International Guidelines For Management

JURNAL
READING
INTERNATIONAL GUIDELINES FOR

MANAGEMENT
OF SEVERE SEPSIS AND SEPTIC SHOCK : 2012
By Siti Novita Kuman ( 20110310223)
Preceptor : dr. Dimas Arya Kusuma Sp.B
Definition
Sepsis
Severe
sepsis
Septic
Shock
defined as the presence (probable or documented) of

infection together with systemic manifestations of
infection.
defined as sepsis plus sepsis-induced organ dysfunction

or tissue hypoperfusion
defined as sepsis-induced hypotension persisting

despite adequate fluid resuscitation. Sepsis-induced
tissue hypoperfusion is defined as infection-induced
hypotension, elevated lactate, or oliguria.
DIAGNOSTIC CRITERIA FOR SEPSIS
MANAGEMENT OF SEVERE SEPSIS

InitialScreening
Resuscitation
and Infection Issues
for
Initial
Resuscitation
sepsis and
performance
Improvement
Diagnosis
Antimicrobial
Therapy
Source Control
Infection
Pervention
Hamodynamic Support and Adjuntive Therapy

Fluid Therapy of Severe
Sepsis
Vasopressors
Inotropic Therapy
Corticosteroid
Initial Resuscitation and Infection Issues
INITIAL RESUSCITATION
quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion
(defined in this document as hypotension persisting after initial fluid challenge or
blood lactate concentration 4 mmol/L). This protocol should be initiated as soon as
hypoperfusion is recognized and should not be delayed pending ICU admission.
During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsisinduced hypoperfusion should include all of the following as a part of a treatment
protocol (grade 1C):
CVP 812 mm Hg
MAP 65 mm Hg
Urine output 0.5 mLkghr
Superior vena cava oxygenation saturation (Scvo2) or mixed venous oxygen saturation (Svo2) 70% or
65%, respectively.
targeting resuscitation to normalize lactate in patients with elevated lactate levels as

a marker of tissue hypoperfusion (grade 2C).
DIAGNOSIS
obtaining appropriate cultures before antimicrobial therapy is
initiated if such cultures do not cause significant delay (> 45
minutes) in the start of antimicrobial(s) administration (grade 1C).
To optimize identification of causative organisms, we recommend
obtaining at least two sets of blood cultures (both aerobic and
anaerobic bottles) before antimicrobial therapy, with at least one
drawn percutaneously and one drawn through each vascular access
device, unless the device was recently (< 48 hours) inserted. These
blood cultures can be drawn at the same time if they are obtained
from different sites. Cultures of other sites (preferably quantitative
where appropriate), such as urine, cerebrospinal fluid, wounds,
respiratory secretions, or other body fluids that may be the source
of infection, should also be obtained before antimicrobial therapy if
doing so does not cause significant delay in antibiotic
administration (grade 1C).
Antimicrobial Therapy
The administration of effective intravenous antimicrobials within the first hour of recognition of septic shock
(grade 1B) and severe sepsis without septic shock (grade 1C) should be the goal of therapy. Remark: Although
the weight of the evidence supports prompt administration of antibiotics following the recognition of severe
sepsis and septic shock, the feasibility with which clinicians may achieve this ideal state has not been
scientifically evaluated.
We recommend that initial empiric anti-infective therapy include one or more drugs that have activity against all
likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into the tissues
presumed to be the source of sepsis (grade 1B).
The antimicrobial regimen should be reassessed daily for potential de-escalation to prevent the development of
resistance, to reduce toxicity, and to reduce costs (grade 1B)
We suggest that combination therapy, when used empirically in patients with severe sepsis, should not be
administered for longer than 3 to 5 days. De-escalation to the most appropriate single-agent therapy should be
performed as soon as the susceptibility profile is known (grade 2B). Exceptions would include aminoglycoside
monotherapy, which should be generally avoided, particularly for P. aeruginosa sepsis, and for selected forms of
endocarditis, where prolonged courses of combinations of antibiotics are warranted.
We suggest the use of low procalcitonin levels or similar biomarkers to

assist the clinician in the discontinuation of empiric antibiotics in
patients who appeared septic, but have no subsequent evidence of
infection
Empiric therapy should attempt to provide antimicrobial activity against the most
likely pathogens based upon each patients presenting illness and local patterns of
infection. We suggest combination empiric therapy for neutropenic patients with
severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrug-resistant
bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B). For
selected patients with severe infections associated with respiratory failure and septic
shock, combination therapy with an extended spectrum beta-lactam and either an
aminoglycoside or a fluoroquinolone is suggested for P. Aeruginosa bacteremia (grade
2B). Similarly, a more complex combination of beta-lactam and a macrolide is
suggested for patients with septic shock from bacteremic Streptococcus pneumoniae
infections (grade 2B).
We suggest that the duration of therapy typically be 7 to 10 days if

clinically indicated; longer courses may be appropriate in patients
who have a slow clinical response, undrainable foci of infection,
bacteremia with S. aureus; some fungal and viral infections, or
immunologic deficiencies, including neutropenia (grade 2C).
We suggest that antiviral therapy be initiated as early as possible in
patients with severe sepsis or septic shock of viral origin (grade
2C).
We recommend that antimicrobial agents not be used in patients

