
02/10/2021
By: Jefe de grupo | 0 Comments
Surviving sepsis campaign: international
guidelines for management of sepsis and septic
shock 2021
Screening and early treatment
Screening for patients with sepsis and septic shock
Recommendation | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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1. For hospitals and health systems, we recommend using a performance improvement programme for sepsis, including sepsis screening for acutely ill, high-risk patients and standard operating procedures for treatment | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Strong recommendation, moderate quality of evidence for screening | ||||||||||||||||||||||||||||||||||||||||||||||||||||
Strong recommendation, very low-quality evidence for standard operating procedures
Initial resuscitation
Mean arterial pressure
Admission to intensive care
Diagnosis of infection
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Source control
Recommendation |
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27. For adults with sepsis or septic shock, we recommend rapidly identifying or excluding a specific anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical |
Best Practice Statement |
Recommendation |
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28. For adults with sepsis or septic shock, we recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established |
Best Practice Statement |
De-escalation of antibiotics
Recommendation |
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29. For adults with sepsis or septic shock, we suggest daily assessment for de-escalation of antimicrobials over using fixed durations of therapy without daily reassessment for de-escalation |
Weak recommendation, very low quality of evidence |
Duration of antibiotics
Recommendation |
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30. For adults with an initial diagnosis of sepsis or septic shock and adequate source control, we suggest using shorter over longer duration of antimicrobial therapy |
Weak recommendation, very low quality of evidence |
Biomarkers to discontinue antibiotics
Recommendation |
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31. For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear, we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone |
Weak recommendation, low quality of evidence |
Haemodynamic management
Fluid management
Recommendations |
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32. For adults with sepsis or septic shock, we recommend using crystalloids as first-line fluid for resuscitation Strong recommendation, moderate quality of evidence |
33. For adults with sepsis or septic shock, we suggest using balanced crystalloids instead of normal saline for resuscitation Weak recommendation, low quality of evidence |
34. For adults with sepsis or septic shock, we suggest using albumin in patients who received large volumes of crystalloids over using crystalloids alone Weak recommendation, moderate quality of evidence |
35. For adults with sepsis or septic shock, we recommend against using starches for resuscitation Strong recommendation, high quality of evidence |
36. For adults with sepsis and septic shock, we suggest against using gelatin for resuscitation Weak recommendation, moderate quality |
Vasoactive agents
Recommendations |
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37. For adults with septic shock, we recommend using norepinephrine as the first-line agent over other vasopressors. Strong recommendation Dopamine. High quality evidence Vasopressin. Moderate-quality evidence Epinephrine. Low-quality evidence Selepressin. Low-quality evidence Angiotensin II. Very low-quality evidence Remark In settings where norepinephrine is not available, epinephrine or dopamine can be used as an alternative, but we encourage efforts to improve the availability of norepinephrine. Special attention should be given to patients at risk for arrhythmias when using dopamine and epinephrine |
38. For adults with septic shock on norepinephrine with inadequate MAP levels, we suggest adding vasopressin instead of escalating the dose of norepinephrine Weak recommendation, moderate-quality evidence Remark In our practice, vasopressin is usually started when the dose of norepinephrine is in the range of 0.25–0.5 μg/kg/min |
39. For adults with septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we suggest adding epinephrine Weak recommendation, low-quality evidence |
40. For adults with septic shock, we suggest against using terlipressin Weak recommendation, low quality of evidence |
Inotropes
Recommendations |
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41. For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we suggest either adding dobutamine to norepinephrine or using epinephrine alone Weak recommendation, low quality of evidence |
42. For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we suggest against using levosimendan Weak recommendation, low quality of evidence |
Monitoring and intravenous access
Recommendations |
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43. For adults with septic shock, we suggest using invasive monitoring of arterial blood pressure over non-invasive monitoring, as soon as practical and if resources are available Weak recommendation, very low quality of evidence |
44. For adults with septic shock, we suggest starting vasopressors peripherally to restore MAP rather than delaying initiation until a central venous access is secured Weak recommendation, very low quality of evidence Remark When using vasopressors peripherally, they should be administered only for a short period of time and in a vein in or proximal to the antecubital fossa |
Fluid balance
Recommendation |
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45. There is insufficient evidence to make a recommendation on the use of restrictive versus liberal fluid strategies in the first 24 h of resuscitation in patients with sepsis and septic shock who still have signs of hypoperfusion and volume depletion after initial resuscitation |
Remarks Fluid resuscitation should be given only if patients present with signs of hypoperfusion |
Ventilation
Oxygen targets
Recommendation | |
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46. There is insufficient evidence to make a recommendation on the use of conservative oxygen targets in adults with sepsis-induced hypoxemic respiratory failure |
