Ref: Crit Care Med 2008 Vol. 36, No. 1;
Initial resuscitation (first 6 hrs)
● Begin resuscitation immediately in patients with hypotension or elevated serum lactate more than 4 mmol/L; do not delay pending ICU admission (1C)
● Resuscitation goals (1C)
- CVP 8-12 mm Hg (higher target CVP of 12–15 mm Hg is recommended in the presence of mechanical ventilation or preexisting decreased ventricular compliance.)
- Mean arterial pressure more than or equal to 65 mm Hg
- Urine output more than or equal to 0.5 mL per kg per hr
- Central venous (superior vena cava) oxygen saturation more than 70% or mixed venous more than 65%
● If venous oxygen saturation target is not achieved (2C)
- Consider further fluid
- Transfuse packed red blood cells if required to hematocrit of more than 30% and/or
- Start dobutamine infusion, maximum 20 microgm per kg per min
Diagnosis
● Obtain appropriate cultures before starting antibiotics provided this does not significantly delay antimicrobial administration (1C)
- Obtain two or more blood cultures
- One or more Blood Cultures should be percutaneous
- One BC from each vascular access device in place for more than 48 hrs
- Culture other sites as clinically indicated
● Perform imaging studies promptly to confirm and sample any source of infection, if safe to do so (1C)
Antibiotic therapy
● Begin intravenous antibiotics as early as possible and always within the first hour of recognizing severe sepsis (1D) and septic shock (1B)
● Broad-spectrum: one or more agents active against likely bacterial/fungal pathogens and with good penetration into presumed source (1B)
● Reassess antimicrobial regimen daily to optimize efficacy, prevent resistance, avoid toxicity, and minimize costs (1C)
- Consider combination therapy in Pseudomonas infections (2D)
- Consider combination empiric therapy in neutropenic patients (2D)
- Combination therapy for less than 3–5 days and de-escalation following susceptibilities (2D)
● Duration of therapy typically limited to 7–10 days; longer if response is slow or there are undrainable foci of infection or immunologic deficiencies (1D)
● Stop antimicrobial therapy if cause is found to be noninfectious (1D)
Source identification and control:
● A specific anatomic site of infection should be established as rapidly as possible (1C) and within first 6 hrs of presentation (1D)
● Formally evaluate patient for a focus of infection amenable to source control measures (e.g. abscess drainage, tissue debridement) (1C)
● Implement source control measures as soon as possible following successful initial resuscitation (1C) (exception: infected pancreatic necrosis, where surgical intervention is best delayed) (2B)
● Choose source control measure with maximum efficacy and minimal physiologic upset (1D)
● Remove intravascular access devices if potentially infected (1C)
Thursday, April 2, 2009
International Surviving Sepsis Guidelines, 2008
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wats this 1c, 2b
ReplyDeleteThey are the GRADE Criteria used to grade the level of recommendation based on the Quality of Evidence available.The article mention states: "Quality of evidence was judged by predefined
ReplyDeleteGrades of Recommendation, Assessment, Development and Evaluation (GRADE)Criteria. The GRADE system is based on a sequential assessment of the quality of evidence, followed by assessment of the balance between benefits vs. risks, burden, and cost and, based on the preceding, development and grading of a management recommendations. Keeping the rating of quality of evidence and strength of recommendation explicitly separate constitutes a crucial and defining feature of the GRADE approach. This system classifies quality of evidence as high (grade A), moderate (grade B), low (grade C), or very low(grade D). Randomized trials begin as high quality evidence but may be downgraded due to limitations in implementation, inconsistency or imprecision of the results, indirectness of the evidence, and possible reporting bias. Observational (nonrandomized) studies begin as low-quality evidence, but the quality level may be upgraded on the basis of large magnitude of effect.
The GRADE system classifies recommendations as strong (grade 1) or weak (grade 2). The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. The committee assessed whether the desirable effects of adherence will outweigh the undesirable effects, and the strength of a recommendation reflects the group’s degree of confidence in that assessment. While the degree of confidence is a continuum and there is no precise threshold between a strong and a weak recommendation, the presence of important concerns about one or more of the preceding factors makes a weak recommendation more likely."