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![The Third International Consensus Definitions
for Sepsis and Septic Shock (Sepsis-3)
Sepsis: is a life-threatening organ dysfunction caused by a dysregulated host response to
infection. For clinical operationalization, organ dysfunction can be represented by an increase in
the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more,
which is associated with an in-hospital mortality greater than 10%.
Septic shock: is a subset of sepsis in which particularly profound circulatory,
cellular, and metabolic abnormalities are associated with a greater risk of mortality than with
sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement
to maintain a mean arterial pressure of 65mmHg or greater and serum lactate level greater than
2 mmol/L (>18mg/dL) in the absence of hypovolemia. This combination is associated with
hospital mortality rates greater than 40%.
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287](https://image.slidesharecdn.com/articlepresentation-220616121543-06f518c2/75/Article-presentation-Surviving-sepsis-campaign-international-guidelines-for-management-of-sepsis-and-septic-shock-2021-2-2048.jpg)
![Goals of care
74. For adults with sepsis or septic shock, we recommend discussing goals of care and prognosis
with patients and families over no such discussion. (Best Practice Statement)
75. For adults with sepsis or septic shock, we suggest addressing goals of care early (within 72 h)
over late [72] (Weak recommendation, low-quality evidence)
76. There is insufficient evidence to make a recommendation for any specific standardised
criterion to trigger goals of care discussion](https://image.slidesharecdn.com/articlepresentation-220616121543-06f518c2/75/Article-presentation-Surviving-sepsis-campaign-international-guidelines-for-management-of-sepsis-and-septic-shock-2021-61-2048.jpg)
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Article presentation / Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021
The document outlines the 2021 international guidelines for the management of sepsis and septic shock, emphasizing the importance of early recognition and immediate treatment. It details clinical definitions, screening recommendations, resuscitation protocols, and antibiotic administration strategies, aiming to improve patient outcomes. Key recommendations include the use of crystalloids for fluid resuscitation and timely administration of antimicrobials, while also addressing various treatment considerations based on individual patient risks.
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Article presentation / Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021
- 1. Article presentation | Survivingsepsis campaign: international guidelines for management of sepsis and septic shock 2021, Part I SUPERVISED BY: DR. KHALED AL OWEIDAT DONE BY: DR. FAISAL RAWAGAH 14.04.2022
- 2. The Third InternationalConsensus Definitions for Sepsis and Septic Shock (Sepsis-3) Sepsis: is a life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock: is a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65mmHg or greater and serum lactate level greater than 2 mmol/L (>18mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287
- 3.
- 4. Screening for patientswith sepsis and septic shock New! 1. For hospitals and health systems, we recommend using a performance improvement programs for sepsis, including sepsis screening for acutely ill, high-risk patients and standard operating procedures for treatment. (Strong Recommendation, Moderate Quality Evidence) 2. We recommend against using qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock. (Strong Recommendation, Moderate Quality Evidence) 3. For adults suspected of having sepsis, we suggest measuring blood lactate. (Weak Recommendation, V. low Quality Evidence) (SIRS) – systemic inflammatory response syndrome (qSOFA) – quick Sequential Organ Failure Score (SOFA) – Sequential Organ Failure Assessment (NEWS) – National Early Warning Score (MEWS) – Modified Early Warning Score
- 5. Initial resuscitation New! 4.Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately. (Best Practice) New! 5. For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of intravenous (IV) crystalloid fluid should be given within the first 3 h of resuscitation. (Weak Recommendation, Low Quality Evidence)
- 6. 6. For adultswith sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation, over physical examination or static parameters alone. (Weak Recommendation, V. Low Quality Evidence) Remarks: Dynamic parameters include response to a passive leg raise or a fluid bolus, using stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), or echocardiography.
- 7. 7. For adultswith sepsis or septic shock, we suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate level, over not using serum lactate. (Weak Recommendation, Low Quality Evidence) Remarks: During acute resuscitation, serum lactate level should be interpreted considering the clinical context and other causes of elevated lactate. New! 8. For adults with septic shock, we suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion. (Weak Recommendation, Low Quality Evidence)
- 8. Mean arterial pressure 9.For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets. (Strong Recommendation, Moderate Quality Evidence)
- 9. Admission to intensivecare 10. For adults with sepsis or septic shock who require ICU admission, we suggest admitting the patients to the ICU within 6 h. (Weak Recommendation, Low Quality Evidence) Mortality of 1.5% for each hour delay of ED to ICU transfer.
- 10.
