Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock 2012

Transcription

1 本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時, 須獲得原期刊之同意授權 Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock 2012

2 Definition Sepsis the presence of infection with systemic manifestations of infection Severe sepsis sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion Septic shock sepsis-induced hypotension persisting despite adequate fluid resuscitation

3 Definition Sepsis-induced hypotension systolic blood pressure (SBP) < 90 mm Hg mean arterial pressure (MAP) < 70 mm Hg SBP decrease > 40 mmhg or less than two standard deviations below normal for age absence of other causes of hypotension Sepsis-induced tissue hypoperfusion infection-induced hypotension elevated lactate oliguria

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6 History of the Guidelines 2004 The initial SSC guidelines incorporated the evidence available through the end of publication analyzed evidence available through the end of The most current iteration is based on updated literature search incorporated into the evolving manuscript through fall 2012

7 Selection and Organization of Committee Members Appointed by the Society of Critical Care Medicine and European Society of Intensive Care Medicine Sepsis expertise Four clinicians with experience in the GRADE process application (referred to in this document as GRADE group or Evidence-Based Medicine [EBM] group)

8 Search Techniques Search terms sepsis, severe sepsis, septic shock, and sepsis syndrome All questions used in the previous guidelines publications were searched Database MEDLINE, EMBASE, Cochrane Library, ACP Journal Club, Evidence-Based Medicine Journal, Cochrane Registry of Controlled Clinical Trials, International Standard Randomized Controlled Trial Registry

9 Grading Grading of Recommendations Assessment, Development and Evaluation (GRADE) system Quality of evidence High (grade A) Moderate (grade B) Low (grade C) Very low (grade D) Classification of recommendations Strong (grade 1) Weak (grade 2)

10 Grading Throughout the document are a number of statements that either follow graded recommendations or are listed as stand-alone numbered statements followed by ungraded in parentheses (UG).

11 MANAGEMENT OF SEVERE SEPSIS Initial Resuscitation and Infection Issues Hemodynamic Support and Adjunctive Therapy Supportive Therapy of Severe Sepsis

12 Initial Resuscitation and Infection Issues

13 Initial Resuscitation and Infection Issues A. Initial Resuscitation B. Screening for Sepsis and Performance Improvement (New) C. Diagnosis D. Antimicrobial Therapy E. Source Control F. Infection Prevention (New)

14 A. Initial Resuscitation

15 A. Initial Resuscitation 1. We recommend the protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion This protocol should be initiated as soon as hypoperfusion is recognized not be delayed pending ICU admission

16 A. Initial Resuscitation The first 6 hrs of resuscitation goals (grade 1C) (1C) : a) CVP 8 12 mm Hg b) MAP 65 mm Hg c) Urine output 0.5 ml/kg/hr d) Superior vena cava oxygenation saturation (ScvO2) 70% or mixed venous oxygen saturation (SvO2) 65%,

17 A. Initial Resuscitation 2. We suggest targeting resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (grade 2C)

18 B. Screening for Sepsis and Performance Improvement (NEW)

19 B. Screening for Sepsis and Performance Improvement (NEW) 1. We recommend routine screening of potentially infected seriously ill patients for severe sepsis to increase the early identification of sepsis and allow implementation of early sepsis therapy (grade 1C). 2. Performance improvement efforts in severe sepsis should be used to improve patient outcomes (UG).

