Episode 10 – Surviving Sepsis Campaign (SSC) Guidelines 2012 - a podcast by Scott D. Weingart, MD FCCM

See the Guidelines at (CCM 2013;41(2):580)

Diagnosis of Sepsis



Diagnosis of Severe Sepsis



The New Bundles



A. Initial Resuscitation



* Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ? 4 mmol/L). Goals during the first 6 hrs of resuscitation:



* Central venous pressure 8–12 mm Hg

* Mean arterial pressure (MAP) ? 65 mm Hg

* Urine output ? 0.5 mL/kg/hr

* Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C).





* In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).



B. Screening for Sepsis and Performance Improvement



* Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C).

* Hospital–based performance improvement efforts in severe sepsis (UG).



C. Diagnosis



* Cultures as clinically appropriate before antimicrobial therapy if no significant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted (grade 1C).

* Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection.

* Imaging studies performed promptly to confirm a potential source of infection (UG).



D. Antimicrobial Therapy



* Administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy.

* Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential deescalation (grade 1B).

* Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C).

* Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with difficult-to-treat, multidrugresistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B). For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is for P. aeruginosa bacteremia (grade 2B). A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B). Empiric combination therapy should not be administered for more than 3–5 days. De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profile is known (grade 2B).

* Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus; some fungal and viral infections or immunologic deficiencies, including neutropenia (grade 2C).

* Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C).

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