The Surviving Sepsis Campaign (SSC) is the leading organization responsible for educating healthcare professionals on the most current scientific evidence on the timely and appropriate treatment of sepsis. This ultimately allows us to positively impact sepsis-related morbidity and mortality.

Over the past year and a half there have been several major updates to best practices in the field of sepsis. In 2016, Singer, et al., published “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” which provided updated definitions and clinical criteria for Sepsis and Septic Shock with the elimination of the terms severe sepsis and SIRS. The new terminology defines sepsis as life threatening organ dysfunction caused by a dysregulated host response to infection and septic shock as a subset of sepsis in which underlying circular and cellular/metabolic abnormalities are profound enough to substantially increased mortality (Singer et al. 2016). Clinically, the septic shock subset are those patients with refractory hypotension despite adequate fluid resuscitation requiring vasoactive medications to maintain a mean arterial pressure (MAP) > 65 mmHg.

In March 2017, the Surviving Sepsis Campaign (SSC) published updated guidelines on the management of Sepsis and Septic Shock. This document, titled “Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” provides updated recommendations to the version published in 2012 and includes 93 statements on early management of sepsis and septic shock. A major difference evident in the new guidelines is a movement from protocolized management to a more individualized, “patient-centered” approach guided by dynamic variables and ongoing evaluation of clinical response to treatment (DeBaker & Dorman, 2017).

As the scientific and medical community’s understanding of sepsis and the pathobiology driving this life-threatening condition grows, it is essential that the APN stays abreast of changes to management based on the most up-to-date information.

Below is a summary of the recent SSC guidelines (Rhodes, et al., 2017) with a focus on material most pertinent to our practice as APNs.

1. Initial Resuscitation
   1. Fluids
      1. Begin fluid resuscitation with crystalloid fluids immediately for sepsis-induced hypo-perfusion. Ideally, aim for at least 30 mL/kg completed within the first 3 hours from time of diagnosis.
         • Crystalloids are the fluid of choice for initial fluid resuscitation.
         • Recommendations against hydroxyethyl starches or bicarbonate therapy as an agent to improve hemodynamics or reduce vasopressor requirement.
      2. Following initial resuscitation, hemodynamic assessment should be used to guide further fluid administration using invasive and non-invasive measures.
         • Include clinical exam and evaluation of available physiologic variables including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output.
      3. Evaluate fluid responsiveness by the following means:
         • Dynamic variables:
           • Passive leg raise
           • Pulse or stroke volume variations induced by mechanical ventilation
         • Lactate clearance
      4. Discontinue fluid administration if response is no longer beneficial.
      5. Target a mean arterial pressure (MAP) of 65 mmHg in those with septic shock.
   2. Vasoactive Medications
      1. Initial vasoactive medication of choice should be norepinephrine.
      2. Consider the addition of vasopressin (at 0.03 units/min) or epinephrine to reach target MAP or to decrease the dose of norepinephrine.
      3. Consider arterial catheter placement for the monitoring of blood pressure in those requiring the use of vasoactive medications.
   3. In the absence of response or if clinical assessment does not lead to clear diagnosis, consider evaluation for other types of shock (DeBaker & Dorman, 2017).
2. Diagnosis/Source Control – obtain both as soon as possible with early antibiotic therapy.
   1. Goal to identify or exclude anatomic source requiring emergent intervention as soon as possible; this includes removal of intravascular access if possible source of infection.
   2. Obtain at least two sets of blood cultures prior to initiation of antibiotics in all patients with suspected sepsis or septic shock if it will not delay initiation of treatment.  
3. Antibiotic therapy
   1. Initiate one or more empiric broad-spectrum antibiotics as early as possible and within 1 hour (maximum) of recognition of sepsis or septic shock to cover all suspected pathogens.
   2. Evaluate daily for potential de-escalation/narrowing of antibiotics based on pathogen identification and clinical improvement.  
   3. Limit combination therapy (double coverage) to patients with septic shock.
   4. Do not continue antibiotics for severe inflammatory states (i.e. systemic inflammatory response syndrome [SIRS]) with no infectious etiology.
   5. Duration of antibiotic treatment should be 7-10 days.
      • Extend for slow clinical response, undrainable foci, staph aureus, or neutropenia.
      • Shorten course for quick clinical response, adequate source-controlled, GU/UTI or simple pyelonephritis.
   6. Consider procalcitonin measurement to support de-escalation of antibiotics in patients with sepsis and to support discontinuation of antibiotics in those who ultimately have limited clinical evidence of bacterial infection.
      • Although there is low quality of evidence and a weak recommendation by the SSC, many institutions have adopted use of this biomarker in the management of sepsis.
4. Blood products
   1. Limit red blood cell transfusions to those patients with hemoglobin concentration < 7 g/dL. Consider higher threshold in select clinical populations (i.e. acute hemorrhage/ongoing active bleeding, acute coronary syndrome with ischemia, symptomatic anemia).  
5. Mechanical ventilation
   1. In all mechanically ventilated patients with sepsis:
      1. Utilize lower tidal volume strategy using predicted body weight.
      2. HOB 30-45 degrees.
      3. Spontaneous breathing trials in those ready for weaning.
      4. Minimize sedation and set targets for titration end points.
   2. In patients with sepsis-induced acute respiratory distress syndrome (ARDS):
      1. Target tidal volume = 6 mL/kg
      2. Upper limit goal for plateau pressures of 30 cm H₂0
      3. Higher PEEP strategy
      4. Recruitment maneuvers for those with sepsis-induced severe-ARDS and refractory hypoxemia  
      5. Consider prone positioning if paO₂/FiO₂ ratio < 150.
      6. Conservative fluid strategy
6. Glucose Control
   1. Begin an insulin administration protocol for patients with sepsis and two consecutive blood glucose readings > 180 mg/dL.
   2. Target glucose ≤ 180 mg/dL, rather than upper limit ≤ 110 mg/dL
7. Nutrition
   1. Begin early enteral nutrition rather than parenteral nutrition or combination in critically ill patients with sepsis or septic shock (Rhodes et al. 2017).
   2. If early enteral feeds are not possible, begin IV dextrose and advance enteral feeds as tolerated rather than initiating parenteral nutrition during the first seven days of critical illness. This may include trophic or hypocaloric feedings and advance as tolerated.
   3. Gastric residual volumes should only be considered when there is enteral feeding intolerance or high risk of aspiration, rather than routinely.
8. Stress Ulcer prophylaxis
   1. Begin in those patients with sepsis and septic shock AND risk factors for gastrointestinal bleeding; may use either proton pump inhibitor or histamine-2 blocker.
9. VTE prophylaxis
   1. Initiate pharmacologic prophylaxis unless contraindicated. Rhodes et al. (2017) recommends LMWH rather than UFH in absence of contraindications to LMWH, in combination with mechanical prophylaxis in absence of contraindications.
10. Communication
    1. Discuss goals of care and prognosis with patients and family as early as feasible, incorporating end-of-life planning and palliative care principles, when appropriate.

References:
De Backer, D. and Dorman, T. (2017). Surviving Sepsis Guidelines. A Continuous Move Towards Better Care of Patients With Sepsis. The Journal of the American Medical Association, 317(8).
Rhodes, M.B., Evans, L.E., Alhazzani, W, et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
Singer M, Deutschman CS, Seymour CW, et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).