- 11. Diagnosis of infection 11.For adults with suspected sepsis or septic shock but unconfirmed infection, we recommend continuously re-evaluating and searching for alternative diagnoses and discontinuing empiric antimicrobials if an alternative cause of illness is demonstrated or strongly suspected. (Best Practice)
- 12. Time to antibiotics New!12. For adults with possible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials immediately, ideally within 1 h of recognition. (Strong Recommendation, Low Quality Evidence) 13. For adults with possible sepsis without shock, we recommend rapid assessment of the likelihood of infectious versus non-infectious causes of acute illness. (Best Practice) Remarks: Rapid assessment includes history and clinical examination, tests for both infectious and non-infectious causes of acute illness and immediate treatment for acute conditions that can mimic sepsis. Whenever possible this should be completed within 3 h of presentation so that a decision can be made as to the likelihood of an infectious cause of the patient’s presentation and timely antimicrobial therapy provided if the likelihood of sepsis is thought to be high.
- 13. New! 14. Foradults with possible sepsis without shock, we suggest a timelimited course of rapid investigation and if concern for infection persists, the administration of antimicrobials within 3 h from the time when sepsis was first recognized. (Weak Recommendation, V. Low Quality Evidence) New! 15. For adults with a low likelihood of infection and without shock, we suggest deferring antimicrobials while continuing to closely monitor the patient. (Weak Recommendation, V. Low Quality Evidence)
- 15. Biomarkers to startantibiotics 16. For adults with suspected sepsis or septic shock, we suggest against using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone. (Weak Recommendation, V. Low Quality Evidence)
- 16. Antimicrobial choice New! 17.For adults with sepsis or septic shock at high risk of methicillin resistant staph aureus (MRSA), we recommend using empiric antimicrobials with MRSA coverage over using antimicrobials without MRSA coverage. (Best Practice) New! 18. For adults with sepsis or septic shock at low risk of methicillin resistant staph aureus (MRSA), we suggest against using empiric antimicrobials with MRSA coverage, as compared with using antimicrobials without MRSA coverage. (Weak Recommendation, Low Quality Evidence)
- 17. 19. For adultswith sepsis or septic shock and high risk for multidrug resistant (MDR) organisms, we suggest using two antimicrobials with gram-negative coverage for empiric treatment over one gram-negative agent. (Weak Recommendation, V. Low Quality Evidence) 20. For adults with sepsis or septic shock and low risk for multidrug resistant MDR organisms, we suggest against using two Gram-negative agents for empiric treatment, as compared to one Gram-negative agent. (Weak Recommendation, V. Low Quality Evidence) 21. For adults with sepsis or septic shock, we suggest against using double gram-negative coverage once the causative pathogen and the susceptibilities are known. (Weak Recommendation, V. Low Quality Evidence)
- 18. Antifungal therapy New! 22.For adults with sepsis or septic shock at high risk of fungal infection, we suggest using empiric antifungal therapy over no antifungal therapy. (weak Recommendation, Low Quality Evidence) New! 23. For adults with sepsis or septic shock at low risk of fungal infection, we suggest against empiric use of antifungal therapy. (weak Recommendation, Low Quality Evidence) Antiviral therapy 24. We make no recommendation on the use of antiviral agents.
- 19. Delivery of antibiotics 25.For adults with sepsis or septic shock, we suggest using prolonged infusion of beta-lactams for maintenance (after an initial bolus) over conventional bolus infusion. (Weak Recommendation, Moderate Quality Evidence) Pharmacokinetics and pharmacodynamics 26. For adults with sepsis or septic shock, we recommend optimising dosing strategies of antimicrobials based on accepted pharmacokinetic/pharmacodynamic (PK/PD) principles and specific drug properties. (Best Practice)
- 20. Source control 27. Foradults with sepsis or septic shock, we recommend rapidly identifying or excluding a specific anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical. (Best Practice) 28. For adults with sepsis or septic shock, we recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established. (Best Practice)
- 21. De-escalation of antibiotics 29.For adults with sepsis or septic shock, we suggest daily assessment for de-escalation of antimicrobials over using fixed durations of therapy without daily reassessment for de- escalation. (weak Recommendation, V. Low Quality Evidence) Duration of antibiotics 30. For adults with an initial diagnosis of sepsis or septic shock and adequate source control, we suggest using shorter over longer duration of antimicrobial therapy. (Weak Recommendation, V. Low Quality Evidence)
- 22. Biomarkers to discontinueantibiotics 31. For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear, we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone. (Weak Recommendation, V. Low Quality Evidence)
- 23.
