Surviving Sepsis - APSA Practice Gaps 2019

The Surviving Sepsis Campaign guidelines first came out in 2004, were modified in 2008, and the last modification was in 2016. The latest pediatric guidelines are from 2012.

In adults, norepinephrine is the vasopressor of choice according to the Surviving Sepsis Campaign.

For children, dopamine used to be the fallback vasopressor for the longest time.

Two recent randomized trials compared dopamine with epinephrine in children: one study showed better mortality for those randomized to epinephrine, and the other study showed epinephrine had better, more rapid and sustained improvement in systolic blood pressure compared to dopamine.

Epinephrine is probably the treatment of choice among vasopressor options for pediatric septic shock.

There is good adult data to suggest that the use of vasopressin or vasopressin-like drugs can be very efficacious in increasing blood pressure.

In pediatric trials of vasopressin, there have been too few and they were not randomized, therefore the data is not there yet.

In the Surviving Sepsis Campaign, there is a role for hydrocortisone for patients who are vasopressor refractory, meaning you started vasopressors and their systolic blood pressure remains low.

The 2012 pediatric sepsis guidelines recommend giving 20 mL/kg boluses of isotonic fluid (saline) or colloid (like albumin), up to 60 mL/kg total.

The goal of fluid resuscitation is perfusion improvement. At 40 mL/kg, if you're seeing perfusion improvement, you don't have to give the third bolus.

You stop fluid resuscitation if you're seeing over-perfusion, for example patients develop rales on auscultation or their liver gets large and enlarged.

There is data to show in adults especially that if you wait over 3 hours to start antibiotics in a patient who's septic, your survival goes down.

The recommendation for antibiotics is broad spectrum coverage, such as an extended spectrum penicillin like piperacillin-tazobactam or ampicillin-sulbactam.

The revised adult guidelines from 2016 emphasized that you draw blood for lactate level and send cultures just prior to starting antibiotics. You don't wait, but you want to send those cultures as soon as possible.

Previous sepsis campaigns led to patients being on broad spectrum antibiotics for a very prolonged period of time, which led to a subsequent recommendation for antibiotic stewardship.

The adult Surviving Sepsis Campaign talks about managing infection, managing resuscitation, using ventilation where required, and finally system improvement.

In the manage infection component, antibiotics is just one thing; source control is key. If you have an abscess, perforated appendicitis, or something of that nature, source control is key.

The adult Surviving Sepsis Campaign introduced antibiotic stewardship as the third part of manage infection.

In one study, the odds ratio for not starting antibiotics within 3 hours in children was 3.92, meaning they were almost four times more likely to die.

The manage resuscitation component includes fluids, a target mean arterial pressure target, and the use of vasopressors. These steps have been shown to clearly reduce mortality in patients with sepsis.

In patients who have not responded to vasopressors and remain hypotensive after starting hydrocortisone and giving boluses, three adjuncts have been brought up: extracorporeal life support (ECMO), renal replacement therapy, and plasmapheresis.

Of the three adjuncts (ECMO, renal replacement therapy, plasmapheresis), the one that's been studied the most and is still in use is extracorporeal life support.

ECMO is not formally mentioned in the sepsis guidelines, but it certainly is there as an adjunct in institutions where you have the ability to use ECMO for patients who are still not responding.

The survival for patients who went on ECMO with severe sepsis with refractory hypotension is about 46% overall when you look at all comers, which is better than zero.