20 B. Screening for Sepsis and Performance Improvement The early identification of sepsis and implementation of early evidence-based therapies have been documented to improve outcomes and decrease sepsis-related mortality. -- Levy MM, Dellinger RP, Townsend SR, et al; Surviving Sepsis Campaign: The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010; 38:

21 B. Screening for Sepsis and Performance Improvement Performance improvement efforts in sepsis have been associated with improved patient outcomes Kortgen A, Niederprüm P, Bauer M: implementation of an evidencebased standard operating procedure and outcome in septic shock. Crit Care Med 2006; 34: Rivers EP, Ahrens T: Improving outcomes for severe sepsis and septic shock: Tools for early identification of at-risk patients and treatment protocol implementation. Crit Care Clin 2008; 24(3 Suppl):S1 47 Gao F, Melody T, Daniels DF, et al: The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: A prospective observational study. Crit Care 2005; 9:R764 R770 Schorr C: Performance improvement in the management of sepsis. Crit Care Clin 2009; 25: Girardis M, Rinaldi L, Donno L, et al; Sopravvivere alla Sepsi Group of the Modena-University Hospital: Effects on management and outcome of severe sepsis and septic shock patients admitted to the intensive care unit after implementation of a sepsis program: A pilot study. Crit Care 2009; 13:R143 Pestaña D, Espinosa E, Sangüesa-Molina JR, et al; REASEP Sepsis Study Group: Compliance with a sepsis bundle and its effect on intensive care unit mortality in surgical septic shock patients. J Trauma 2010; 69:

22 B. Screening for Sepsis and Performance Improvement Evaluation of process change requires Consistent education Protocol development and implementation Data collection Measurement of indicators Feedback to facilitate the continuous performance improvement

23 B. Screening for Sepsis and Performance Improvement Application of the SSC sepsis bundles led to sustained, continuous quality improvement in sepsis care and was associated with reduced mortality Analysis of the data from nearly 32,000 patient charts gathered from 239 hospitals in 17 countries through September 2011 as part of phase III of the campaign informed the revision of the bundles in conjunction with the 2012 guidelines

24 B. Screening for Sepsis and Performance Improvement In 2012 version the management bundle was dropped the resuscitation bundle was broken into two parts and modified

25 B. Screening for Sepsis and Performance Improvement

26 C. Diagnosis

27 C. Diagnosis 1.We recommend obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay (> 45 minutes) in the start of antimicrobial(s) administration (grade 1C) (1C)

28 C. Diagnosis 2. We suggest the use of the 1,3 β-d-glucan assay (grade 2B), mannan and anti-mannan antibody assays (grade 2C) when invasive candidiasis is in the differential diagnosis of infection. (New)

29 C. Diagnosis 3. We recommend that imaging studies be performed promptly in attempts to confirm a potential source of infection (UG).

30 C. Diagnosis Blood culture Obtaining at least two sets of blood cultures (both aerobic and anaerobic bottles) before antimicrobial therapy, At least one drawn percutaneously and one drawn through each vascular access device, unless the device was recently (< 48 hours) inserted Can be drawn at the same time if they are obtained from different sites

31 C. Diagnosis Cultures of other sites should also be obtained before antimicrobial therapy if doing so does not cause significant delay in antibiotic administration (grade 1C). such as urine, cerebrospinal fluid, wounds, respiratory secretions, or other body fluids that may be the source of infection

32 C. Diagnosis The Gram stain can be useful in particular for respiratory tract specimens, to determine if inflammatory cells are present Rapid influenza antigen testing during periods of increased influenza activity in the community is also recommended

33 C. Diagnosis The potential role of biomarkers (PCT, CRP) for diagnosis of infection in patients presenting with severe sepsis remains undefined for distinguish between severe infection and other acute inflammatory states, no recommendation can be given for discriminate the acute inflammatory pattern of sepsis from other causes of generalized inflammation (eg, postoperative, other forms of shock) has not been demonstrated.

34 C. Diagnosis Imaging studies Potential sources of infection should be sampled as they are identified Consideration of patient risk for transport and invasive procedures (eg, careful coordination and aggressive monitoring if the decision is made to transport for a CTguided needle aspiration). Bedside studies, such as ultrasound, may avoid patient transport

35 D. Antimicrobial Therapy

36 D. Antimicrobial Therapy 1. The administration of effective intravenous antimicrobials within the first hour of recognition of septic shock (grade 1B) (1B) and severe sepsis without septic shock (grade 1C) (1D) should be the goal of therapy.

