Introduction
- June 12, 2007 – A review in the June issue of the Southern Medicine Journal provides evidence-based guidelines to help detect and treat sepsis. These treatment guidelines are endorsed by 11 professional societies representing multispecialty groups.
- The authors performed a literature review concerning the epidemiology and pathophysiology of severe sepsis, including alterations in inflammation, coagulation, and impaired fibrinolysis occurring during the course.
- Severe sepsis is common, with multiple organ dysfunction and very high mortality rate.
- Deficiencies in management include inconsistency in the early diagnosis of severe sepsis and septic shock, frequent inadequate volume resuscitation without defined endpoints, late or inadequate use of antibiotics, frequent failure to support the cardiac output when depressed, frequent failure to control hyperglycemia adequately, frequent failure to use low tidal volumes and pressures in acute lung injury, and frequent failure to treat adrenal inadequacy in refractory shock.
- To address these deficiencies, the Surviving Sepsis Campaign and IHI have revised and added to the Surviving Sepsis Guidelines and created 2 sepsis treatment protocols (resuscitation and management) to guide therapy for patients with severe sepsis.
- The sepsis resuscitation protocol, which should be accomplished as soon as possible and scored during the first 6 hours, includes the following:
- Measure serum lactate level.
- Obtain blood cultures before antibiotic administration.
- From the time of presentation, administer broad-spectrum antibiotics within 3 hours for emergency department admissions and within 1 hour for non-emergency department intensive care unit (ICU) admissions.
- In the event of hypotension and/or lactate level greater than 4 mmol/L (36 mg/dL), deliver an initial minimum dose of 20 mL/kg of crystalloid (or colloid equivalent); use vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure of 65 mm Hg or greater.
- In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate level greater than 4 mmol/L (36 mg/dL), achieve central venous pressure of 8 mm Hg or greater and achieve central venous oxygen saturation of 70% or greater or a mixed venous oxygen saturation of 65% or greater.
- “Timely recognition and diagnosis of severe sepsis is the first step”, the authors write. “Applying the evidence-based guidelines created under the auspices of the Surviving Sepsis Campaign is the second step. Following up by measuring adherence to the guidelines is equally important to successfully implement change”.
- The sepsis management protocol, which should be accomplished as soon as possible with objective scoring during the first 24 hours, includes the following:
- Low-dose steroids should be administered for septic shock, following a standardized ICU protocol.
- Activated drotrecogin Alfa should be administered following a standardized ICU protocol.
- Should maintain glucose level at or above the lower limit of normal, but less than 150 mg/dL.
- For mechanically ventilated patients, inspiratory plateau pressures should be maintained at less than 30 cm H2O.
- The authors conclude, “Hopefully, once the patient is identified, multidisciplinary teams will rapidly and appropriately apply a series of evidence-based interventions. If the interventions are applied in a systematic fashion and adherence to standardized guidelines is followed and measured, then we will know if the Surviving Sepsis Campaign’s goal of a 25% reduction in mortality from sepsis by the year 2009 had been obtained”.
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