The Surviving Sepsis Campaign (SSC) guidelines are the most comprehensive guidelines available for the management of sepsis and septic shock, funded by SCCM and ESICM and endorsed by more than 30 organizations. The SSC guidelines were first published in 2004, with revisions in 2008 and 2012. The fourth revision was published in January 20171. The guidelines aim to reduce mortality from sepsis and to improve its management, diagnosis and treatment.
The guidelines are intended to provide guidance for the clinician caring for adults with sepsis or septic shock, but cannot replace the clinician’s decision-making competence when presented with a patient’s unique set of clinical variables.
Methods
A consensus committee of 55 international experts representing 25 international organizations intervened to develop the guidelines. The GRADE methodology was used in the assessment of quality of evidence. Only therapies with RCTs or other substantial evidence were included in the guidelines.
Results
A total of 93 statements were provided for the following topics:
- Initial resuscitation
- Screening for sepsis and performance improvement
- Diagnosis
- Antimicrobial therapy
- Source control
- Fluid therapy
- Vasoactive medications
- Corticosteroids
- Blood products
- Immunoglobulins
- Blood purification
- Anticoagulants
- Mechanical ventilation
- Sedation and analgesia
- Glucose control
- Renal replacement therapy
- Bicarbonate therapy
- Venous thromboembolism prophylaxis
- Stress ulcer prophylaxis
- Nutrition
- Setting goals of care
Early diagnosis, aggressive resuscitation, adequate antibiotic therapy, source control and organ support remain the key elements of sepsis management.
Initial resuscitation has changed from an early goal-directed therapy (EGDT) approach in previous guidelines to a more personalized approach with frequent reevaluation and patient-specific hemodynamic therapy. Strong recommendations are given for the following standardized care elements:
- Initial fluid volume: 30 mL/kg of intravenous crystalloid within 3 hours with additional fluid based on frequent reassessment.
- Blood pressure targets: Mean arterial pressure (MAP) of 65 mmHg for patients with sepsis shock requiring vasopressor therapy.
- Vasopressor choice: Norepinephrine as first-choice vasopressor.
Antimicrobial therapy should be initiated with broad-spectrum antibiotics as soon as possible and within one hour after recognition of both sepsis and septic shock.
Anatomic source control should be obtained as rapidly as practical.
Blood purification has been described for the first time in the SSC guidelines. Polymyxin B hemoperfusion therapy is cited as the most largely studied of blood purification therapies for the treatment of sepsis. The meta-analysis by Zhou et al.2 published in 2013 is cited as a study that demonstrated a positive effect of PMX-HP on mortality. The French ABDOMIX study performed by Payen et al.3 is mentioned as a study with questionable results, particularly due to the low severity of illness of the patients that were included in the study. The EUPHRATES study is mentioned as an ongoing multicenter, blinded RCT, which should provide stronger evidence concerning PMX-HP for the treatment of sepsis and septic shock4.
Coupled plasma filtration and adsorption (CPFA) is mentioned, but the only RCT conducted for this technique was stopped for futility and the authors raise doubts about the feasibility of CPFA.
No other blood purification techniques are mentioned due to the lack of RCTs or other substantial evidence.
Renal replacement therapy (RRT), intermittent or continuous, is suggested only in patients with sepsis-induced acute kidney injury.
Conclusion
The SSC guidelines are built on evidence-based medicine and are the most comprehensive guidelines available for the management of sepsis and septic shock.
Polymyxin B hemoperfusion therapy is described for the first time in the SSC guidelines.
References
- Rhodes A, Evans LE, Alhazzani W, et al.: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive care medicine. 2017 (PubMed).
- Zhou F, Peng Z, Murugan R, et al.: Blood purification and mortality in sepsis: a meta-analysis of randomized trials. Critical care medicine. 41:2209-2220, 2013 (PubMed).
- Payen DM, Guilhot J, Launey Y, et al.: Early use of polymyxin B hemoperfusion in patients with septic shock due to peritonitis: a multicenter randomized control trial. Intensive care medicine. 2015 (PubMed).
- Klein DJ, Foster D, Schorr CA, et al.: The EUPHRATES trial (Evaluating the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock): study protocol for a randomized controlled trial. Trials. 15:218, 2014 (PubMed).