37 D. Antimicrobial Therapy 2a. We recommend that initial empiric anti-infective therapy include one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) that penetrate in adequate concentrations into the tissues presumed to be the source of sepsis (grade 1B) (1B)

38 D. Antimicrobial Therapy 2b. The antimicrobial regimen should be reassessed daily for potential de-escalation to prevent the development of resistance, to reduce toxicity, and to reduce costs (grade 1B) (1C).

39 D. Antimicrobial Therapy 3. We suggest the use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who appeared septic, but have no subsequent evidence of infection (grade 2C).

40 D. Antimicrobial Therapy 4a. Empiric therapy should attempt to provide antimicrobial activity against the most likely pathogens We suggest combination empiric therapy for neutropenic patients with severe sepsis (grade 2B) (2D) difficult-to-treat, multidrug-resistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. (grade 2B).

41 D. Antimicrobial Therapy 4a. For selected patients with severe infections associated with respiratory failure and septic shock for P. aeruginosa bacteremia combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fluoroquinolone is suggested (grade 2B) (2D). for Streptococcus pneumoniae bacteremia a more complex combination of beta-lactam and a macrolide is suggested for patients with septic shock (grade 2B).

42 D. Antimicrobial Therapy 4b. We suggest that combination therapy, when used empirically in patients with severe sepsis, should not be administered for longer than 3 to 5 days. De-escalation to the most appropriate single-agent therapy should be performed as soon as the susceptibility profile is known (grade 2B) (2D). Exceptions would include aminoglycoside monotherapy, which should be generally avoided, particularly for P. aeruginosa sepsis, and for selected forms of endocarditis, where prolonged courses of combinations of antibiotics are warranted

43 D. Antimicrobial Therapy 5. We suggest that the duration of therapy typically be 7 to 10 days if clinically indicated(grade 2C) (1D) 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 immunologic deficiencies, including neutropenia

44 D. Antimicrobial Therapy 6. We suggest that antiviral therapy be initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C). 7. We recommend that antimicrobial agents not be used in patients with severe inflammatory states determined to be of noninfectious cause (UG) (1D)

45 E. Source Control

46 E. Source Control 1. We recommend that a specific anatomical diagnosis of infection requiring consideration for emergent source control be sought and diagnosed or excluded as rapidly as possible intervention be undertaken for source control within the first 12 hr after the diagnosis is made, if feasible (grade 1C). (necrotizing soft tissue infection, peritonitis, cholangitis, intestinal infarction)

47 E. Source Control 2. We suggest that when infected peripancreatic necrosis is identified as a potential source of infection, definitive intervention is best delayed until adequate demarcation of viable and nonviable tissues has occurred (grade 2B) (2B).

48 E. Source Control 3. When source control in a severely septic patient is required, the effective intervention associated with the least physiologic insult should be used (eg, percutaneous rather than surgical drainage of an abscess) (UG) (1D).

49 E. Source Control 4. If intravascular access devices are a possible source of severe sepsis or septic shock, they should be removed promptly after other vascular access has been established (UG) (1C).

50 F. Infection Prevention (New)

51 F. Infection Prevention (New) 1a. We suggest that selective oral decontamination (SOD) and selective digestive decontamination (SDD) should be introduced and investigated as a method to reduce the incidence of ventilator-associated pneumonia (VAP); this infection control measure can then be instituted in healthcare settings and regions where this methodology is found to be effective (grade 2B).

52 F. Infection Prevention 1b. We suggest oral chlorhexidine gluconate (CHG) be used as a form of oropharyngeal decontamination to reduce the risk of VAP in ICU patients with severe sepsis (grade 2B).

53 F. Infection Prevention Careful infection control practices should be instituted during the care of septic patients as reviewed in the nursing considerations for the Surviving Sepsis Campaign hand washing expert nursing care, catheter care barrier precautions airway management elevation of the head of the bed subglottic suctioning

54 To Be Continue.Thank You

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