Updated global adult sepsis guidelines, released in October 2021 by the Surviving Sepsis Campaign (SSC), place an increased emphasis on improving the care of sepsis patients after they are discharged from the intensive care unit (ICU) and represent greater geographic and gender diversity than previous versions. The new guidelines specifically address the challenges of treating patients experiencing the long-term effects of sepsis. Patients often experience lengthy ICU stays and then face a long, complicated road to recovery. In addition to physical rehabilitation challenges, patients and their families are often uncertain how to coordinate care that promotes recovery and matches their goals of care.

1. SURVIVING SEPSIS CAMPAIGN:
INTERNATIONAL GUIDELINES FOR MANAGEMENT
OF SEPSIS AND SEPTIC SHOCK 2021
Dr. Rabindra Tamang
MCh Urology Resident
Department of Urology and Transplant Surgery
MMC

2. OBJECTIVES
 Define sepsis and septic shock
 Screening and early treatment
 Infection
 Hemodynamic management
 Ventilation
 Additional therapies
 Long term outcomes and goals of care

3. SEPSIS
 SIRS due to a suspected or confirmed infection
with 2 or more of the following criteria:
 Temperature > 38 C
 HR > 90 bpm
 RR > 20 bpm
 WBC < 4000 or > 12000
Surviving Sepsis Campaign, 2004

4.  Severe sepsis:
 Sepsis with organ dysfunction including
serum lactate > 2 mmol/L
 Septic shock:
 Fluid resistant hypotension requiring
vasopressors or a lactate level of at least 4
mmol/L
Surviving Sepsis Campaign, 2004

5. SCREENING AND EARLY TREATMENT
 Use sepsis performance improvements
programs for sepsis
 Sepsis screening tools
SIRS
qSOFA
SOFA
NEWS
MEWS

6.  qSOFA as a single screening tool is not
recommended
 Measure blood lactate
 In unconfirmed cases of sepsis

7. INITIAL RESUSCITATION
 Start treatment and resuscitation
immediately
 At least 30mL/kg of iv crystalloid within 3
hours of resuscitation
 Dynamic parameters should be used

8. PASSIVE LEG RAISE TEST

9.  Decrease lactate level in elevated cases
 Use capillary refill time
 Mean arterial pressure:
 65 mmHg
 Admit in Intensive Care Unit within 6 hours

10. INFECTION
 Diagnosis should be continuously evaluated
and searched for.
 Microbiological cultures should be send before
starting antimicrobial therapy.

11. ANTIBIOTICS

12.  Do not use procalcitonin to start antibiotics

13. ANTIMICROBIAL CHOICE
 Use empirical antibiotics with MRSA
coverage at high risk patients
 For high risk of multi drug resistant (MDR)
organisms, use two antimicrobials with gram
negative coverage.
 Antifungal therapy in high risk patients

15.  Antiviral therapy: not recommended

16. DELIVERY OF ANTIBIOTICS
 Prolonged beta lactams infusion for maintenance
 Optimize dosing strategies based on
pharmacokinetics / pharmacodynamics principles
 De-escalation of antibiotics
 Shorter duration of antimicrobial therapy
 Procalcitonin to discontinue antibiotics

17. SOURCE CONTROL
 Abscess
 Necrotic tissue
 Devices

18. HEMODYNAMIC MANAGEMENT
 Fluid management:
 Crystalloids as first line
 Balanced solutions vs normal saline
 Albumin
 Starches
 Gelatin

19. VASOACTIVE AGENTS
 First line: Nor epinephrine
 Second line: Vasopressin (0.03 units/min)
 Third line: Epinephrine
 Terlipressin
 Patient with cardiac dysfunction, add
dobutamine.

20. VENTILLATION
 High nasal flow oxygen
 Low tidal volume strategy (6L/min)
 Higher PEEP
 Traditional recruitment maneuvers
 Prone ventilation
 Intermittent Neuromuscular blocking agents

21. ADDITIONAL THERAPIES
 Corticosteroids
 Stress ulcer prophylaxis
 Venous thromboembolism prophylaxis
 Renal replacement therapy
 Glucose control
 Enteral nutrition

22. LONG TERM OUTCOMES & GOALS OF CARE
 Goals of care and prognosis
 Palliative care consultation
 Peer support groups
 Transitions of care
 Sepsis education

23. DISCHARGE PLANNING
 Discharge should include
 ICU stay
 Sepsis and related diagnosis
 Treatments
 Common impairments

24. POST DISCHARGE FOLLOW UP
 Physical, cognitive and emotional problems
 Post hospital rehabilitation

25. TAKE HOME MESSAGE
 Prompt diagnosis of sepsis and septic shock is
important and treatment should be started
immediately.
 Along with various parameters, clinical evaluations
and judgments play a pivotal role.
 Our job as health professionals do not end after the
patient is discharged.

26. Thank You