20170128-1300 - a perner - sepsis€¦ · • nutrition • setting goals of care 93...

Sepsis

University of

Copenhagen

Anders Perner

COI: Research funds from Fresenius Kabi, CSL Behring, Ferring

Sepsis-3

• Sepsis: Infection and new organ failure

• Septic shock:

– Vasopressor use AND

– Lactate > 2 mM

• quick-SOFA for screening:– RR > 22/min

– Altered mentation

– Systolic blood pressure < 100mmHg

Methodology

• Adults only

• GRADE

• Methodologists from McMaster

• PICOs, librarians

• COI’s declared

• Voting

Metrics

• 55 experts from 25 organizations

• 74 pages, 655 references

• 93 statements

– 32 strong recommendations

– 39 weak

– 18 BPS

Quality of the evidence

• 93 statements

– 7 high-quality evidence

– 28 moderate

– 58 low/very low/BPS

• Initial resuscitation

• Screening

• Diagnosis

• Antibiotics

• Source control

• Fluids

• Vasoactives

• Steroids

• Tx

• IVIG

• Blood purification

• Anti-coagulants

• Mechanical ventilation

• Sedation

• Glucose control

• Bicarbonate

• RRT

• VTE prophylaxis

• Stress ulcer prophylaxis

• Nutrition

• Setting goals of care

93 recommendations and BPS

• Initial resuscitation 1/7

• Screening 0/1

• Diagnosis 0/1

• Antibiotics 3/15

• Source control 0/2

• Fluids 2/6

• Vasoactives 3/6

• Steroids 0/1

• Tx 2/4

• IVIG 0/1

Moderate - high quality

• Initial resuscitation 1/7

• Screening 0/1

• Diagnosis 0/1

• Antibiotics 3/15

• Source control 0/2

• Fluids 2/6

• Vasoactives 3/6

• Steroids 0/1

• Tx 2/4

• IVIG 0/1

Moderate - high quality

• Anti-coagulants 1/2

• Mechanical ventilation 12/15

• Sedation 0/1

• Glucose control 1/4

• Bicarbonate 1/1

• RRT 1/3

• VTE prophylaxis 2/4

• Stress ulcer prophylaxis 0/3

• Nutrition 5/12

• Setting goals of care 1/3

Moderate - high quality

• Anti-coagulants 1/2

• Mechanical ventilation 12/15

• Sedation 0/1

• Glucose control 1/4

• Bicarbonate 1/1

• RRT 1/3

• VTE prophylaxis 2/4

• Stress ulcer prophylaxis 0/3

• Nutrition 5/12

• Setting goals of care 1/3

Moderate - high quality

• Against hydroxyethyl starch

• Against ‘renal-dose’ dopamine

• Transfuse only at 7 g/dl (4.3 mM)

• Low tidal volume

• Against routine use of PAC in ARDS

• SBT for weaning

• Glucose control with insulin at 180 mg/dl (10 mM)

7 recommendations based on high

quality evidence

• Against hydroxyethyl starch

• Against ‘renal-dose’ dopamine

• Transfuse only at 7 g/dl (4.3 mM)

• Low tidal volume

• Against routine use of PAC in ARDS

• SBT for weaning

• Glucose control with insulin at 180 mg/dl (10 mM)

7 recommendations based on high

quality evidence

• 30 ml/kg fixed volume fluid resuscitation

• Head of bed elevated 30-45 degrees

• Stress ulcer prophylaxis in pts at risk

• Against 3-omega-fatty acids

4 strong recommendations based on

low quality evidence

• 30 ml/kg fixed volume fluid resuscitation

• Head of bed elevated 30-45 degrees

• Stress ulcer prophylaxis in pts at risk

• Against 3-omega-fatty acids

4 strong recommendations based on

low quality evidence

Changed recommendations

Initial resuscitation

3. We recommend that, following initial fluid

resuscitation, additional fluids be guided by frequent

reassessment of hemodynamic status (BPS)

4. We recommend further hemodynamic assessment

to determine the type of shock if the clinical

examination does not lead to a clear diagnosis (BPS)

5. We suggest that dynamic over static variables be

used to predict fluid responsiveness, where available

(weak recommendation, low quality of evidence).

Changed recommendations

Antibiotics

3. We recommend that antimicrobial therapy is

narrowed once pathogen identification and sensitivity

are established and/or adequate clinical improvement is

noted (BPS).

14. We suggest that procalcitonin levels can be used to

support shortening the duration of antibiotics … (weak

recommendation, low quality of evidence).

15. We suggest that procalcitonin levels can be used to

support the discontinuation of empiric antibiotics …

(weak recommendation, low quality of evidence).

Changed recommendations

Fluid therapy

3. We suggest using either balanced

crystalloids or saline for fluid resuscitation …

(weak recommendation, low quality of

evidence).

6. We suggest using crystalloids over gelatins

when resuscitating … (weak recommendation,

low quality of evidence).

Changed recommendations

Blood products

1. We recommend that RBC transfusion occur

only when hemoglobin concentration decreases

to < 7.0 g/dL …in the absence of … myocardial

ischemia, severe hypoxemia, or acute hemorrhage

(strong recommendation, high quality of

evidence).

Changed recommendations

Mechanical ventilation

5. We recommend using prone over supine

position in adult patients with sepsis-induced

ARDS and a PaO2/FIO2 ratio < 150 (strong

recommendation, moderate quality of

evidence).

8. We suggest using neuromuscular blocking

agents for 48-h in adult patients with sepsis-

induced ARDS and a PaO2/FIO2 ratio < 150

(weak recommendation, moderate quality of

evidence).

Changed recommendations

Nutrition

2. We recommend against the administration of

parenteral nutrition alone or in combination with

enteral feeds over the first 7 days … (strong

recommendation, moderate quality of evidence)

11. We recommend against the use of glutamine

… (strong recommendation, moderate quality of

evidence).

• Dobutamine

• Minimizing sedation

• Stress ulcer prophylaxis

• Head of bed elevation

Down-grading of recommendations

or evidence

• Dobutamine

• Minimizing sedation

• Stress ulcer prophylaxis

• Head of bed elevation

Down-grading of recommendations

or evidence

SSCG 2016

• Very extensive cover

• Reasonably balanced text

• Progress, better evidence in some areas

• Still some ‘strong – low’ mismatches

• Worrying low evidence in key areas

• Academic bias difficult to control

anders.perner@regionh.dk

University ofCopenhagen