San Juan, Puerto Rico—The 2012 Surviving Sepsis Guidelines Committee officially released updated guidelines for managing severe sepsis and septic shock during the Society of Critical Care Medicine's 42nd Congress here last week.
Recommendations were designated as strong (1) or weak (2) based on evidence that ranged from high (A) to very low (D). A new category of "ungraded" or "UG" evidence was introduced to signify recommendations the guidelines committee felt were not conducive to grading. Changes in the new version from the 2008 version include:
- Initial fluid resuscitation with crystalloid (1B). The 2008 guidelines didn't specify a preference for crystalloid vs. colloid fluid resuscitation (1B).
- Norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mm Hg (1B). The 2008 guidelines didn't specify a preference for norepinephrine vs. dopamine (1C).
- Avoidance of neuromuscular blockers if possible in patients without acute respiratory distress syndrome (ARDS) (1C) and a short course (≤48 hours) of neuromuscular blockers for patients with early ARDS and a Pao2/Fio2 <150 mm Hg (2C). The 2008 guidelines suggested blanket avoidance of neuromuscular blockers if possible (1B).
- A protocolized approach to blood glucose management that starts insulin dosing when two consecutive blood glucose levels are >180 mg/dL and targets an upper blood glucose ≤180 mg/dL (1A). The 2008 guidelines suggested targeting a blood glucose <150 mg/dL after initial stabilization (1C).
- Oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hours after a diagnosis of severe sepsis/septic shock (1C). The 2008 guidelines didn't discuss feedings.
- Addressing goals of care, such as treatment plans and end-of-life planning as appropriate (1B), as early as possible, but within 72 hours of ICU admission (2C). The 2008 guidelines didn't specify a time period for advance care planning (1D).
Though many recommendations remained unchanged from the 2008 version, their quality of evidence grades were updated. For example, the strong recommendation to institute protocols for weaning and sedation was upgraded from "B" in 2008 to "A" in 2012 based on newer clinical trials. Likewise, the strong recommendation to promptly perform imaging studies to confirm a potential source of infection went from "C" to "UG".
"Most of these recommendations are appropriate for the severe sepsis patient in the ICU and non-ICU settings," the committee wrote. "In fact, the committee believes the greatest outcome improvement can be made through education and process changes for those caring for severe sepsis patients in the non-ICU setting and across the spectrum of acute care."
The guidelines committee comprised representatives of 30 international groups, with co-chairs and executive members appointed by the Society of Critical Care Medicine and European Society of Intensive Care Medicine governing bodies. The guidelines, based on literature published through fall 2012, also appear in the February issue of Critical Care Medicine and will appear in February'sIntensive Care Medicine .