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- Most research indicates that antimicrobial therapy should be started within three hours of presentation. The latest guidelines recommend starting antimicrobials within one hour, but this is controversial. Vasopressor therapy is indicated if hypotension persists despite fluid administration.
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When should antibiotic therapy be initiated for sepsis & septic shock?
Oct 4, 2021 · Updated global adult sepsis guidelines, released in October 2021 by the Surviving Sepsis Campaign (SSC), place an increased emphasis on improving the care of sepsis patients after they are discharged from the intensive care unit (ICU) and represent greater geographic and gender diversity than previous versions.
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Complete blood counts with differential, chemistries, liver function tests, and coagulation studies including D-dimer level. Results from these studies may support the diagnosis, indicate the severity of sepsis, and provide baseline to follow the therapeutic response. Arterial blood gas (ABG) analysis ABGs may reveal acidosis, hypoxemia, or hyperc...
Serum lactate An elevated serum lactate (eg, >2 mmol/L or greater than the laboratory upper limit of normal) may indicate the severity of sepsis and is used to follow the therapeutic response [3,4,14-16].
Procalcitonin While the diagnostic value of procalcitonin in patients with sepsis is poorly supported by evidence, its value in deescalating antibiotic therapy is well established in populations other than those with sepsis, in particular, those with community acquired pneumonia and respiratory tracts infections. Measurement of procalcitonin to gu...
Tissue perfusion is predominantly achieved by the aggressive administration of intravenous fluids (IVF), usually crystalloids (balanced crystalloids or normal saline) given at 30 mL/kg (actual body weight) within the first three hours following presentation.
Three subsequent multicenter randomized trials of patients with septic shock, ProCESS [9], ARISE [10], and ProMISE [11] and two meta-analyses [12,13] all reported no mortality benefit (mortality ranged from 20 to 30 percent), associated with an identical protocol compared with protocols that used some of these targets or usual care. In contrast, on...
A lack of benefit of resuscitation protocols has also been reported in low income settings. As an example, in a randomized trial of 212 patients with sepsis (defined as suspected infection plus two systemic inflammatory response syndrome criteria) and hypotension (systolic blood pressure 90 mmHg or mean arterial pressure <65 mmHg) in Zambia, a prot...
Crystalloid versus albumin Among patients with sepsis, several randomized trials and meta-analyses have reported no difference in mortality when albumin was compared with crystalloids, although one meta-analysis suggested benefit in those with septic shock [22,29,30]. In the Saline versus Albumin Fluid Evaluation (SAFE) trial performed in critical...
Invasive fungal infections The routine administration of empirical antifungal therapy is not generally warranted in non-neutropenic critically-ill patients. Invasive fungal infections occasionally complicate the course of critical illness, especially when the following risk factors are present: surgery, parenteral nutrition, prolonged antimicrobia...
While one early trial of patients with septic shock reported a mortality benefit to these parameters in a protocol-based therapy, trials published since then (ProCESS, ARISE, ProMISe) have reported no mortality benefit in association with their use [8-11]. (See 'Initial resuscitative therapy' above.)
The lactate clearance is defined by the equation [(initial lactate lactate >2 hours later)/initial lactate] x 100. The lactate clearance and interval change in lactate over the first 12 hours of resuscitation has been evaluated as a potential marker for effective resuscitation [14,80-84]. One meta-analysis of five low quality trials reported that ...
Arterial blood gases It is prudent to follow arterial blood gas parameters including the arterial partial pressure of oxygen:fraction of inspired oxygen ratio as well as severity and type of acidosis (resolution of metabolic acidosis and avoidance of hyperchloremic acidosis). Worsening gas exchange may indicate pulmonary edema from fluid resuscita...
Source control Source control (ie, physical measures to eradicate a focus of infection and eliminate or treat microbial proliferation and infection) should be undertaken since undrained foci of infection may not respond to antibiotics alone (table 2). As examples, potentially infected vascular access devices should be removed (after other vascular...
However, we believe the initial choice of vasopressor in patients with sepsis is often individualized and determined by additional factors including the presence of coexistent conditions contributing shock (eg, heart failure), arrhythmias, organ ischemia, or agent availability. For example, in patients with significant tachycardia (eg, fast atrial ...
The impact of agent availability was highlighted by one study of nearly 28,000 patients from 26 hospitals, which reported that during periods of norepinephrine shortages, phenylephrine was the most frequent alternative agent chosen by intensivists (use rose from 36 to 54 percent) [111]. During the same period, mortality rates from septic shock rose...
Support for a restrictive transfusion strategy (goal hemoglobin >7 g/dL) is derived from direct and indirect evidence from randomized studies of patients with septic shock:
One multicenter randomized study of 998 patients with septic shock reported no difference in 28-day mortality between patients who were transfused when the hemoglobin was 7 g/dL (restrictive strategy) and patients who were transfused when the hemoglobin was 9 g/dL (liberal strategy) [120]. The restrictive strategy resulted in 50 percent fewer red b...
One randomized trial initially reported a mortality benefit from a protocol that included transfusing patients to a goal hematocrit >30 (hemoglobin level 10 g/dL) [8]. However, similarly designed studies published since then reported no benefit to this strategy [9-11]. These studies are discussed below.
There are no high quality trials testing safety of de-escalation of antibiotic therapy in adult patients with sepsis or septic shock [130-133]. However, most observational trials report equivalent or improved outcomes with this strategy.
Apr 1, 2020 · Fluid resuscitation is the priority in early management, including administering an intravenous crystalloid at 30 mL per kg within the first three hours. Antimicrobial therapy should also be...
This guideline is intended for adult patients. We recommend following the Surviving Sepsis Campaign’s International Guidelines for the Management of Sepsis and Septic Shock (2021) 2, on which this guideline is based. We also endorse the SEP-1 treatment bundle ( Figure 1) as standard of care for the initial management of a patient with sepsis.
Jan 30, 2024 · This WHO guideline will use the best evidence to help patients and the healthcare workers looking after them. 3 It will focus on making global recommendations for early recognition, initial resuscitation, and the early treatment of sepsis during which periods patients are most vulnerable.
2022. 2012 Adult Guidelines. 2021 Adult. Guidelines. 2014 Data published on. 30,000. published for 2020 SSC COVID-19 Guidelines. 2018 Sepsis research priorities. patients from SSC. database demonstrating 25% RRR death. Guideline Development Process. 4. Completion of Guidelines.
Septic shock is sepsis that results in tissue hypoperfusion, with vasopressor-requiring hypotension and elevated lactate levels. 1 Sepsis is a leading cause of death, morbidity, and expense, contributing to one-third to half of deaths of hospitalized patients, 2 depending on definitions. 3 Management of sepsis is a complicated clinical challenge...
