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Updated Surviving Sepsis Campaign (SSC) guidelines reflect new advances in resuscitating adult patients with sepsis or septic shock and managing their antibiotic therapy. SSC is a global initiative launched in 2002 to boost educational efforts and awareness about these life-threatening conditions.
This is the fourth revision to these guidelines, which were first published in 2004 by the Society of Critical Care Medicine (SCCM), and European Society of Intensive Care Medicine (ESICM) and last updated in 2012. The 2016 guidelines featuring 93 recommendations, were unveiled at SCCM’s 46th annual meeting and appeared online in Critical Care Medicine and Intensive Care Medicine. Additionally, the Journal of the American Medical Association (JAMA) released a synopsis of the guidelines.
“Among the various topics covered, initial resuscitation and antibiotic therapy are the domains in which the most important changes and advances were made,” observed Daniel De Backer, MD, and Todd Dorman, MD, PhD, in a related editorial in JAMA.
Reversing a 2012 recommendation, the new guidelines did away with standard early goal-directed therapy (EGDT) resuscitation targets on the basis that recent clinical trials didn’t vigorously support this method. “These trials suggest that while EGDT is safe, it is not superior to usual, nonprotocolized care. Usual care has also evolved since these trials to include more aggressive fluid resuscitation,” the authors explained.
To assess fluid responsiveness, clinicians should choose dynamic variables over static ones. As De Backer and Dorman explain, dynamic options might include a passive leg rest, or pulse or stroke volume variations induced by mechanical variation. Intravascular pressures or volumes are examples of static variables. “This is a significant change, as previous guidelines recommended that clinicians should target specific values of central venous pressure. Subsequent data have shown that central venous pressure has limited value for the prediction of the response to fluids,” they wrote.
Several recommendations address management of infection in sepsis patients. Once sepsis is recognized in a patient, clinicians should intravenously administer broad spectrum antibiotics within the hour, and obtain anatomic source control as quickly as possible.
The guidelines also addressed a number of lab testing protocols, including the handling of blood products and glucose testing.
In a recommendation classified as “strong,” meaning there was substantial evidence to support it, the authors suggested red blood cell count (RBC) transfusions in the event a patient’s hemoglobin concentration drops to <7.0 g/dL “in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, or acute hemorrhage.”
To manage blood glucose in intensive care unit patients with sepsis, the recommendation is to start insulin dosing when two consecutive blood glucose levels are >180 mg/dL. “This approach should target an upper blood glucose level ≤180 mg/dL rather than an upper target blood glucose level ≤110 mg/dL,” according to the guidelines.
Clinicians should monitor blood glucose values every 1 to 2 hours, until insulin infusion rates and glucose values stabilize. For patients who receive insulin infusions, monitoring should continue every 4 hours thereafter. The guidelines’ authors cautioned that point-of-care tests used to measure glucose levels from capillary blood might not yield the most accurate results.
“We suggest the use of arterial blood rather than capillary blood for point-of-care testing using glucose meters if patients have arterial catheters,” they recommended.
In other lab-related recommendations, the authors suggested that measurement of procalcitonin levels could be used in certain instances to guide the duration of antimicrobial therapies.