- 24. Fluid management 32. Foradults with sepsis or septic shock, we recommend using crystalloids as first-line fluid for resuscitation. (Strong Recommendation, Moderate Quality Evidence) New! 33. For adults with sepsis or septic shock, we suggest using balanced crystalloids instead of normal saline for resuscitation. (Weak Recommendation, Low Quality Evidence) 34. For adults with sepsis or septic shock, we suggest using albumin in patients who received large volumes of crystalloids over using crystalloids alone. (Weak Recommendation, Moderate Quality Evidence)
- 25. 35. For adultswith sepsis or septic shock, we recommend against using starches for resuscitation. (Strong Recommendation, High Quality Evidence) New! 36. For adults with sepsis and septic shock, we suggest against using gelatin for resuscitation. (Weak Recommendation, Moderate Quality Evidence)
- 26. Vasoactive agents 37. Foradults with septic shock, we recommend using norepinephrine as the first-line agent over other vasopressors. (Dopamine. Vasopressin. Epinephrine. Selepressin. Angiotensin II) (Strong Recommendation, High Quality Evidence) Remark: In settings where norepinephrine is not available, epinephrine or dopamine can be used as an alternative, but we encourage efforts to improve the availability of norepinephrine. Special attention should be given to patients at risk for arrhythmias when using dopamine and epinephrine.
- 27. 38. For adultswith septic shock on norepinephrine with inadequate MAP levels, we suggest adding vasopressin instead of escalating the dose of norepinephrine. (Weak Recommendation, Moderate Quality Evidence) Remark: In our practice, vasopressin is usually started when the dose of norepinephrine is in the range of 0.25–0.5 μg/kg/min.
- 28. 39. For adultswith septic shock and inadequate MAP levels despite norepinephrine and vasopressin, we suggest adding epinephrine. (Weak Recommendation, Low Quality Evidence) 40. For adults with septic shock, we suggest against using terlipressin. (Weak Recommendation, Low Quality Evidence)
- 29. Inotropes 41. For adultswith septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we suggest either adding dobutamine to norepinephrine or using epinephrine alone. (Weak Recommendation, Low Quality Evidence) New! 42. For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we suggest against using levosimendan. (weak Recommendation, Low Quality Evidence)
- 31. Monitoring and intravenousaccess 43. For adults with septic shock, we suggest using invasive monitoring of arterial blood pressure over non-invasive monitoring, as soon as practical and if resources are available. (Weak Recommendation, Low Quality Evidence) New! 44. For adults with septic shock, we suggest starting vasopressors peripherally to restore MAP rather than delaying initiation until a central venous access is secured. (Weak Recommendation, Low Quality Evidence) Remark: When using vasopressors peripherally, they should be administered only for a short period of time and in a vein in or proximal to the antecubital fossa.
- 32. Fluid balance New! 45.There is insufficient evidence to make a recommendation on the use of restrictive versus liberal fluid strategies in the first 24 h of resuscitation in patients with sepsis and septic shock who still have signs of hypoperfusion and volume depletion after initial resuscitation. Remarks: Fluid resuscitation should be given only if patients present with signs of hypoperfusion.
- 33. References -Singer M, DeutschmanCS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287 -Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247. doi: 10.1007/s00134-021-06506-y. Epub 2021 Oct 2. PMID: 34599691; PMCID: PMC8486643.
- 34. Thank you Supervised by: Dr.Khaled Al Oweidat Pulmonologists Consultant Done by: Dr. Faisal Rawagah Critical Care Fellow Jordan University Hospital 14.04.2022
- 35. Article presentation | Survivingsepsis campaign: international guidelines for management of sepsis and septic shock 2021, Part II SUPERVISED BY: DR. KHALED AL OWEIDAT DONE BY: DR. FAISAL RAWAGAH 16.06.2022
- 36.
- 37. Oxygen targets 46. Thereis insufficient evidence to make a recommendation on the use of conservative oxygen targets in adults with sepsis-induced hypoxemic respiratory failure. Conservative oxygen targets (generally defined as PaO2 55–70 mmHg; SpO2 88–92%) ICU-ROX Trial- Did not significantly affect the primary outcome, The number of ventilator-free days. Mortality at 90 and 180 days did not differ. The LOCO-2 study - was terminated early by the data safety and monitoring board and reported no difference in 28-day survival in ARDS patients managed with a conservative oxygenation strategy.
