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Sepsis and septic shock guidelines 2021. part 1

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Dr Essam A. Salem
ICU Head Meeqat General Hospital
,Medinah Munawarah , KSA

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Sepsis and septic shock guidelines 2021. part 1

  1. 1. Sepsis and septic shock guidelines 2021. part 1 Dr Essam A. Salem ICU specialist
  2. 2. Sepsis can be described as a critical imbalance between oxygen supply and demand. Serum lactate levels tend to rise in a response to tissue hypoxia (though don’t think that lactate is all bad – it’s a compound we need, and at times of stress the heart runs on lactate!), and the higher the level of lactate, the poorer the patient outcome is likely to be. The rate at which lactate improves following initiation of fluid resuscitation is indicative of survival.
  3. 3. 1- For hospitals and health systems, we recommend using a performance improvement programm for sepsis, including sepsis screening for acutely ill, high-risk patients and standard operating procedures for treatment. 2- We recommend against using qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock. Sepsis and septic shock guidelines 2021
  4. 4. 3- For adults suspected of having sepsis, we suggest measuring blood lactate. 4- Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately.
  5. 5. 5- For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of intravenous (IV) crystalloid fluid should be given within the first 3 hours of resuscitation. 6- For adults with sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation, over physical examination, or static parameters alone.
  6. 6. 7- For adults with sepsis or septic shock, we suggest guiding resuscitation to decrease serum lactate patients with elevated lactate level, over no using serum lactate. 8- For adults with septic shock, we suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion.
  7. 7. 9- For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets. 10- For adults with sepsis or septic shock who require ICU admission, we suggest admitting the patient to the ICU within 6 hours.
  8. 8. 11- For adults with suspected sepsis or septic shock but unconfirmed infection, we recommend continuously re-evaluating and searching for alternative diagnoses and discontinuing empiric Antimicrobials if an alternative cause of illness is demonstrated Or strongly suspected. 12- For adults with passible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials immediately, ideally within one hour of recognition.
  9. 9. 13- For adults with possible sepsis without shock, we recommend rapid assessment of the likelihood of infection versus non-infection causes of acute illness. 14- For adults with possible sepsis without shock, we suggest a time-limited course of rapid investigation and if concern for the infection persists, the administration of antimicrobials within 3 hours from the time when sepsis was first recognaized.
  10. 10. 15- For adults with a low likelihood of infection and without shock, we suggest deferring antimicrobials while continuing to closely monitor the patient. 16- For adults with suspected sepsis or septic shock, we suggest against using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone.
  11. 11. 17- For adults with sepsis or septic shock at high risk of MRSA, we recommend using empiric antimicrobials with MRSA coverage over using antimicrobials without MRSA coverage. 18- For adults with sepsis or septic shock at low risk of MRSA, we suggest against using empiric antimicrobials with MRSA coverage, as compared with using antimicrobials without MRSA coverage.
  12. 12. 19- For adults with sepsis or septic shock and high risk for multidrug resistant (MDR) organisms, we suggest using two antimicrobials with gram- negative coverage, for empiric treatment over one gram-negative agent. 20- For adults with sepsis or septic shock and low risk for multidrug resistant (MDR) organisms, we suggest against using two gram-negative agents for empiric treatment as compared to one gram- negative agent.
  13. 13. 21- For adults with sepsis or septic shock, we suggest against using double gram-negative coverage once the causative pathogen and the susceptibilities are known. 22- For adults with sepsis or septic shock at high risk of fungal infection, we suggest using empiric antifungal therapy. 23- For adults with sepsis or septic shock at low risk of fungal infection, we suggest against empiric use of antifungal therapy.
  14. 14. 25- For adults with sepsis or septic shock, we suggest using prolonged infusion of beta-lactams for maintenance (after an initial bolus) over conventional bolus infusion. 24- We make no recommendation on the use of antiviral agents. 26- For adults with sepsis or septic shock, we recommend optimising dosing strategies of antimicrobials based on accepted pharmacokinetic/pharmacodynamic (PK/PD) principles and specific drug properties.
  15. 15. 27- For adults with sepsis or septic shock, we recommend rapidly identifying or excluding a specific anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical. 28- For adults with sepsis or septic shock, we recommend prompt removal of intravascular access devices that are possible source of sepsis or septic shock after other vascular access has been established.
  16. 16. 29- For adults with sepsis or septic shock, we suggest daily assessment for de-escalation of antimicrobials over using fixed durations of therapy without daily reassessment for de- escalation. 30- For adults with an initial diagnosis of sepsis or septic shock and adequate source control, we suggest using shorter over longer duration of antimicrobial therapy.
  17. 17. 31- For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear, we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone. 32- For adults with sepsis or septic shock, we recommend using crystalloids as first line fluid for resuscitation.
  18. 18. 33- For adults with sepsis or septic shock, we suggest using balanced crystalloids instead of normal saline for resuscitation. 34- For adults with sepsis or septic shock, we suggest using albumin in patients who received large volumes of crystalloids.
  19. 19. 35- For adults with sepsis or septic shock, we recommend against using starches for resuscitation. 36- For adults with sepsis or septic shock, we suggest against using gelatin for resuscitation.
  20. 20. he most important massages: 1- Sepsis is complex, and can affect any system of the body. Symptoms may be subtle, or not as we would expect, but any concern should be given immediate attention. 2- Ensure that all test results are read and acted upon. Some test results, particularly those obtained from blood gases, may only show minimal changes, however these subtle changes could be a result of compensation, and need interpretation by those familiar with sepsis and blood gas analysis. 3- The higher the patient’s lactate level climbs, the worse their prognosis becomes. 4- Sepsis is life-threatening and time-critical. By assessing patients in a systematic way (for example using ABCDE approach), life-threatening problems should be found quickly and treatment can be delivered promptly. It is easy to panic if you find something wrong or “not quite right” with any patient. The important thing if you do not understand the pathophysiology behind what is happening is to escalate care to the appropriate team members who can provide timely treatment.

Dr Essam A. Salem ICU Head Meeqat General Hospital ,Medinah Munawarah , KSA

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