Surviving Sepsis Campaign. Evans et al. 2021. Intensive Care Med Flashcards
What is the current recommendation on utilizing qSOFA as a screening tool for sepsis or septic shock? Why is this recommendation made.
- Recommend against using qSOFA compared to SIRS (NEWS or MEWS) as a single screening tool for sepsis or septic shock
- Specific but poor sensitivity compared to SIRS criteria for screening
- data supporting its use in sepsis-3 supports it as a predictor of poor outcome only
(1) respiratory rate ≥ 22 breaths/min,
(2) altered mental status (GCS <15)
(3) systolic blood pressure (SBP) ≤ 100 mm Hg.
≥ 2 is suggestive of sepsis
strong recommendation, moderate-quality evidence
What is the qSOFA score?
An abbreviation of the SOFA sore limited to clinical assessment only without laboratory tests, includes:
- Mentation/modified glasgow coma scale < 15
- Respiratory Rate > 22 bpm
- Hypotension, systolic BP < 100 mm Hg
A score > 2 indicates a high risk for poor outcome (i.e., positive qSOFA)
SOFA and qSOFA was developed and integrated to the sepsis assessment because it was concluded inflammation (SIRS criteria) is not assessing for organ dysfunction, an important component of sepsis (sepsis-3)
What is the recommendation for lactate measurement?
What is the rational?
Measuring lactate is recommended if sepsis is suspected
- part of the sepsis-3 definition of identifying septic shock
- presence of abscence of hyperlactatemia has shown to significantly increased or decreaseed the likelihood of sepsis if sepsis is suspected
- Part of the 1-hour bundle
weak recommendation, low-quality evidence
What is the recommendation for IV fluid therapy volume and timing in patients with sepsis?
If sepsis-induced hypoperfusion –> 30 mL/kg within first 3 hours
rational: only observational evidence
weak recommendation, low-quality evidence
What is the recommendation for monitoring response to fluid therapy?
- dynamic measures over physical exam or static parameters alone
includes: passive leg raise + CO monitor, fluid challenge against SV/ SAP/ PP, SV changes in response to intrathoracic pressure changes - guide resuscitation to decreased lactate cc if hyperlactatemia present
make note that impossible to normalize in some patients and must be evaluated in the light of the patient - use CRT as adjunt to other measures
What is the target BP for septic shock on pressors?
MAP of 65 or higher
What is the recommendation for empirical Abx tx (severity groups and timing)
- possible septic shock or high likelihood sepsis –> Abx immediately, within 1 hour of recognition
- possible sepsis without shock –> assess for likelihood of infection, time-limited investigation –> if concern persists –> Abx within 3 hours
- low likelihood of infection, no shock –> deferr Abx while monitoring closely
Strong evidence for mortality reduction with early Abx in septic shock
What is procalcitonin and what is the recommendation for its use?
Acute phase protein
not recommended to use procalcitonin to decide when to start abx
rational: no proven benefit over clinical evaluation alone
What is the recommendation for MRSA and MDR-coverage Abx therapy?
MRSA-coverage only if suspected MRSA infection/at high risk
Risk factors: prior hx of MRSA, recent IV abx, hx of recurrent skin infections or chronic wounds, presence of invasive devices, hemodialysis, recent hospital admission, severity of illness
If high risk for MDR infection - use two abx with gram-negative coverage
Risk factors: MDR infection within preceding year, local prevalence of MDR or travel to such country, hospital-acquired infection, broad spectrum abx use within preceding 90 days, hospitalization abroad within preceding 90 days
How are beta-lactam antibiotics supposed to be administered?
prolonged infusion (over at least half of the dosing interval time) or as CRI after giving an inital bolus dose
showed improved survival compared to just intermittent boluses
How fast should source control be implemented? At what time point is survival reduced?
Within 6-12 hours. Reduced survival beyond that point shown in studies
How should intravascular access devices be managed when sepsis or septic shock is identified?
prompt removal of devices that are a possible source of sepsis - AFTER alternative vascular access has been established
What is the recommendation for duration of administration and deescalation of abx tx?
- recommend daily assessment and de-escalation over predetermined duration of treatment
- recommend shorter over longer duration of tx if adequate source control provided
- if optimal duration is unclear: recommend procalcitoning with clinical evaluation to decide on discontinuation of Abx
List the recommendations made for IV fluid therapy - in regards to fluid type
- recommend crystalloids for first-line
- suggest balanced crystalloid over saline
SMART trial: improved 30-day mortality
- suggest albumin + crystalloid over crystalloid alone if large volumes needed
lack of evidence that albumin is superior if added right away, but may reduce fluid requirements if large volume needed
- recommend against starches
Higher risk of RRT and death
- suggest against gelatin
may affect hemostasis and mortality
What are the recommendations for vasopressor therapy?
- epinephrine as first line over other vasopressors
lower mortality and less arrhythmias over dopamine
vasopressin does not improve mortality as first-line treatment, but actually reduces risk of RRT
- inadequate MAP on norepinephrine => recommend adding vasopressin instead of escalating norepi more
usually started when norepi of 0.25-0.5 mcg/kg/min reached
reduced mortality with combintion therapy, reduced risk of afib
Mention relative vasopressin deficiency after 24-48 hours as shock continues
- inadequate MAP on norepi + vasopressin => add epinephrine