- 38. High-flow nasal oxygentherapy New! 47. For adults with sepsis-induced hypoxemic respiratory failure, we suggest the use of high flow nasal oxygen over non-invasive ventilation (Weak recommendation, low quality of evidence) HFNC compared with NIV: Intubation rate at 28 days was not different. More days free of mechanical ventilation during a 28-day study period. Improved 90-day survival rat. *Hoc analysis* In Severe hypoxemia (PaO2/FiO2 ≤ 200 mmHg) lower intubation rates (35% versus 58%)
- 39. Non-invasive ventilation 48. Thereis insufficient evidence to make a recommendation on the use of non-invasive ventilation in comparison to invasive ventilation for adults with sepsis-induced hypoxemic respiratory failure.
- 40. Protective ventilation inacute respiratory distress syndrome (ARDS) 49. For adults with sepsis-induced ARDS, we recommend using a low tidal volume ventilation strategy (6 mL/kg), over a high tidal volume strategy (> 10 mL/kg). (Strong recommendation, high quality of evidence) 50. For adults with sepsis-induced severe ARDS, we recommend using an upper limit goal for plateau pressures of 30 cm H2O, over higher plateau pressures. (Strong recommendation, moderate quality of evidence) 51. For adults with moderate to severe sepsis-induced ARDS, we suggest using higher PEEP over lower PEEP. (Weak recommendation, moderate quality of evidence)
- 41. *Titrate the PEEP 1-According to Bedside measurements of thoracopulmonary compliance with the objective of obtaining the best compliance or lowest driving pressure. 2- While the patient is receiving a tidal volume of 6 mL/kg PBW, until the plateau airway pressure is 28 cm H2O. 3- Using a PEEP/FiO2 titration table that titrates PEEP based on the combination of FiO2 and PEEP required to maintain adequate oxygenation. Esophageal pressure guided PEEP titration- no significant difference in a composite outcome of death and days free from mechanical ventilation through day 28.
- 42. Ventilation with lowertidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301.
- 43. Low tidal volumein non-ARDS respiratory failure 52. For adults with sepsis-induced respiratory failure (without ARDS), we suggest using low tidal volume as compared to high tidal volume ventilation. (Weak recommendation, low quality of evidence) Low tidal volume (Vt) ventilation (Vt 4–8 mL/ kg of predicted body weight), over higher tidal volumes (Vt > 8 mL/kg) No difference in mortality with low Vt ventilation (RR 1.07; 95% CI 0.91–1.26), with a trend towards lower risk of developing ARDS (RR 0.59; 95% CI 0.34–1.02).
- 44. Recruitment manoeuvres 53. Foradults with sepsis-induced moderate-severe ARDS, we suggest using traditional recruitment maneuvers. (Weak recommendation, moderate quality of evidence) 54. When using recruitment maneuvers, we recommend against using incremental PEEP titration/strategy. (Strong recommendation, moderate quality of evidence)
- 45. Prone ventilation 55. Foradults with sepsis-induced moderate-severe ARDS, we recommend using prone ventilation for more than 12 h daily (Strong recommendation, moderate quality of evidence) PROSEVA trial (published in 2013)- supine position within the first 36 h of intubation, when performed for > 12 h a day, showed improved survival. ◦ Reduced mortality -(RR 0.74; 95% CI 0.56–0.99) ◦ Change in PaO2/FiO2 ratio (median 23.5 higher; 95% CI 12.4–34.5 higher)
- 46. Neuromuscular blocking agents 56.For adults with sepsis induced moderate-severe ARDS, we suggest using intermittent NMBA boluses, over NMBA continuous infusion. (Weak recommendation, moderate quality of evidence) ROSE Trial- continuous NMBA infusion did not improve mortality when compared to a light sedation strategy with as needed NMBA boluses (RR 0.99; 95% CI 0.86–1.15), but continuous NMBA infusion reduced mortality when compared to deep sedation with as needed NMBA boluses (RR 0.71; 95% CI 0.57–0.89). - Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, Constantin JM, Courant P, Lefrant JY, Guérin C, Prat G, Morange S, Roch A; ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010 Sep 16;363(12):1107-16. doi: 10.1056/NEJMoa1005372. PMID: 20843245. - National Heart, Lung, and Blood Institute PETAL Clinical Trials Network, Moss M, Huang DT, Brower RG, Ferguson ND, Ginde AA, Gong MN, Grissom CK, Gundel S, Hayden D, Hite RD, Hou PC, Hough CL, Iwashyna TJ, Khan A, Liu KD, Talmor D, Thompson BT, Ulysse CA, Yealy DM, Angus DC. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. N Engl J Med. 2019 May 23;380(21):1997-2008. doi: 10.1056/NEJMoa1901686. Epub 2019 May 19. PMID: 31112383; PMCID: PMC6741345.
