R. Phillip Dellinger, MD, MCCM, FCCP Acting Chair & Chief of Department of Medicine Head, Division of Critical Care Medicine Cooper University Hospital Camden, New Jersey Professor of Medicine Cooper Medical School of Rowan University What’s new with the 2012 guidelines and associated changes in the database R. Phillip Dellinger MD, MCCM Christa A. Schorr RN, MSN, FCCM Cooper Medical School Rowan University Cooper University Hospital Camden, NJ Potential Conflicts of Interest • Neither has direct or indirect potential financial conflict of interest as to any material presented in this presentation • As to potential intellectual conflict of interest both hold leadership positions in Surviving Sepsis Campaign Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012 R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung, Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus, Clifford S. Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Crit Care Med 2013; 41:580-637 Intensive Care Medicine 2013; .. Currently Funded with a Gordon and Betty Moore Foundation Grant No direct or indirect industry support for guidelines revision Grading Quality of Evidence GRADE System • A- high quality • B- intermediate • C- low • D- very low – Case series or expert opinion • Upgrade capability • Ungraded (UG) recommendation Grading Strength of Recommendation GRADE System • 1- strong recommendation – We recommend • 2- weak recommendation – We suggest Early Screening and a Performance Improvement Program Antibiotic Therapy • We recommend that intravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (1C). (Best Practice versus Stand of Care) Resuscitation of Sepsis Induced Tissue Hypoperfusion • Recommend MAP 65 mm Hg FLUID THERAPY Fluid therapy 1. We recommend crystalloids be used in the initial fluid resuscitation of severe sepsis (Grade 1B). Fluid therapy 1. We suggest the use of albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (Grade 2C). Fluid challenge Initial fluid challenge in sepsis-induced tissue hypoperfusion (hypotension or elevated lactate) A minimum of 30ml/kg of crystalloids (a portion of this may be albumin equivalent). (1B) Vasopressors Vasopressors 1. We recommend norepinephrine as the first choice vasopressor (Grade 1 B). Vasopressors 2. We suggest epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain blood pressure (Grade 2B). Vasopressors 3. Vasopressin .03 units/min can be added to norepinephrine with the intent of raising MAP to target or decreasing or decreasing norepinephrine dosage. (UG) Phenylephrine Pure vasopressor and in general not recommended Sepsis Induced Tissue Hypoperfusion (Recommend Quantitative Resuscitation) Requirement for vasopressors after fluid challenge or Lactate ≥ 4 mg/dL Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion Recommend Insertion central venous catheter • Central venous pressure: 8–12 mm Hg • Higher with altered ventricular compliance or increased intrathoracic pressure Grade 1C Arterial Systolic Pressure Variation Parry-Jones, et al. Int J Respir Crit Care Med 2003;2:67 Effect on Stroke Volume Part A t Effect on Stroke Volume Effect on Cardiac Filling Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion Recommend Insertion central venous catheter • ScvO2 saturation (SVC) 70% Grade 1C Lactate Clearance In patients with elevated lactate levels as a marker of tissue hypoperfusion we suggest targeting resuscitation to normalize lactate as rapidly as possible (grade 2C).