Sepsis Management : Review of

Surviving Sepsis Campaign and Early

Goal Directed Therapy
Frans Arifin
General Surgery Departement
Airlangga University Medical School
Overview
 Definition of Sepsis
 Management of Sepsis
◦ Surviving Sepsis Campaign
◦ Early Goal Directed Therapy for Sepsis
 Examples of EGDT and SSC Application
(The Stanford Hospital and Clinics Sepsis Management in the ICU)

 Conclusion
What Is Sepsis ?
SIRS is…
SIRS is defined by 2 or more of the
following clinical findings that occur as a
result of tissue injury:
 Temperature > 38C or < 36C
 Heart rate > 90
 Respiratory rate > 20 or respiratory
alkalosis
 WBC >12,000 or < 4,000 or >10%
immature (bands)
Continuum of Sepsis
Infection or
Trauma SIRS Sepsis Severe Sepsis

Sepsis ＋  1 organ failure:

- Refractory hypotension
- Renal
- Respiratory
- Hepatic
- Hematologic Shock
- CNS
- Unexplained metabolic
acidosis

Bone et al. Chest. 1992;101:1644;

Wheeler and Bernard. N Engl J Med. 1999;340:207.
 Pathophysiology
 Complex
interaction of
inflamatory
mediators
 Disruption of a
homeostasis
(increased of
inflammatory and
counter
inflammatory
cytokines)
Pathophysiology (2)
1. Altered Inflammation
2. Altered Coagulation
3. Altered Fibrinolysis
4. Alteration in Activated Protein C
5. Hormonal Imbalance
6. Multi-Organ Dysfunction Syndrome (MODS)
◦ Hypoxia, hypercarbia, increased ventilation requirements
◦ Hypotension, decreased cardiac output
◦ Oliguria, increased creatinine
◦ Decreased level of consciousness
◦ Metabolic derangements, including lactic acidosis
◦ Rising hepatic enzymes
◦ Coagulopathies
7. Myocardial Dysfunction
8. Systemic Versus Local Response
 Surviving Sepsis Campaign
 2003, 11 organization  consensus for
bedside physician on sepsis management
 Method : Delphi method, consensus
conference
Summary of SSC Guidelines
Initiative Grade
DVT prophylaxis with low dose heparins or A
mechanical devices
Stress ulcer prophylaxis, preferably with H2 A
blockers
Do not use more then 300 mg/day A
hydrocortisone
Weaning protocol with spontaneous breathing A
trials
Do not increase cardiac index to supranormal A
Early initial resuscitation to goals B
Red blood cell transfusion/dobutamine to goals B
Summary of SSC Guidelines
Initiative Grade
Do not use low dose dopamine for renal B
protection
rh Activated Protein C [drotrecogin alfa B
(activated)] in patients with high risk of death
RBC transfusion if hemoglobin <7 g/dL B
Do not use erythropoietin for sepsis caused B
anemia
Avoid high tidal volumes and plateau pressures B
in ALI/ARDS
Continuous vs. intermittent renal replacement B
considered equivalent for acute renal failure
Summary of SSC Guidelines
Initiative Grade
Sedation protocols with goal and assessment B
scale
Daily interruption/lightening if using B
continuous IV sedation
Use colloids or crystalloids C
Corticosteroids for 7 days in septic shock C
patients on vasopressors
Permissive hypercapnia to minimize plateau C
pressures and tidal volumes
Do not use bicarbonate if pH ≥7.15 in C
hypoperfusion lactic acidemia
Semirecumbent positioning to avoid VAP C
(head of bed at 45-degrees)
Summary of SSC Guidelines
Initiative Grade
Cultures before beginning antibiotic therapy D
Initial empirical broad spectrum anti-infectives D
Norepinephrine or dopamine first choice D
pressors
Diagnostic Studies to determine source E
Start IV antibiotics within first hour E
Reassessment of antimicrobials in 48-72 hrs E
Stop antimicrobials if determine noninfectious E
syndrome
Summary of SSC Guidelines
Initiative Grade
Evaluate for and provide source control E
Weigh risk vs benefit of source control methods E
Provide rapid source control as appropriate E
Establish new and then remove IV device if source E
of infection
Fluid challenge for suspected hypovolemia E
Start vasopressors if nonresponsive to fluid E
challenge
 Summary of SSC Guidelines
Initiative Grade
Arterial catheter to measure BP in shock E
Vasopressin if refractory to other pressors E
Dobutamine if low cardiac output E
Consider addition of fludrocortisone E
Do not routinely use FFP in absence of bleeding or E
planned procedures
Do not use antithrombin E
Platelet transfusions E
 Summary of SSC Guidelines
Initiative Grade
Use PEEP to prevent lung collapse, set at minimum E
amount
Prone positioning in ALI/ARDS E
Avoid neuromuscular blockers E
Maintain blood glucose < 150 mg/dL E
Nutrition protocol, preferably enteral when glycemic E
control strategy initiated
Consider limitation of support when appropriate, E
including frequent discussions with family and patient
SSC: Recommendations
Pediatric considerations :
 more likely need for intubation due to low functional
residual capacity;
 more difficult intravenous access
 fluid resuscitation based on weight with 40–60 mL/kg
or higher needed
 decreased cardiac output and increased systemic
vascular resistance as the most common
hemodynamic profile
 greater use of physical examination therapeutic end
points
 unsettled issue of high-dose steroids for therapy of
septic shock
 greater risk of hypoglycemia with aggressive glucose
control.
Early Goal Directed Therapy : Study Design
EDGT : Protocol
EGDT : Results
Early Goal-Directed Therapy for
Severe Sepsis and Septic Shock
Rivers et al. N Engl J Med 2001;345:1368-77

Severe Sepsis +
↓Blood Pressure or
↑Lactic acid

Standard (n 133) EGDT (n 130)

Mortality 46.5% Mortality 30.5%
Sepsis Management
in the ICU
Stanford Hospital and Clinics
2006

Stanford Hospital and Clinics 2006

 ICU Sepsis Management

 Order set has 4 sections: Each has an

algorithm followed by detailed therapies:
1. Assessment of sepsis and potential organ failure
2. Early goal directed therapy (EGDT)
3. Antibiotic selection and administration
4. ICU management

Stanford Hospital and Clinics 2006

Assessment of Sepsis and potential
organ failure

Stanford Hospital and Clinics 2006

Early Goal Directed Therapy

Stanford Hospital and Clinics 2006

Antibiotic Selection & Administration

Stanford Hospital and Clinics 2006

ICU Management

Stanford Hospital and Clinics 2006

Conclusion
 Sepsis is a complex syndrome with
multiple interacting process, based on
prolonged disruption of homeostasis
 EDGT is beneficial in early management
of sepsis patient (Start early !)
 Although there are many sepsis
treatment, SSC had provided an evidence
based review of recommended treatment
THANK YOU !