- 47. Extracorporeal membrane oxygenation (ECMO) New!57. For adults with sepsis-induced severe ARDS, we suggest using venovenous (VV) ECMO when conventional mechanical ventilation fails in experienced centers with the infrastructure in place to support its use. (Weak recommendation, low quality of evidence).
- 48.
- 49. Corticosteroids New! 58. Foradults with septic shock and an ongoing requirement for vasopressor therapy we suggest using IV corticosteroids. (Weak recommendation; moderate quality of evidence) Remark: The typical corticosteroid used in adults with septic shock is IV hydrocortisone at a dose of 200 mg/day given as 50 mg intravenously every 6 h or as a continuous infusion. It is suggested that this is commenced at a dose of norepinephrine or epinephrine ≥ 0.25 mcg/kg/min at least 4 h after initiation. ◦ ADRENAL ◦ APROCCHSS ◦ VANISH
- 50. Blood Purification New! 59.For adults with sepsis or septic shock, we suggest against using polymyxin B haemoperfusion. (Weak recommendation; low quality of evidence) 60. There is insufficient evidence to make a recommendation on the use of other blood purification techniques.
- 51. Red blood cell(RBC) transfusion targets 61. For adults with sepsis or septic shock, we recommend using a restrictive (over liberal) transfusion strategy. (Strong recommendation; moderate quality of evidence) Remark: A restrictive transfusion strategy typically includes a haemoglobin concentration transfusion trigger of 70 g/L; however, RBC transfusion should not be guided by haemoglobin concentration alone. Assessment of a patient’s overall clinical status and consideration of extenuating circumstances such as acute myocardial ischaemia, severe hypoxemia or acute haemorrhage is required TRISS trial- similar 90-day mortality, ischaemic events, and use of life support. (1000 pt) TRICC trial- no difference in the primary outcome (30-day mortality). (838 pt) TRICOP trial- At 90 days after randomisation,mortality rate in the liberal group was lower (59% vs 70%) than in the restrictive group (hazard ratio, 0.72; 95%CI 0.53–0.97). (300 pt)
- 52. Immunoglobulins 62. For adultswith sepsis or septic shock, we suggest against using intravenous immunoglobulins. (Weak recommendation, low quality of evidence)
- 53. Stress ulcer prophylaxis 63.For adults with sepsis or septic shock, and who have risk factors for gastrointestinal (GI) bleeding, we suggest using stress ulcer prophylaxis. (Weak recommendation, moderate quality of evidence)
- 54. Venous thromboembolism (VTE) prophylaxis 64.For adults with sepsis or septic shock, we recommend using pharmacologic VTE prophylaxis unless a contraindication to such therapy exists. (Strong recommendation, moderate quality of evidence) 65. For adults with sepsis or septic shock, we recommend using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for VTE prophylaxis. (Strong recommendation, moderate quality of evidence) 66. For adults with sepsis or septic shock, we suggest against using mechanical VTE prophylaxis in addition to pharmacological prophylaxis, over pharmacologic prophylaxis alone. (Weak recommendation, low quality of evidence)
- 55. Renal replacement therapy 67.In adults with sepsis or septic shock and AKI who require renal replacement therapy, we suggest using either continuous or intermittent renal replacement therapy. (Weak recommendation, low quality of evidence) 68. In adults with sepsis or septic shock and AKI, with no definitive indications for renal replacement therapy, we suggest against using renal replacement therapy. (Weak recommendation, moderate quality of evidence) Absolute indications for dialysis: (uremic complications, refractory academia, refractory fluid overload or hyperkalemia).
- 56. Glucose control 69. Foradults with sepsis or septic shock, we recommend initiating insulin therapy at a glucose level of ≥ 180 mg/dL (10 mmol/L). (Strong recommendation; moderate quality of evidence) Remark: Following initiation of an insulin therapy, a typical target blood glucose range is 144– 180 mg/dL (8–10 mmol/L).
