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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016
The new edition of Surviving Sepsis Campaign (SSC), published simultaneously in European and North American Journals, summarizes the current thinking about treatment of sepsis and septic shock. In the guidelines, the authors distinguish between recommendations, which should be followed (strong recommendations), and suggestions, which may be followed (weak recommendations).
For parts 1, 2, and 3, see Publications of the Week from January 30, 2017: http://empendium.com/mcmtextbook/week_publications/157968,publications-of-the-week-january30.
Part 4: More on ventilation and on nonspecific treatments of patients with sepsis
The recommendation (rather than suggestion) to use prone ventilation reflects increased confidence that this intervention is beneficial. On the other hand, there is a new recommendation against the use of high-frequency oscillatory ventilation. Suggestions to use short-term (<48 hours) neuromuscular blocking agents in severe acute respiratory distress syndrome (ARDS) and conservative fluid strategy in ARDS outside the period of shock remain.
In the area of sedation, the principles are generally strengthened: there are recommendations to avoid continuous or scheduled intermittent sedation (as a minimum, daily reassessment of the use and doses) and give primary consideration to the use of analgesia (opioids) rather than sedation.
On the metabolic site, the recommendation to aim at moderate levels of glucose control (<180 mmol/L) rather than strict control (<110 mmol/L) remains in place. There is also indication of the lack of clear advantage of a specific mode of dialysis – although continuous mode is suggested, on the basis of very low quality of evidence, in hemodynamically unstable patients. The use of bicarbonates is discouraged in septic situations with pH >7.15; at the same time, the guidelines are silent on bicarbonate use in more acidotic environments (likely leaving room for the individual clinician’s judgment).
Part 5: More on nonspecific treatments of patients with sepsis
In the area of thromboprophylaxis, a strong recommendation to use prophylaxis, strong recommendation to use low-molecular-weight heparin rather than unfractionated heparin, and weak recommendation to combine pharmacological prophylaxis with mechanical prophylaxis are provided again. The recommendation for stress ulcer prophylaxis remains in place – to use proton pump inhibitors (PPIs) or histamine-2 receptor antagonists in people with risk factors (mainly mechanical ventilation and presence of coagulopathy, ie, platelet counts <50,000 and/or international normalized ratio >1.5) – as well as the suggestion not to use prophylaxis in patients without those risk factors. The preference (suggestion) for PPIs is provided.
For nutrition, some strong recommendations clarify what should not be done: there is a clear “no” to early parenteral nutrition if patients may be fed enterally and a “no” to supplemental parenteral treatment within the first 7 days. The suggestions are for the possibility of early trophic/hypocaloric enteral feeding (in patients not tolerating full feeding), against routine monitoring of gastric residual volumes (except in those not tolerating food or at high risk of aspiration), and for the use of prokinetic agents in patients with feeding intolerance. There are also recommendations against the use of a variety of supplements (omega-3 fatty acids, selenium, and glutamine) and a suggestion not to use arginine.
The final and increasingly more prominent section “Setting goals of care” includes recommendations on the need for communication with patients and (frequently) with their families, for discussion of prognosis and realistic goals of care, and considerations of end-of-life care. The authors suggest that those issues are considered and discussed, as appropriate, within 72 hours of admission.
