International Guidelines Issued for Management of Sepsis, Septic Shock

The Surviving Sepsis Campaign, with the Society of Critical Care Management and the European Society of Intensive Care Medicine, published international guidelines for the management of sepsis and septic shock in hospitalized patients.

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The guideline—which appeared in JAMA (published online January 19, 2017; doi:10.1001/jama.2017.0131)—aims to standardize treatment, management, and resuscitation in patients diagnosed with sepsis, and to identify areas where further research remains necessary.

“Sepsis is a leading cause of death, morbidity, and expense, contributing to one-third of deaths in hospitalized patients, depending on definitions,” Michael D Howell, MD, MPH, and Andrew M Davis, MD, MPH, both of the Center for Healthcare Delivery and Science at University of Chicago (Chicago, IL), wrote. “Management of sepsis is a complicated clinical challenge requiring early recognition and management of infection, hemodynamic issues, and other organ dysfunctions.”

The conflicting results of three major clinical trials—PROCESS, conducted in the United States; PROMISE, conducted in the United Kingdom; and ARISE, conducted in Australia and New Zealand—have resulted in international uncertainty as to the most appropriate management of patients with sepsis. Drs Howell and Davis performed an extensive literature review to determine best practices in several areas within this topic.

Because sepsis frequently results from infection, the authors issued a strong recommendation to administer broad-spectrum antibiotics within 1 hour of a sepsis diagnosis. They further recommended as best practice that caregivers obtain source control of the infection as soon as possible, and that patients should be assessed daily to determine whether antibiotic de-escalation should occur.

With regards to resuscitation, the authors issued strong recommendations on the use of norepinephrine as the first-choice vasopressor, and that patients requiring vasopressors should target a mean arterial pressure of 65 mm Hg. Patients with sepsis-induced hypoperfusion should receive intravenous (IV) crystalloid within 3 hours of diagnosis, at a rate of 30 mL/kg.

For patients requiring mechanical ventilation due to acute respiratory distress syndrome, strong evidence suggests that care providers should target a tidal volume of 6 mL/kg of predicted body weight, and that the plateau pressure should be ≤ 30 cm H2O. Drs Howell and Davis further asserted that treatment centers should work to improve sepsis care through better detection practices, including screening.

The authors acknowledged areas within sepsis care where best practices remain undetermined, such as the use of hemodynamic therapy. “The best approach for hemodynamic therapy for sepsis has become more as evidence has accumulated,” Drs Howell and Davis wrote. “This extends even to the degree to which clinicians should use IV fluids as a foundation for resuscitation in some patient groups. The guideline correctly identifies this as a key area for further research.”—Cameron Kelsall