Surviving Sepsis Campaign：Internaninal guidelines for management of sever sepsis and septic shock：2008.ppt
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清华大学第一附属医院ICU
Surviving Sepsis Campaign：
Internaninal guidelines for
management of sever sepsis
and septic shock：2008
Objective
To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock," published in 2004.
Methods:Grading system
Underlying methodology:
* A RCT
* B Downgraded RCT or upgraded observational studies
* C Well-done observational studies
* D Case series or expert opinion
(RCT: randomized controlled trial)
Methods:Grading system
Factors that may decrease the strength of evidence:
* 1. Poor quality of planning and implementation of available RCTs suggesting high likelihood of bias
* 2. Inconsistency of results (including problems with subgroup analyses)
* 3. Indirectness of evidence (differing population, intervention, control, outcomes, comparison)
* 4. Imprecision of results
* 5. High likelihood of reporting bias
Methods:Grading system
Main factors that may increase the strength of evidence:
* 1. Large magnitude of effect (direct evidence, relative risk (RR) >2 with no plausible confounders)
* 2. Very large magnitude of effect with RR >5 and no threats to validity (by two levels)
* 3. Dose response gradient
Management of Severe Sepsis
Management of Severe Sepsis
A.Initial Resuscitation
The goals during the first 6 hrs:
* Central venous pressure (CVP): 8-12mm Hg
* Mean arterial pressure (MAP) ≥ 65mm Hg
* Urine output ≥ 0.5mL/kg/hr
* Central venous (superior vena cava) or mixed venous oxygen saturation ≥ 70% or ≥ 65%, respectively(Grade 1C)
Management of Severe Sepsis
A.Initial Resuscitation
Rationale:
* Early goal therapy improves survival
* Reduce 28-day mortality rate
* Although blood lactate concentration may lack precision as a measure of tissue metabolic status,elevated levels in sepsis support aggressive resuscitation.
Management of Severe Sepsis
Management of Severe Sepsis
A.Initial Resuscitation
* Elevated central venous pressures may also be seen with pre-existing clinically significant pulmonary artery hypertension.
* Although the cause of tachycardia in septic patients may be multifactorial, a decrease in elevated pulse rate with fluid resuscitation is often a useful marker of improving intravascular filling.
Management of Severe Sepsis
A.Initial Resuscitation
Recently published observational studies
have demonstrated an association between good
clinical outcome in septic shock and MAP ≥
65mm Hg as well as central venous oxygen
saturation (ScvO2, measured in superior vena
cava, either intermittently or continuously) of ≥
70%
Management of Severe Sepsis
A.Initial Resuscitation
We suggest during the first 6 hrs of
resuscitation of severe sepsis or septic shock, if
SCVO2 or SvO2 of 70% or 65% respectively is
not achieved with fluid resuscitation to the CVP
target, then transfusion of packed red blood cells
to achieve a hematocrit of ≥ 30% and/or
administration of a dobutamine infusion (up to a
maximum of 20ug/kg/min) be utilized to achieve
this goal (Grade 2C).
Management of Severe Sepsis
A.Initial Resuscitation
Rationale:
The protocol used in the study cited previously
targeted an increase in SCVO2 to ≥ 70% . This
was achieved by sequential institution of initial
fluid resuscitation, then packed red blood cells,and then dobutamine.This protocol was
associated with an improvement in survival.
Management of Severe Sepsis
B.Diagnosis
We recommend:
* Obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay in antibiotic administration.
* At least two blood cultures be obtained prior to
antibiotics with at least one drawn percutaneously and one drawn through each vascular access device, unless the device was recently (< 48 h) inserted.
* Cultures of other sites such as urine, cerebrospinal fluid, wounds, respiratory secretions, or other body fluids that may be the source of infection should also be obtained before antibiotic therapy if not associated with significant delay in antibiotic administration(Grade 1C).
Management of Severe Sepsis
B.Diagnosis
Rationale:
* Samples can be kept in the refrigerator or frozen if processing cannot be performed immediately.
* Immediate transport to a microbiological lab is necessary.
* Because rapid sterilization of blood cultures can occur within a few hours after the first antibiotic dose, obtaining those cultures before starting therapy is essential if the causative organism is to be identified.
Management of Severe Sepsis
B.Diagnosis
* Obtaining blood cultures peripherally and through a vascular access device is an importantstrategy.If the same organism is recovered from both cultures, the likelihood that the organism is causing the severe sepsis is enhanced.
* In addition, if the culture drawn through the vascular access device is positive much earlier than the peripheral blood culture (i. e., > 2 hrs earlier), the data support the concept that the vascular access device is the source of the infection.
Management of Severe Sepsis
B.Diagnosis
* Quantitative cultures of catheter and peripheral blood are also useful for determining whether the catheter is the source of infection. Volume of blood drawn with the culture tube should be at least 10 ml.
* Quantitative (or semi-quantitative) cultures of respiratory tract secretions are recommended for the diagnosis of ventilator-associated pneumonia.
* Gram stain can be useful, in particular for respiratory tract specimens,to help decide the micro-organisms to be targeted.......（后略) ......