with severe inflammatory states determined to be of noninfectious
cause (UG
Source Control
We recommend that a specific anatomical diagnosis of infection requiring consideration for emergent
source control (eg, necrotizing soft tissue infection, peritonitis, cholangitis, intestinal infarction) be
sought and diagnosed or excluded as rapidly as possible, and intervention be undertaken for source
control within the first 12 hr after the diagnosis is made, if feasible (grade 1C).
We suggest that when infected peripancreatic necrosis is identified as a potential source of infection,
definitive intervention is best delayed until adequate demarcation of viable and nonviable tissues has
occurred (grade 2B).
When source control in a severely septic patient is required, the effective intervention associated with
the least physiologic insult should be used (eg, percutaneous rather than surgical drainage of an
abscess) (UG).
If intravascular access devices are a possible source of severe sepsis or septic shock, they should be
removed promptly after other vascular access has been established (UG).
Infection Pervention
1a. We suggest that selective oral decontamination (SOD) and selective
digestive decontamination (SDD) should be introduced and investigated as a
method to reduce the Special Article Critical Care Medicine
www.ccmjournal.org 595 incidence of ventilator-associated pneumonia (VAP);
this infection control measure can then be instituted in healthcare settings
and regions where this methodology is found to be effective (grade 2B).
1b. We suggest oral chlorhexidine gluconate (CHG) be used as a form of
oropharyngeal decontamination to reduce the risk of VAP in ICU patients with
severe sepsis (grade 2B).
Hemodynamic
Support and
Adjunctive
Therapy
Hamodynamic Support and Adjuntive Therapy
Fluid Therapy of Severe Sepsis
We recommend crystalloids be used as the initial fluid of choice in the

resuscitation of severe sepsis and septic shock grade 1B).
We recommend against the use of hydroxyethyl starches (HES) for fluid
resuscitation of severe sepsis and septicshock (grade 1B). (This recommendation
is based on the results of the VISEP [128], CRYSTMAS [122], 6S [123], and CHEST
[124] trials. The results of the recently completed CRYSTAL trial were not
considered.)
We suggest the use of albumin in the fluid resuscitation of severe sepsis and
septic shock when patients require substantial amounts of crystalloids (grade 2C).
Vasopressors
We recommend norepinephrine as the first-choice vasopressor (grade 1B).
We suggest epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed
to maintain adequate blood pressure (grade 2B).
Vasopressin (up to 0.03 U/min) can be added to norepinephrine with the intent of raising MAP to target or decreasing
norepinephrine dosage (UG).
5. Low-dose vasopressin is not recommended as the single initial vasopressor for treatment of sepsis-induced
hypotension, and vasopressin doses higher than 0.030.04 U/min should be reserved for salvage therapy (failure to
achieve an adequate MAP with other vasopressor agents) (UG).
6. We suggest dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (eg,
patients with low risk of tachyarrhythmias and absolute or relative bradycardia) (grade 2C).
Phenylephrine is not recommended in the treatment of septic shock except in the following circumstances: (a)
norepinephrine is associated with serious arrhythmias, (b) cardiac output is known to be high and blood pressure
persistently low, or (c) as salvage therapy when combined inotrope/ vasopressor drugs and low-dose vasopressin have
failed to achieve the MAP target (grade 1C).
Inotropic Therapy
We recommend that a trial of

dobutamine infusion up to 20
g/kg/min be administered or added
to vasopressor (if in use) in the
presence of: a) myocardial
dysfunction, as suggested by
elevated cardiac filling pressures
and low cardiac output, or b)
ongoing signs of hypoperfusion,
despite achieving adequate
intravascular volume and adequate
MAP (grade 1C).
Corticosteroid
We suggest not using intravenous
hydrocortisone as a treatment of
adult septic shock patients if
adequate fluid resuscitation and
vasopressor therapy are able to
restore hemodynamic stability
(see goals for Initial
Resuscitation). If this is not
achievable, we suggest
intravenous hydrocortison alone
at a dose of 200 mg per day
(grade 2C).
We suggest not using the ACTH

stimulation test to identify the
subset of adults with septic shock
who should receive
hydrocortisone (grade 2B).
We suggest that clinicians taper

the treated patient from steroid
therapy when vasopressors are no
longer required (grade 2D).
We recommend that
corticosteroids not be
administered for the treatment of
sepsis in the absence of shock
(grade 1D).
OTHER SUPPORTIVE THERAPY OF

SEVERE SEPSIS
CONT
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JURNAL

INTERNATIONAL GUIDELINES FOR

Preceptor : dr. Dimas Arya Kusuma Sp.B

defined as the presence (probable or documented) of

defined as sepsis plus sepsis-induced organ dysfunction

defined as sepsis-induced hypotension persisting

DIAGNOSTIC CRITERIA FOR SEPSIS

MANAGEMENT OF SEVERE SEPSIS

Hamodynamic Support and Adjuntive Therapy

Initial Resuscitation and Infection Issues

targeting resuscitation to normalize lactate in patients with elevated lactate levels as

We suggest the use of low procalcitonin levels or similar biomarkers to

We suggest that the duration of therapy typically be 7 to 10 days if

We recommend that antimicrobial agents not be used in patients

Hamodynamic Support and Adjuntive Therapy

Fluid Therapy of Severe Sepsis

We recommend crystalloids be used as the initial fluid of choice in the

We recommend that a trial of

We suggest not using the ACTH

We suggest that clinicians taper

OTHER SUPPORTIVE THERAPY OF

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