High-flow nasal oxygen therapy
Recommendation |
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47. For adults with sepsis-induced hypoxemic respiratory failure, we suggest the use of high flow nasal oxygen over non-invasive ventilation |
Weak recommendation, low quality of evidence |
Non-invasive ventilation
Recommendation | |
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48. There is insufficient evidence to make a recommendation on the use of non-invasive ventilation in comparison to invasive ventilation for adults with sepsis-induced hypoxemic respiratory failure |
Protective ventilation in acute respiratory distress syndrome (ARDS)
Recommendation |
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49. For adults with sepsis-induced ARDS, we recommend using a low tidal volume ventilation strategy (6 mL/kg), over a high tidal volume strategy (> 10 mL/kg) |
Strong recommendation, high quality of evidence |
Recommendation |
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50. For adults with sepsis-induced severe ARDS, we recommend using an upper limit goal for plateau pressures of 30 cm H2O, over higher plateau pressures |
Strong recommendation, moderate quality of evidence |
Recommendation | |
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51. For adults with moderate to severe sepsis-induced ARDS, we suggest using higher PEEP over lower PEEP Weak recommendation, moderate quality of evidence |
Low tidal volume in non-ARDS respiratory failure
Recommendation |
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52. For adults with sepsis-induced respiratory failure (without ARDS), we suggest using low tidal volume as compared to high tidal volume ventilation |
Weak recommendation, low quality of evidence |
Recruitment manoeuvres
Recommendations |
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53. For adults with sepsis-induced moderate-severe ARDS, we suggest using traditional recruitment maneuvers Weak recommendation, moderate quality of evidence |
54. When using recruitment maneuvers, we recommend against using incremental PEEP titration/strategy Strong recommendation, moderate quality of evidence |
Prone ventilation
Recommendation |
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55. For adults with sepsis-induced moderate-severe ARDS, we recommend using prone ventilation for more than 12 h daily |
Strong recommendation, moderate quality of evidence |
Neuromuscular blocking agents
Recommendation |
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56. For adults with sepsis induced moderate-severe ARDS, we suggest using intermittent NMBA boluses, over NMBA continuous infusion |
Weak recommendation, moderate quality of evidence |
Extracorporeal membrane oxygenation (ECMO)
Recommendation |
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57. For adults with sepsis-induced severe ARDS, we suggest using veno-venous (VV) ECMO when conventional mechanical ventilation fails in experienced centers with the infrastructure in place to support its use |
Weak recommendation, low quality of evidence |
Additional therapies
Corticosteroids
Recommendation |
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58. For adults with septic shock and an ongoing requirement for vasopressor therapy we suggest using IV corticosteroids Weak recommendation; moderate quality of evidence |
Remark The typical corticosteroid used in adults with septic shock is IV hydrocortisone at a dose of 200 mg/day given as 50 mg intravenously every 6 h or as a continuous infusion. It is suggested that this is commenced at a dose of norepinephrine or epinephrine ≥ 0.25 mcg/kg/min at least 4 h after initiation |
Blood Purification
Recommendations |
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59. For adults with sepsis or septic shock, we suggest against using polymyxin B haemoperfusion Weak recommendation; low quality of evidence |
60. There is insufficient evidence to make a recommendation on the use of other blood purification techniques |
Red blood cell (RBC) transfusion targets
Recommendation |
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61. For adults with sepsis or septic shock, we recommend using a restrictive (over liberal) transfusion strategy Strong recommendation; moderate quality of evidence |
Remark A restrictive transfusion strategy typically includes a haemoglobin concentration transfusion trigger of 70 g/L; however, RBC transfusion should not be guided by haemoglobin concentration alone. Assessment of a patient’s overall clinical status and consideration of extenuating circumstances such as acute myocardial ischaemia, severe hypoxemia or acute haemorrhage is required |
Immunoglobulins
Recommendation |
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62. For adults with sepsis or septic shock, we suggest against using intravenous immunoglobulins |
Weak recommendation, low quality of evidence |
Stress ulcer prophylaxis
Recommendation |
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63. For adults with sepsis or septic shock, and who have risk factors for gastrointestinal (GI) bleeding, we suggest using stress ulcer prophylaxis |
Weak recommendation, moderate quality of evidence |
Venous thromboembolism (VTE) prophylaxis
Recommendations |
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64. For adults with sepsis or septic shock, we recommend using pharmacologic VTE prophylaxis unless a contraindication to such therapy exists Strong recommendation, moderate quality of evidence |
65. For adults with sepsis or septic shock, we recommend using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for VTE prophylaxis Strong recommendation, moderate quality of evidence |
66. For adults with sepsis or septic shock, we suggest against using mechanical VTE prophylaxis in addition to pharmacological prophylaxis, over pharmacologic prophylaxis alone Weak recommendation, low quality of evidence |
Renal replacement therapy
Recommendations |
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67. In adults with sepsis or septic shock and AKI who require renal replacement therapy, we suggest using either continuous or intermittent renal replacement therapy Weak recommendation, low quality of evidence |
68. In adults with sepsis or septic shock and AKI, with no definitive indications for renal replacement therapy, we suggest against using renal replacement therapy Weak recommendation, moderate quality of evidence |
Glucose control
Recommendation |