- 57. Vitamin C New! 70.For adults with sepsis or septic shock, we suggest against using IV vitamin C. (Weak recommendation, low quality of evidence) Updated Meta-analysis: The use of vitamin C did not reduce mortality compared to usual care (RR 0.79; 95% CI 0.57–1.1, low quality) (416 critically ill patients)
- 58. Bicarbonate therapy 71. Foradults with septic shock and hypoperfusion-induced lactic acidemia, we suggest against using sodium bicarbonate therapy to improve haemodynamics or to reduce vasopressor requirements. (Weak recommendation, low quality of evidence) 72. For adults with septic shock, severe metabolic acidemia (pH ≤ 7.2) and AKI (AKIN score 2 or 3), we suggest using sodium bicarbonate therapy (Weak recommendation, low quality of evidence)
- 59. Nutrition 73. For adultpatients with sepsis or septic shock who can be fed enterally, we suggest early (within 72 h) initiation of enteral nutrition. (Weak recommendation; very low quality of evidence)
- 60. Long-term outcomes and goalsof care
- 61. Goals of care 74.For adults with sepsis or septic shock, we recommend discussing goals of care and prognosis with patients and families over no such discussion. (Best Practice Statement) 75. For adults with sepsis or septic shock, we suggest addressing goals of care early (within 72 h) over late [72] (Weak recommendation, low-quality evidence) 76. There is insufficient evidence to make a recommendation for any specific standardised criterion to trigger goals of care discussion
- 62. Palliative care 77. Foradults with sepsis or septic shock, we recommend integrating principles of palliative care (which may include palliative care consultation based on clinician judgement) into the treatment plan, when appropriate, to address patient and family symptoms and suffering. (Best Practice Statement) 78. For adults with sepsis or septic shock, we suggest against routine formal palliative care consultation for all patients over palliative care consultation based on clinician judgement. (Weak recommendation, low-quality evidence)
- 63. Peer support groups 79.For adult survivors of sepsis or septic shock and their families, we suggest referral to peer support groups over no such referral. (Weak recommendation, very low quality of evidence)
- 64. Transitions of care 80.For adults with sepsis or septic shock, we suggest using a handoff process of critically important information at transitions of care, over no such handoff process. (Weak recommendation, very low-quality evidence) 81. There is insufficient evidence to make a recommendation for the use of any specific structured handoff tool over usual handoff processes.
- 65. Screening for economicor social support 82. For adults with sepsis or septic shock and their families, we recommend screening for economic and social support (including housing, nutritional, financial, and spiritual support), and make referrals where available to meet these needs (Best Practice Statement)
- 66. Sepsis education forpatients and families 83. For adults with sepsis or septic shock and their families, we suggest offering written and verbal sepsis education (diagnosis, treatment, and post-ICU/post-sepsis syndrome) prior to hospital discharge and in the follow-up setting. (Weak recommendation, very low-quality evidence)
- 67. Shared decision making 84.For adults with sepsis or septic shock and their families, we recommend the clinical team provide the opportunity to participate in shared decision making in post-ICU and hospital discharge planning to ensure discharge plans are acceptable and feasible. (Best Practice Statement)
- 68. Discharge planning 85. Foradults with sepsis and septic shock and their families, we suggest using a critical care transition programme, compared to usual care, upon transfer to the floor (Weak recommendation, very low-quality evidence) 86. For adults with sepsis and septic shock, we recommend reconciling medications at both ICU and hospital discharge (Best Practice Statement) 87. For adult survivors of sepsis and septic shock and their families, we recommend including information about the ICU stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal hospital discharge summary (Best Practice Statement)
- 69. 88. For adultswith sepsis or septic shock who developed new impairments, we recommend hospital discharge plans include follow-up with clinicians able to support and manage new and long-term sequelae (Best Practice Statement) 89. There is insufficient evidence to make a recommendation on early post-hospital discharge follow-up compared to routine posthospital discharge follow-up
- 70. Cognitive therapy 90. Thereis insufficient evidence to make a recommendation on early cognitive therapy for adult survivors of sepsis or septic shock
- 71. Post-discharge follow-up 91. Foradult survivors of sepsis or septic shock, we recommend assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge (Best Practice Statement) 92. For adult survivors of sepsis or septic shock, we suggest referral to a post-critical illness follow-up programme if available (Weak recommendation, very low-quality evidence) 93. For adult survivors of sepsis or septic shock receiving mechanical ventilation for > 48 h or an ICU stay of > 72 h, we suggest referral to a post-hospital rehabilitation programme. (Weak recommendation, very low-quality evidence)
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- 73. Thank you Supervised by: Dr.Khaled Al Oweidat Pulmonologists Consultant Done by: Dr. Faisal Rawagah Critical Care Fellow Jordan University Hospital 16.06.2022