An update of the 2008 Surviving Sepsis Campaign (SSC) guidelines is expected in the early part of 2013. Key elements of this update were previewed at the 2012 meetings of the Society of Critical Care Medicine (SCCM) and the American College of Emergency Physicians (ACEP), and will be briefly reviewed here.
One of the more significant changes will be the demotion of dopamine from a first-line vasopressor to a second- or third-line choice due its higher risk of inducing arrhythmias compared with other agents. Multiple studies over the past 4 years found that dopamine is associated with higher incidence of arrhythmia, and perhaps to higher mortality in certain populations being treated for sepsis (such as patients with cardiogenic shock). Dopamine will be recommended only in select patients who are at low risk of arrhythmias and have a low cardiac output and/or heart rate. Norepinephrine will remain the preferred first-line vasopressor along with vasopressin which may be used to augment or substitute it. Epinephrine will be recommended as a 2nd-line agent when additional BP support is required.
Another important update will be the recommendation to use serial lactate and lactate normalization to monitor sepsis treatment progress in early goal-directed therapy (EGDT) if central venous oxygen saturation (ScvO2) monitoring is not available. A number of studies have shown that using lactate clearance and normalization as an early goal in sepsis therapy is as effective as using ScvO2, and may even lead to reduced mortality.
Also significant will be a recommendation to use crystalloids as first-line IVF therapy, and a strong recommendation against the use of high-molecular-weight hetastarches (>200 kDa) as these have been implicated in renal damage and increased mortality among septic shock patients (VISEP trial). Newer studies suggest that even use of lower- molecular-weight starches, such as hydroxyethyl starch 130 kDa/0.4, may lead to poorer outcomes. A final recommendation on these is pending the results of recent studies with these agents. Albumin is considered to be a safe colloid, and the SSC guidelines are expected to recommend its addition to crystalloid fluids in cases of severe sepsis and shock.
Other significant updates will include recommendations for the use of emerging sepsis tests and markers including disseminated candidiasis assays (eg, 1,3-beta-D-glucan) and procalcitonin as a bacterial sepsis marker and guide for antibiotic discontinuation.
Below is a summary of these and other key elements of the anticipated update. some of which may change in the final version of the update.
- Additional evidence to support the importance of administering antibiotics within the first hour of diagnosis
- Additional evidence that each hour of delay increases mortality by a significant percentage
IV Fluid resuscitation:
- Initial IVF challenge of at least 1 L of crystalloid, and a minimum of 30 mL/kg of crystalloid in the first 4-6 hours; incremental IVF boluses should be used while patients continue to show hemodynamic improvement
- Weak recommendation for adding albumin to initial fluid resuscitation with crystalloid for severe sepsis and septic shock
- Strong recommendation against the use of high-molecular-weight hetastarches/hydroxyethyl starches (MW >200 kDa); recommendation for use of low-molecular-weight hetastarches is pending publication of results of recent trials with these agents, expected in early 2013
- Norepinephrine will continue to be recommended as preferred first-line vasopressor; vasopressin 0.03 U/min may substitute NE or be added to it
- The addition of epinephrine as a second-line agent will be recommended if additional blood pressure support is required
- Dopamine will no longer be recommended as a first-line therapy alternative of norepinephrine due to recent studies associating it with a higher incidence of arrhythmia and, in some studies, higher mortality; dopamine will be recommended only in highly select patients whose risk for arrhythmias is felt to be very low and who have a low heart rate and/or cardiac output
- Dobutamine continues to be strongly recommended (by itself or in addition to a vasopressor) for patients with cardiac dysfunction (high filling pressure, low CO, clinical signs of hypoperfusion after adequate volume replacement)
- IV corticosteroid therapy should not be used in patients in whom fluid resuscitation and vasopressors can restore an adequate blood pressure
- Hydrocortisone IV 200 mg/24 hours may be used in refractory septic shock
Mechanical ventilation in sepsis-induced ARDS:
- Using higher levels of PEEP
- Recruitment maneuvers for patients with severe hypoxemia while receiving high PEEP and FiO2
- Prone positioning for patients with PaO2/FiO2 ratios < 100 despite such maneuvers
- Lactate level: Recommendation for using normalization of lactate levels as an alternate goal in early goal-directed therapy (EGDT) for severe sepsis if central venous oxygenation monitoring (ScvO2) is not available
- Fungal infection testing: For patients at risk for fungal infection as a source for severe sepsis, checking one of the newer assays for invasive candidiasis such as 1,3-beta-D-glucan, mannan, or anti-mannan ELISA antibody testing
- Procalcitonin: When no infection can be found during empiric antibiotic therapy, consider using a low procalcitonin level as a supportive tool for the decision to stop antibiotics
The Sepsis Clinical Guide app has been updated to reflect some of these changes in sepsis care based on the expected SSC guideline update and other sources including those listed in the References section at the end of this article.
The Surviving Sepsis Campaign (SSC) is a collaboration of the European Society of Intensive Care Medicine (ESICM), the International Sepsis Forum (ISF), and the Society of Critical Care Medicine (SCCM). The SSC sepsis management guidelines were initially published in 2004 and updated in 2008.
Daniel Nichita, MD
- Sakr Y, Reinhart K, Vincent JL, et al. Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Crit Care Med 2006;34: 589-97. [PubMed]
- De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 2010;362:779-89. [PubMed]
- Patel GP, Grahe JS, Sperry M, et al. Efficacy and safety of dopamine versus norepinephrine in the management of septic shock. Shock 2010;33:375-80. [PubMed]
- De Backer D,Â Aldecoa C, Njimi H,Â Vincent JL. Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis. Crit Care Med.Â 2012Â Mar;40(3):725-30. [PubMed]
- Jones AE, Shapiro NI, Trzeciak S, et al. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy. A Randomized Clinical Trial. JAMA. 2010;303(8):739-746. [PubMed]
- Nguyen HB, Kuan WS, Batech M, et al, the ATLAS (Asia Network to Regulate Sepsis care) Investigators. Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation. Crit Care. 2011; 15(5): R229. [PubMed]
- Cannon CM, Holthaus CV, Zubrow MT, et al. The GENESIS Project (GENeralized Early Sepsis Intervention Strategies): A Multicenter Quality Improvement Collaborative. J Intensive Care Med. 2012 Aug 17. [Epub ahead of print]. [PubMed]
- Brunkhorst FM, Engel C, Bloos F, et al. Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis. N Engl J Med 2008; 358:125-139. [PubMed]
- Perner A, Haase N, Guttormsen AB, Tenhunen J, et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med. 2012 Jul 12;367(2):124-34. [PubMed]
- The SAFE Study Investigators. A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. N Engl J Med 2004; 350:2247. [PubMed]
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