When to Reach for Albumin in Sepsis and Septic Shock: A Step-by-Step Reference Guide for Emergency Physicians

In Sepsis, a Report of No Difference May Make a Lot of Difference

The challenge of sepsis

Surviving Sepsis Campaign.

Point: Adherence to Early Goal-Directed Therapy: Does It Really Matter? Yes. After a Decade, the Scientific Proof Speaks for Itself

In 2002 and 2007, the American College of Critical Care Medicine (ACCCM) provided clinical guidelines for hemodynamic support of pediatric and neonatal patients in septic shock. In 2008 and 2013, the Surviving Sepsis Campaign (SSC) Guidelines Committee offered up-to-date clinical guidelines for the management of severe sepsis and septic shock in adults and in pediatric patients. The aim of this study was to assess the standard of care of neonates with severe sepsis and septic shock in German neonatal intensive care units (NICUs) with regard to variability in management and guideline conformity. 199 pediatric clinics in Germany were asked to describe their management of septic neonates in a telephone survey. The questionnaire that was used for the preliminary survey was designed based on the ACCCM and SSC clinical guidelines. A total of 90 (45%) surveys were completed and analyzed. Among all hospitals, the guidelines most commonly included in current practice patterns were obtaining cultures before administering antibiotics (100%), determining capillary refill time (99%), and using crystalloids for initial fluid therapy (97%). The guidelines least commonly included in current practice were determination of ammoniac to rule out inborn errors of metabolism (51%) and the use of dopamine as the first choice of hemodynamic support (48%). The management of sepsis, severe sepsis, and septic shock in neonates is not always guideline consistent, but quite a number of ACCCM and SSC guidelines were included in the current practice pattern.

Severe sepsis and septic shock represent common presentations in the emergency department (ED) and have high rates of mortality. Guideline-recommended goals of care have been shown to benefit these patients, but can be difficult to provide. To determine whether the use of a premixed bag consisting of 2 g cefepime and 1 g vancomycin in 1000 mL of normal saline increases the probability of patients receiving Surviving Sepsis Campaign (SSC) recommendations for the initiation of antimicrobials and fluid challenge. This was a 6-month retrospective analysis conducted to determine the impact of an intervention on time to antimicrobials and fluid administration in patients with severe sepsis and septic shock. Patients presenting to the ED who received a diagnosis of severe sepsis or septic shock and were administered 2 antibiotics were eligible for inclusion. The primary outcome assessed was compliance with SSC recommendations for antibiotic and fluid goals within 3 hours of ED arrival. A total of 160 patients were included. In the intervention group, 63.8% of patients met the primary outcome compared with 22.5% in the historical group (odds ratio = 2.32; 95% CI = 1.67-3.23). Time to administration of antibiotics was less with the combination antibiotic bag (CAB: median (IQR) = 72 (48-115) minutes; non-CAB: median (IQR) = 135 (102-244) minutes; P ≤ 0.001). This intervention significantly increased the proportion of patients provided with SSC goals of care. Such interventions have not been reported previously and could be meaningful in the management of severe sepsis and septic shock.

To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004. Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

ObjectiveTo provide an update to the original Surviving Sepsis Campaign clinical management guidelines, “Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock,” published in 2004.DesignModified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding.MethodsWe used the GRADE system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation [1] indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost), or clearly do not. Weak recommendations [2] indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations.ResultsKey recommendations, listed by category, include: early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures prior to antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7–10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure ≥ 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for post-operative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7–9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B) targeting a blood glucose < 150 mg/dL after initial stabilization ( 2C ); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper GI bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D).Recommendations specific to pediatric severe sepsis include: greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); a recommendation against the use of recombinant activated protein C in children (1B).ConclusionThere was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Early Goal-Directed Therapy in Severe Sepsis and Septic Shock: Converting Science to Reality

