Adjunctive therapies in sepsis: An evidence-based review

Abstract

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for adjunctive therapies in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis. The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. Glycemic control (maintenance of glucose <150 mg/dL) is recommended. The beneficial effect of glycemic control appears to be related control of glucose and not the administration of insulin. Glycemic control should be combined with a nutritional protocol. The dialysis dose is important in sepsis-induced acute renal failure. Continuous hemofiltration offers easier management of fluid balance in hemodynamically unstable septic patients but in the absence of hemodynamic instability is equivalent to intermittent hemodialysis. It is uncertain whether high-volume hemofiltration improves prognosis in sepsis. Bicarbonate therapy is not recommended for the purpose of improving hemodynamics or reducing vasopressor requirements in the presence of lactic academia and pH >7.15.