清华大学第一附属医院ICU
Surviving Sepsis Campaign：
Internaninal guidelines for
management of sever sepsis
and septic shock：2008
Objective
To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock," published in 2004.
Methods:Grading system
Underlying methodology:
* A RCT
* B Downgraded RCT or upgraded observational studies
* C Well-done observational studies
* D Case series or expert opinion
(RCT: randomized controlled trial)
Methods:Grading system
Factors that may decrease the strength of evidence:
* 1. Poor quality of planning and implementation of available RCTs suggesting high likelihood of bias
* 2. Inconsistency of results (including problems with subgroup analyses)
* 3. Indirectness of evidence (differing population, intervention, control, outcomes, comparison)
* 4. Imprecision of results
* 5. High likelihood of reporting bias
Methods:Grading system
Main factors that may increase the strength of evidence:
* 1. Large magnitude of effect (direct evidence, relative risk (RR) >2 with no plausible confounders)
* 2. Very large magnitude of effect with RR >5 and no threats to validity (by two levels)
* 3. Dose response gradient
Management of Severe Sepsis
Management of Severe Sepsis
A.Initial Resuscitation
The goals during the first 6 hrs:
* Central venous pressure (CVP): 8-12mm Hg
* Mean arterial pressure (MAP) ≥ 65mm Hg
* Urine output ≥ 0.5mL/kg/hr
* Central venous (superior vena cava) or mixed venous oxygen saturation ≥ 70% or ≥ 65%, respectively(Grade 1C)
Management of Severe Sepsis
A.Initial Resuscitation
Rationale:
* Early goal therapy improves survival
* Reduce 28-day mortality rate
* Although blood lactate concentration may lack precision as a measure of tissue metabolic status,elevated levels in sepsis support aggressive resuscitation.
Management of Severe Sepsis
Management of Severe Sepsis
A.Initial Resuscitation
* Elevated central venous pressures may also be seen with pre-existing clinically significant pulmonary artery hypertension.
* Although the cause of tachycardia in septic patients may be multifactorial, a decrease in elevated pulse rate with fluid resuscitation is often a useful marker of improving intravascular filling.
Management of Severe Sepsis
A.Initial Resuscitation
Recently published observational studies
have demonstrated an association between good
clinical outcome in septic shock and MAP ≥
65mm Hg as well as central venous oxygen
saturation (ScvO2, measured in superior vena
cava, either intermittently or continuously) of ≥
70%
Management of Severe Sepsis
A.Initial Resuscitation
We suggest during the first 6 hrs of
resuscitation of severe sepsis or septic shock, if
SCVO2 or SvO2 of 70% or 65% respectively is
not achieved with fluid resuscitation to the CVP
target, then transfusion of packed red blood cells
to achieve a hematocrit of ≥ 30% and/or
administration of a dobutamine infusion (up to a
maximum of 20ug/kg/min) be utilized to achieve
this goal (Grade 2C).
Management of Severe Sepsis
A.Initial Resuscitation
Rationale:
The protocol used in the study cited previously
targeted an increase in SCVO2 to ≥ 70% . This
was achieved by sequential institution of initial
fluid resuscitation, then packed red blood cells,and then dobutamine.This protocol was
associated with an improvement in survival.
Management of Severe Sepsis
B.Diagnosis
We recommend:
* Obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay in antibiotic administration.
* At least two blood cultures be obtained prior to
antibiotics with at least one drawn percutaneously and one drawn through each vascular access device, unless the device was recently (< 48 h) inserted.
* Cultures of other sites such as urine, cerebrospinal fluid, wounds, respiratory secretions, or other body fluids that may be the source of infection should also be obtained before antibiotic therapy if not associated with significant delay in antibiotic administration(Grade 1C).
Management of Severe Sepsis
B.Diagnosis
Rationale:
* Samples can be kept in the refrigerator or frozen if processing cannot be performed immediately.
* Immediate transport to a microbiological lab is necessary.
* Because rapid sterilization of blood cultures can occur within a few hours after the first antibiotic dose, obtaining those cultures before starting therapy is essential if the causative organism is to be identified.
Management of Severe Sepsis
B.Diagnosis
* Obtaining blood cultures peripherally and through a vascular access device is an importantstrategy.If the same organism is recovered from both cultures, the likelihood that the organism is causing the severe sepsis is enhanced.
* In addition, if the culture drawn through the vascular access device is positive much earlier than the peripheral blood culture (i. e., > 2 hrs earlier), the data support the concept that the vascular access device is the source of the infection.
Management of Severe Sepsis
B.Diagnosis
* Quantitative cultures of catheter and peripheral blood are also useful for determining whether the catheter is the source of infection. Volume of blood drawn with the culture tube should be at least 10 ml.
* Quantitative (or semi-quantitative) cultures of respiratory tract secretions are recommended for the diagnosis of ventilator-associated pneumonia.
* Gram stain can be useful, in particular for respiratory tract specimens,to help decide the micro-organisms to be targeted.......（后略) ......