Purpose of ReviewThis review highlights recent advances in the treatment of severe sepsis and septic shock, emphasizing new strategies aimed at improving overall survival and reducing mortality in this patient population.Recent FindingsThe primary organization responsible for guiding sepsis management is the Surviving Sepsis Campaign (SSC). Several recent studies, which will be summarized in this article, have investigated sepsis screening tools, capillary refill time, antibiotic timing, intravenous fluids, vasopressor use, corticosteroids, and even vitamin C, all of which contribute to the development of new and effective guidelines for managing severe sepsis and septic shock.SummaryDespite years of research on sepsis, ongoing updates continue to introduce new strategies aimed at improving survival rates and reducing mortality. Timely diagnosis, intervention, and disposition are essential for optimizing outcomes. Emergency physicians and intensive care unit specialists will find this thorough review of novel updates in the management of severe sepsis and septic shock particularly valuable. A summary of recommendations which can be utilized as a quick bedside reference is found in Table 1.

Severe sepsis and septic shock are common health care problem with high mortality. In 2001, Early goal directed therapy was introduced, early appropriate therapy impact on the outcome. In 2012, the “Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012” was updated. Since then, several landmark studies recently demonstrated that modified guidelines. We review the treatment guidelines of severe sepsis and septic shock. Key Words: Severe sepsis; Septic shock; Management of sepsis

Sepsis and septical shock clinical criteria were agreed in Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Despite the imperfections of SIRS criteria (low specificity), their sensitivity reaches 100%. According to modern ideas, sepsis is a systemic inflammatory response to infection (Systemic Inflammatory Response Syndrome – SIRS) always associated with the presence of infectious agent in the body. Clinical and metabolical manifestations of sepsis are similar to symptoms and criteria of system inflammatory response syndrome. Physiological features of pregnant women are making adjustments to the classical picture of diagnosis and treatment. In the first trimester of pregnancy 15% of women are suffering from dyspnea. Increased heart rate is normal manifestation of the third mechanism of regulation of cardiac output (volume of circulating blood – first, the contractile ability of the myocardium – second). Increase in the number of leukocytes in peripheral blood of pregnant/postpartum women is a physiological process and creates difficulties in diagnostic process. The aim of study was to determine peculiarities of sepsis and septical shock in pregnant and postpartum women according to instructions of Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. The problem of sepsis is currently very severe in obstetrics. In now days, infections occupy third place in the structure of maternal mortality and make up about 15%. Systemic manifestations of sepsis/septical shock in pregnant/postpartum women (including the development of multiple organ dysfunction) can significantly outpace local changes of purulent source. If the primal source of infection is located in the uterus, the development of septical shock is not always accompanied by symptoms of “classical” metroendometritis, making it difficult to diagnose. It also detains radical sanation of the infectious source contributing to progression of multiple organ dysfunction. In 2001 E.P. Rivers et al. published an article in highly ranked journal N Eng J Med, which is cited by various authors until now. The whole algorithm of infusion and inotropic therapy was developed on its basis for patients with sepsis and septic shock. Despite this, in present time many authors doubt in expediency of achieving CVP 8-13 mmHg (J.H.Boyd et al 2011; M.Cessoni et al 2011; Marik P.E. et al 2008)., sodium ions accumulate in the extracellular space (interstitial and intravascular) in pregnant; as a result tissues become hydrophilic and tissue “phisiological edema” develops. Given the presence of capillary loss syndrome in pregnant/ postpartum women (preeclampsia / eclampsia) controversial is the question of the qualitative composition of the infusion therapy. There are no safe antibiotics for pregnant women according to Food and Drug Administration – FDA (USA). Therefore, the problem of antibiotic therapy in these patients also have its own features. Physiological features of pregnant woman are making adjustments to the classical picture of diagnosis and treatment of sepsis/septical shock in this group of patients. The aim of study was to determine peculiarities of sepsis and septical shock in pregnant and postpartum women according to instructions of Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. The problem of sepsis is currently very severe in obstetrics. In now days, infections occupy third place in the structure of maternal mortality and make up about 15%.In this article we have discussed the results of the diagnosis and treatment of 14 pregnant /postpar tum women with sepsis, who came to the clinic of anesthesiology and intensive care of the Lviv Regional Hospital from 2010 to 2016.Chorioamnionitis and endometritis were the main reasons of peritonitis and sepsis. Intensive therapy (volemic resuscitation, cardio-respiratory support, antibiotic therapy) and surgical intervention (eliminating the causes of peritonitis, sanitation and drainage of the abdominal cavity) were conducted to all the patients. The patient’s general condition was evaluated by APACHE II scale at 14,5 ± 1,5 points and multiple organ dysfunction was evaluated at 5,0 ± 1 points by SOFA scale.

