Document Detail


Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.
MedLine Citation:
PMID:  18158437     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
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. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.
Authors:
R Phillip Dellinger; Mitchell M Levy; Jean M Carlet; Julian Bion; Margaret M Parker; Roman Jaeschke; Konrad Reinhart; Derek C Angus; Christian Brun-Buisson; Richard Beale; Thierry Calandra; Jean-Francois Dhainaut; Herwig Gerlach; Maurene Harvey; John J Marini; John Marshall; Marco Ranieri; Graham Ramsay; Jonathan Sevransky; B Taylor Thompson; Sean Townsend; Jeffrey S Vender; Janice L Zimmerman; Jean-Louis Vincent; ; ; ; ; ; ; ; ; ; ; ; ; ; ;
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Publication Detail:
Type:  Consensus Development Conference; Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Critical care medicine     Volume:  36     ISSN:  1530-0293     ISO Abbreviation:  Crit. Care Med.     Publication Date:  2008 Jan 
Date Detail:
Created Date:  2007-12-25     Completed Date:  2008-02-12     Revised Date:  2009-04-16    
Medline Journal Info:
Nlm Unique ID:  0355501     Medline TA:  Crit Care Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  296-327     Citation Subset:  AIM; IM    
Affiliation:
Cooper University Hospital, Camden, NJ, USA. Dellinger-Phil@CooperHealth.edu
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MeSH Terms
Descriptor/Qualifier:
Adrenal Cortex Hormones / therapeutic use
Adult
Analgesia / methods
Anti-Bacterial Agents / therapeutic use
Bicarbonates / therapeutic use
Blood Glucose / metabolism
Blood Transfusion / methods
Cardiotonic Agents / therapeutic use
Child
Conscious Sedation / methods
Critical Care / methods,  standards*
Delphi Technique
Drug Monitoring / methods
Drug Therapy, Combination
Fluid Therapy / methods
Humans
Neuromuscular Blockade / methods
Peptic Ulcer / etiology,  prevention & control
Practice Guidelines as Topic*
Protein C / therapeutic use
Recombinant Proteins / therapeutic use
Renal Replacement Therapy / methods
Respiratory Distress Syndrome, Adult / etiology,  therapy
Resuscitation / methods
Sepsis / blood,  complications,  diagnosis*,  therapy*
Shock, Septic / blood,  complications,  diagnosis,  therapy
Vasoconstrictor Agents / therapeutic use
Venous Thrombosis / etiology,  prevention & control
Grant Support
ID/Acronym/Agency:
K23 GM071399-03/GM/NIGMS NIH HHS
Chemical
Reg. No./Substance:
0/Adrenal Cortex Hormones; 0/Anti-Bacterial Agents; 0/Bicarbonates; 0/Blood Glucose; 0/Cardiotonic Agents; 0/Protein C; 0/Recombinant Proteins; 0/Vasoconstrictor Agents; 0/drotrecogin alfa activated
Comments/Corrections
Comment In:
Crit Care Med. 2008 Sep;36(9):2716-7   [PMID:  18728507 ]
Crit Care Med. 2008 Aug;36(8):2489-90; author reply 2490   [PMID:  18664828 ]
Crit Care Med. 2009 Feb;37(2):796-7; author reply 797-8   [PMID:  19325399 ]
Crit Care Med. 2008 Aug;36(8):2488; author reply 2488-9   [PMID:  18664827 ]
Crit Care Med. 2008 Aug;36(8):2490; author reply 2490-1   [PMID:  18664830 ]
Crit Care Med. 2008 Aug;36(8):2487; author reply 2487-8   [PMID:  18664825 ]
Crit Care. 2008;12(3):162   [PMID:  18598386 ]
Erratum In:
Crit Care Med. 2008 Apr;36(4):1394-6

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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