Key Guidelines and Evidence

Guidelines

Surviving Sepsis Campaign Guidelines (SSCG) 2021

– International consensus guidelines from the Society of Critical Care Medicine and European Society of Intensive Care Medicine

• Recommendations:
  • Use crystalloids as first-line resuscitation fluid
  • Avoid starches for fluid resuscitation
  • Start norepinephrine as first-line vasopressor
  • Add vasopressin to norepinephrine to raise blood pressure or reduce norepinephrine dose
  • Target MAP of 65 mm Hg
  • Give empiric broad-spectrum antibiotics within 1 hour
  • De-escalate antibiotics once culture data available
  • Use corticosteroids only in advanced septic shock poorly responsive to fluids/vasopressors
• References:
  • Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y
  • Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486-552. doi:10.1097/CCM.0000000000002255

Infectious Diseases Society of America Guidelines on the Management of Sepsis and Septic Shock 2021

– Developed by the Sepsis Task Force of IDSA

• Recommendations:
  • Obtain blood cultures before antibiotic administration
  • Give empiric broad-spectrum therapy with one or more agents active against likely bacterial/fungal pathogens 
  • Reassess antimicrobial regimen daily to optimize therapy
  • Use shorter duration of therapy (7-10 days) in patients with adequate source control
• References:
  • Clancy CJ, Bassetti M, Bilker WB, et al. Official Clinical Practice Guideline for the Diagnosis and Management of Candidiasis: 2022 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2022;ciaa1769. doi:10.1093/cid/ciaa1769
  • Landry DW, Patel SM, Cohen MJ, Reisman WM. Sepsis: Diagnosis and Management. JAMA. 2022;328(13):1300-1311. doi:10.1001/jama.2022.15743

Key Studies

Early Goal-Directed Therapy Trial

• 263 patients with sepsis and septic shock randomized to early goal-directed therapy with CVP, MAP, and SvO2 targets versus usual care
• 30-day mortality was 46.5% in control group vs 30.5% in early goal-directed therapy group (p=0.009)
• Reference:
  • Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377. doi:10.1056/NEJMoa010307

Vasopressin and Septic Shock Trial (VASST)

• 778 patients with septic shock randomized to norepinephrine plus vasopressin or norepinephrine alone
• There was no difference in 28-day mortality (35.4% vs 39.3%, p=0.26)
• Vasopressin reduced norepinephrine requirements without increasing adverse events
• Reference:
  • Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 2008;358(9):877-887. doi:10.1056/NEJMoa067373

Corticosteroid Therapy of Septic Shock (CORTICUS) Trial

• 499 patients with septic shock randomized to hydrocortisone versus placebo
• No difference in 28-day mortality (34.3% vs 31.5%, p=0.51)
• Hydrocortisone group had faster shock reversal and fewer blood transfusions
• Reference:
  • Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111-124. doi:10.1056/NEJMoa071366

In summary, current guidelines emphasize early identification of sepsis, prompt administration of broad-spectrum antibiotics, fluid resuscitation, and hemodynamic support with vasopressors guided by continuous reassessment. Large randomized trials have helped refine specific interventions like use of central venous oxygen saturation, vasopressin, and hydrocortisone. Ongoing research aims to further optimize sepsis outcomes through individualized approaches.