Expert consensus on the use of human serum albumin in critically ill patients.

Article| January 2023 Surviving Sepsis Campaign 2021 Updates for Management of Sepsis and Septic Shock Ana Maria Crawford, MD, MSc, FASA Ana Maria Crawford, MD, MSc, FASA Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor January 2023, Vol. 87, 30. https://doi.org/10.1097/01.ASM.0000911800.69781.4b Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Ana Maria Crawford; Surviving Sepsis Campaign 2021 Updates for Management of Sepsis and Septic Shock. ASA Monitor 2023; 87:30 doi: https://doi.org/10.1097/01.ASM.0000911800.69781.4b Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: sepsis, septic shock, surviving sepsis campaign Millions of people die each year from sepsis and septic shock. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection (JAMA 2016;315:801-10). The Surviving Sepsis Campaign (SSC) formed in 2002 as a joint collaboration of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). The campaign's mission is the reduction of morbidity and mortality from sepsis and septic shock worldwide. In October 2021, the SSC released their 5th edition of International Guidelines for Management of Sepsis and Septic Shock (Crit Care Med 2021;49:e1063-1143).Previous versions were released in 2004, 2008, 2012, and 2016 (Crit Care Med 2021;49:1974-82). Overall, there are 93 statements in the updated guidelines. Fifteen of the statements are strong recommendations, 54 are weak recommendations, 15 are best practice statements, and nine statements make no recommendation regarding a specific intervention... You do not currently have access to this content.

Severe sepsis (systemic inflammation secondary to infection combined with acute organ dysfunction) and septic shock (severe sepsis combined with hypotension not rectified by fluid resuscitation) are complex multifactorial medical conditions with significant associated morbidity and mortality, and are among the leading causes of death in the intensive care unit (ICU). Even with aggressive treatment, the mortality has been shown to be around 40 percent (Bernard et al., 1997) and in some studies has been reported to be as high as 71.9 percent (Sasse et al., 1995). In 2001, Angus et al conducted a study of the incidence, cost, and outcome of severe sepsis in the United States of America; the results showed an incidence of 3 cases per 1,000 population, a mortality rate of 28.6 percent, and a cost of $22,100 per case, giving an annual cost of $16.7 billion (Angus et al., 2001). The same study showed that the number of deaths per year associated with severe sepsis is equal to that of acute myocardial infarction, yet myocardial infarction has attracted far more attention and funding in terms of treatment and management research, leaving sepsis a relatively unacknowledged problem. With severe sepsis having such a high incidence, high and increasing mortality rate, and high annual cost, it is becoming a prime target for research into improving diagnosis, management, and survival. Reducing morbidity and mortality in severe sepsis and septic shock has been the primary goal of the Surviving Sepsis Campaign (SSC) – a global initiative developed by the European Society of Intensive Care Medicine (ESICM), the International Sepsis Forum (ISF), and the Society of Critical Care Medicine (SCCM) to raise awareness of sepsis among healthcare professionals and to improve and standardize the early diagnosis and treatment of sepsis (Welcome To The Surviving Sepsis Campaign Website,n.d.). Containing a number of the world’s experts on sepsis, this campaign attempts to tackle various challenges in the diagnosis and management of sepsis. Some of the challenges lie in the complexity of the condition and the variability in the presentation and course of sepsis, with many of the symptoms being of a general nature and easily attributable to a number of other conditions and etiologies. This makes it quite difficult to create a standard clinical definition of sepsis. This lack of definitive criteria for a diagnosis of sepsis makes it easily misdiagnosed, and consequently improperly treated. If, however, a diagnosis of sepsis is made, it is often still made late and treatment is less effective if delayed. As is discussed later in this chapter,