Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock 2008

Cooper University Hospital, Camden, NJ, USA.
Critical care medicine (Impact Factor: 6.31). 02/2008; 36(1):296-327. DOI: 10.1097/01.CCM.0000298158.12101.41
Source: PubMed


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.

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    • "Delay in treatment after sepsis is diagnosed is a serious problem, as it may have dire consequences for the patient. It is reported that for every seven hours that the administration of appropriate therapy is delayed, the mortality rate increases by about 7% (Dellinger et al., 2008). Detecting the patient's condition as early as possible can save his or her life. "
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    ABSTRACT: Early classification of time series has been receiving a lot of attention recently. In this paper we present a model, which we call the Early Classification Model (ECM), that allows for early, accurate and patient-specific classification of multivariate observations. ECM is comprised of an integration of the widely used Hidden Markov Model (HMM) and Support Vector Machine (SVM) models. It attained very promising results on the datasets we tested it on: in one set of experiments based on a published dataset of response to drug therapy in Multiple Sclerosis patients, ECM used only an average of 40% of a time series and was able to outperform some of the baseline models, which needed the full time series for classification. In the set of experiments tested on a sepsis therapy dataset, ECM was able to surpass the standard threshold-based method and the state-of-the-art method for early classification of multivariate time series.
    International Journal of Data Mining and Bioinformatics 09/2015; 11(4):392. DOI:10.1504/IJDMB.2015.067955 · 0.50 Impact Factor
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    • "Sepsis has long been a critical issue in intensive care and emergency medicine, and great efforts have been made to develop improved or novel treatment modalities for sepsis and related disorders. The severe systemic inflammation, which is often referred to as systemic inflammatory response syndrome (SIRS) [1], leads to multi-organ failure (MOF) [2]. Severe sepsis most frequently (18%) accompanies respiratory system failure. "
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    ABSTRACT: Sepsis is a severe pathologic event, frequently causing death in critically ill patients. However, there are no approved drugs to treat sepsis, despite clinical trials of many agents that have distinct targets. Therefore, a novel effective treatment should be developed based on the pathogenesis of sepsis. We recently observed that an old hypnotic drug, bromvalerylurea (BU) suppressed expression of many kinds of pro- and anti-inflammatory mediators in LPS- or interferon-γ activated alveolar and peritoneal macrophages (AMs and PMs). Taken the anti-inflammatory effects of BU on macrophages, we challenged it to septic rats that had been subjected to cecum-ligation and puncture (CLP). BU was subcutaneously administered to septic rats twice per day. Seven days after CLP treatment, 85% of septic rats administrated vehicle had died, whereas administration of BU reduce the rate to 50%. Septic rats showed symptoms of multi-organ failure; respiratory, circulatory and renal system failures as revealed by histopathological analyses, blood gas test and others. BU ameliorated these symptoms. BU also prevented elevated serum-IL-6 level as well as IL-6 mRNA expression in septic rats. Collectively, BU might be a novel agent to ameliorate sepsis by preventing the onset of MOF. Copyright © 2015. Published by Elsevier Inc.
    Biochemical and Biophysical Research Communications 02/2015; 459(2). DOI:10.1016/j.bbrc.2015.02.111 · 2.30 Impact Factor
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    • "Forty-six patients received RBC transfusion for ScvO2 < 70% (RBC group). Of the remaining patients, we then matched 71 SS patients that did not receive RBC transfusion (NRBC group) on the following goals (G) based on SSC 2008 criteria [11]: LA obtained within 6 h (G1), antibiotics given within 3 h (G2), 20 mL/kg fluid bolus followed by vasopressors (VP) if needed to keep mean arterial pressure (MAP) > 65 mm Hg (G3), central venous pressure (CVP) ≥ 8 mm Hg within 6 h (G4) and ScvO2 ≥ 70% within 6 h (G5). We calculated average age, average sequential organ failure assessment (SOFA) scores and fluid balance at the end of 6 h for both groups. "
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    ABSTRACT: Background Although the optimum hemoglobin (H) concentration for patients with septic shock (SS) has not been specifically investigated, current guidelines suggest that H of 7 - 9 g/dL, compared with 10 - 12 g/dL, was not associated with increased mortality in critically ill adults. This contrasts with early goal-directed resuscitation protocols that use a target hematocrit of 30% in patients with low central venous oxygen saturation (ScvO2) during the first 6 hours of resuscitation of SS. Methods Data elements were prospectively collected on all patients with SS patients (lactic acid (LA) > 4 mmol/L, or hypotension). Out of a total of 396 SS patients, 46 patients received red blood cell (RBC) transfusion for ScvO2 < 70% (RBC group). We then matched 71 SS patients that did not receive RBC transfusion (NRBC group) on the following goals (G): LA obtained within 6 hours (G1), antibiotics given within 3 hours (G2), 20 mL/kg fluid bolus followed by vasopressors (VP) if needed to keep mean arterial pressure > 65 mm Hg (G3), central venous pressure > 8 mm Hg within 6 hours (G4) and ScvO2 > 70% within 6 hours (G5). Results In the RBC group, after one unit of RBC transfusion, ScvO2 improved from average of 63% (± 12%) to 68% (± 10%) (P = 0.02). Sixteen patients required another unit of RBC, and this resulted in increase of ScvO2 to 78% (± 11%) (P < 0.01). The RBC and NRBC groups were matched on sequential organ failure assessment (SOFA) scores and all five goals. There was no difference in mortality between the two groups: 41% vs. 39.4% (OR: 0.8, 95% CI: 0.4 - 1.7, P = 0.6). Conclusions In our study, transfusion of RBC was not associated with decreased mortality in SS patients.
    Journal of Clinical Medicine Research 12/2014; 6(6):422-8. DOI:10.14740/jocmr1843w
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