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69. For adults with sepsis or septic shock, we recommend initiating insulin therapy at a glucose level of ≥ 180 mg/dL (10 mmol/L) Strong recommendation; moderate quality of evidence |
Remark Following initiation of an insulin therapy, a typical target blood glucose range is 144–180 mg/dL (8–10 mmol/L) |
Vitamin C
Recommendation |
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70. For adults with sepsis or septic shock, we suggest against using IV vitamin C |
Weak recommendation, low quality of evidence |
Bicarbonate therapy
Recommendations |
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71. For adults with septic shock and hypoperfusion-induced lactic acidemia, we suggest against using sodium bicarbonate therapy to improve haemodynamics or to reduce vasopressor requirements Weak recommendation, low quality of evidence |
72. For adults with septic shock, severe metabolic acidemia (pH ≤ 7.2) and AKI (AKIN score 2 or 3), we suggest using sodium bicarbonate therapy Weak recommendation, low quality of evidence |
Nutrition
Recommendation |
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73. For adult patients with sepsis or septic shock who can be fed enterally, we suggest early (within 72 h) initiation of enteral nutrition |
Weak recommendation; very low quality of evidence |
Long-term outcomes and goals of care
Goals of care
Recommendations |
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74. For adults with sepsis or septic shock, we recommend discussing goals of care and prognosis with patients and families over no such discussion Best Practice Statement |
75. For adults with sepsis or septic shock, we suggest addressing goals of care early (within 72 h) over late [72] Weak recommendation, low-quality evidence |
76. There is insufficient evidence to make a recommendation for any specific standardised criterion to trigger goals of care discussion |
Palliative care
Recommendations |
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77. For adults with sepsis or septic shock, we recommend integrating principles of palliative care (which may include palliative care consultation based on clinician judgement) into the treatment plan, when appropriate, to address patient and family symptoms and suffering Best Practice Statement |
78. For adults with sepsis or septic shock, we suggest against routine formal palliative care consultation for all patients over palliative care consultation based on clinician judgement Weak recommendation, low-quality evidence |
Peer support groups
Recommendation |
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79. For adult survivors of sepsis or septic shock and their families, we suggest referral to peer support groups over no such referral |
Weak recommendation, very low quality of evidence |
Transitions of care
Recommendations |
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80. For adults with sepsis or septic shock, we suggest using a handoff process of critically important information at transitions of care, over no such handoff process Weak recommendation, very low-quality evidence |
81. There is insufficient evidence to make a recommendation for the use of any specific structured handoff tool over usual handoff processes |
Screening for economic or social support
Recommendation |
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82. For adults with sepsis or septic shock and their families, we recommend screening for economic and social support (including housing, nutritional, financial, and spiritual support), and make referrals where available to meet these needs |
Best Practice Statement |
Sepsis education for patients and families
Recommendation |
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83. For adults with sepsis or septic shock and their families, we suggest offering written and verbal sepsis education (diagnosis, treatment, and post-ICU/post-sepsis syndrome) prior to hospital discharge and in the follow-up setting |
Weak recommendation, very low-quality evidence |
Shared decision making
Recommendation |
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84. For adults with sepsis or septic shock and their families, we recommend the clinical team provide the opportunity to participate in shared decision making in post-ICU and hospital discharge planning to ensure discharge plans are acceptable and feasible |
Best Practice Statement |
Discharge planning
Recommendations |
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85. For adults with sepsis and septic shock and their families, we suggest using a critical care transition programme, compared to usual care, upon transfer to the floor Weak recommendation, very low-quality evidence |
86. For adults with sepsis and septic shock, we recommend reconciling medications at both ICU and hospital discharge Best Practice Statement |
87. For adult survivors of sepsis and septic shock and their families, we recommend including information about the ICU stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal hospital discharge summary Best Practice Statement |
88. For adults with sepsis or septic shock who developed new impairments, we recommend hospital discharge plans include follow-up with clinicians able to support and manage new and long-term sequelae Best Practice Statement |
89. There is insufficient evidence to make a recommendation on early post-hospital discharge follow-up compared to routine post-hospital discharge follow-up |
Cognitive therapy
Recommendation | |
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90. There is insufficient evidence to make a recommendation on early cognitive therapy for adult survivors of sepsis or septic shock |
Post-discharge follow-up
Recommendations |
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91. For adult survivors of sepsis or septic shock, we recommend assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge Best Practice Statement |
92. For adult survivors of sepsis or septic shock, we suggest referral to a post-critical illness follow-up programme if available Weak recommendation, very low-quality evidence |
93. For adult survivors of sepsis or septic shock receiving mechanical ventilation for > 48 h or an ICU stay of > 72 h, we suggest referral to a post-hospital rehabilitation programme Weak recommendation, very low-quality evidence |
Fuente: Intensive Care Med https://doi.org/10.1007/s00134-021-06506-y
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