Surviving Sepsis Targets



Haemodynamic Targets and Support
  • Recommendation
  • Consider
Fluid therapy
  • Crystalloids or colloids
  • Target CVP >8 mmHg (>12 mmHg if mechanically ventilated)
  • Use fluid challenge technique
  • Give 1000mL crystalloid or 300-500mL colloid over 30 min
  • Reduce infusion rate if cardiac filling pressures rise without haemodynamic improvement
Vasopressors
  • Maintain MAP>65 mmHg
  • Noradrenaline and dopamine are agents of choice
  • Avoid "renal dose" dopamine
  • Arterial catheter as soon as practical
Inotropes
  • Dobutamine if elevated cardiac filling pressure and low cardiac output
Steroids
  • Consider IV hydrocortisone if hypotension responds poorly to vasopressors
  • Do not use ACTH stimulation to identify patients to receive steroids
  • Hydrocortisone is preferred to dexamethasone
  • Fludrocortisone 50 µg/day if using an alternative to hydrocortisone without significant mineralocorticoid activity; optional if using hydrocortisone
  • Hydrocortisone dose <300 mg/day
  • Do not use steroids for sepsis without shock unless warranted by endocrine or steroid history
Recombinant activated protein C
  • Consider in severe sepsis with multi-organ failure
Initial Resuscitation and Infection Issues
  • Recommendation
  • Consider
Initial resuscitation (first 6 hours)
  • Begin immediately in patients with hypotension or serum lactate >4 mmol/L
  • Sepsis identified as 2 of 4: P>90, RR>20, T>38 or <36, WBC>12 or <4
  • Resuscitation goals:
    • CVP 8-12 mmHg (10-16 cmH2O
    • MAP >65 mmHg
    • Urine output >0.5 ml kg-1 hr-1
    • Central venous sat >70%, or mixed venous sat> 65%
  • If central venous sat target not met:
    • consider more fluid
    • transfuse to haematocrit>0.30
    • dobutamine infusion max 20 mcg kg-1 min-1
Diagnosis
  • Obtain cultures first provided antibiotics are not significantly delayed
    • Two or more blood cultures
    • Culture from each vascular catheter in >48 hrs
    • Culture other sites as indicated
  • Prompt imaging studies to identify source if safe to do so
Antibiotic therapy
  • IV antibiotics ASAP and always within first hour
  • Start with one or more broad spectrum agents
  • Reassess daily
  • Typically limited to 7-10 days
  • Consider combination therapy in Pseudomonas infection
  • Consider combination empiric therapy in neutropenic patients
Source identification and control
  • Establish anatomic site ASAP and within 6 hrs
  • Evaluate for focus amenable to drainage or debridement
  • Drain or debride ASAP except for pancreatic necrosis
  • Remove vascular catheters if infected