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Sepsis
University of
Copenhagen
Anders Perner
COI: Research funds from Fresenius Kabi, CSL Behring, Ferring
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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
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Methodology
• Adults only
• GRADE
• Methodologists from McMaster
• PICOs, librarians
• COI’s declared
• Voting
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Metrics
• 55 experts from 25 organizations
• 74 pages, 655 references
• 93 statements
– 32 strong recommendations
– 39 weak
– 18 BPS
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Quality of the evidence
• 93 statements
– 7 high-quality evidence
– 28 moderate
– 58 low/very low/BPS
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• 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
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• 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
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• 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
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• 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
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• 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
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• 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
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• 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
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• 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
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• 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
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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).
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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).
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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).
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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).
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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).
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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).
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• Dobutamine
• Minimizing sedation
• Stress ulcer prophylaxis
• Head of bed elevation
Down-grading of recommendations
or evidence
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• Dobutamine
• Minimizing sedation
• Stress ulcer prophylaxis
• Head of bed elevation
Down-grading of recommendations
or evidence
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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