Episode 159: Updated sepsis guidelines

In this episode, I’ll discuss the updated sepsis guidelines from the 2016 Surviving Sepsis Campaign recently published in Critical Care Medicine.

Here are what I consider the 5 most important updates to the 2016 sepsis guidelines compared to the 2012 version:

1. All patients receive 30 mL/kg of IV crystalloid fluid in the first 3 hours

Fluid administration is essential to the initial resuscitation of a patient with sepsis-induced hypoperfusion. Regardless of other patient factors such as age, ejection fraction, etc… resuscitation should begin with 30 mL/kg IV bolus of crystalloid IV fluid.

Excessive IV fluid administration may be harmful. After the initial 30 mL/kg of IV fluid is given, additional fluid administration is guided by frequent reassessment of hemodynamic status. Use a fluid challenge technique to ensure that further IV fluid is only given if the patient is likely to respond.

2. The recommended vasopressin dose is now 0.03 units/min

Previous guideline versions listed a range of 0.03 to 0.04 units/min of vasopressin. The larger studies of vasopressin as an adjunct to norepinephrine in sepsis studied only 0.03 units/min. Anectdotally, the confusion in the range often results in a small delay in vasopressin administration. For this reason, I am glad the guideline authors simplified the recommendations by listing a single dose of 0.03 units/min instead of a range.

3. The specific time to wait for cultures before giving antibiotics is removed

While cultures drawn before antibiotic administration provide essential treatment information, mortality increases with delays in antibiotic administration. Where the 2012 guideline statement used to specify antibiotics may be delayed up to 45 minutes to allow for cultures to be drawn, the current guideline statement is:

We recommend that appropriate routine microbiologic cultures (including blood) be obtained before starting antimicrobial therapy in patients with suspected sepsis or septic shock if doing so results in no substantial delay in the start of antimicrobials (BPS).

 

The idea of waiting up to 45 minutes for cultures before giving antibiotics is still discussed in the guidelines, but the removal of this timeframe from the guideline statement may prevent organizations such as CMS from using it as a quality metric.

4. Combination antimicrobial therapy is recommended in septic shock only

For patients with septic shock, the guidelines now recommend combination therapy be used against the most likely pathogens during initial management. The guidelines further define combination therapy:

The use of multiple antibiotics (usually of different mechanistic classes) with the specific intent of covering the known or suspected pathogen(s) with more than one antibiotic (e.g., piperacillin/tazobactam and an aminoglycoside or fluoroquinolone for gram-negative pathogens) to accelerate pathogen clearance rather than to broaden antimicrobial coverage. Other proposed applications of combination therapy include inhibition of bacterial toxin production (e.g., clindamycin with β-lactams for streptococcal toxic shock) or potential immune modulatory effects (macrolides with a β-lactam for pneumococcal pneumonia).

 

5. Stress ulcer prophylaxis may be achieved with a PPI or H2RA

Because of uncertainties and ongoing trials, the guideline authors no longer recommend a proton pump inhibitor be used over a histamine-2 receptor antagonist. Instead, selection of stress ulcer prophylaxis is based on patient specific factors and the relative risk of GI bleeding, C. difficile, and pneumonia.

Additional information

Caring for patients with sepsis and septic shock are essential skills for critical care pharmacists. Reading the Surviving Sepsis Guidelines is a great start to understanding how to care for these patients. If you are interested in learning more about caring for septic patients, consider joining my Critical Care Pharmacy Academy. Starting Thursday, February 2, 2017, members of the Academy will have access to my new Masterclass: Management of the patient in septic shock.

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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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