidence to support the use of bicarb in the treatment of lactic acidemia associated with sepsis.

Question 49

DVT Prophylaxis Recommendations:

Answer 49

$ That patients with severe sepsis receive daily DVT prophylaxis with low molecular weight heparin, unless creatinine clearance is < 30, in which case an equivalent drug with less renal metabolism is recommended $ Septic patients who have contraindications for pharmalogical DVT prophylaxis should receive mechanical prophylaxis instead.

Question 50

Stress Ulcer Prophylaxis recommendations:

Answer 50

$ Patients at increased risk of bleeding should receive PPI ulcer prophylaxis. $ Patients without risk factors should not receive it.

Question 51

Nutrition Recommendations:

Answer 51

$ Oral or enteral feedings as tolerated, rather than complete fasting within 48 hrs $ Suggest avoiding mandatory full caloric feeding, but rather suggest low dose, advancing as tolerated $ No specific immuno-modulating supplementation necessary

Question 52

Setting Goals in Sepsis:

Answer 52

$ Recoomend that goals of care & prognosis be discussed with patients & families $ Recommend that the goals be incorporated into treatment & end-of-life care planning, using palliative care principles where appropriate $ Suggest that goals be addressed as early as feasible, no later than 72 hrs after ICU admission