Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008*

Objective: To provide an update to the original Surviving Sepsis Campaign
clinical management guidelines, “Surviving Sepsis Campaign Guidelines for Management
of Severe Sepsis and Septic Shock,” published in 2004.
Design: Modified Delphi method with a consensus conference of 55 international
experts, several subsequent meetings of subgroups and key individuals,
teleconferences, and electronic-based discussion among subgroups and among
the entire committee. This process was conducted independently of any industry
Methods: We used the Grades of Recommendation, Assessment, Development
and Evaluation (GRADE) system to guide assessment of quality of evidence from
high (A) to very low (D) and to determine the strength of recommendations. A
strong recommendation (1) indicates that an intervention’s desirable effects
clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak
recommendations (2) indicate that the tradeoff between desirable and undesirable
effects is less clear. The grade of strong or weak is considered of greater clinical
importance than a difference in letter level of quality of evidence. In areas without
complete agreement, a formal process of resolution was developed and applied.
Recommendations are grouped into those directly targeting severe sepsis, recommendations
targeting general care of the critically ill patient that are considered
high priority in severe sepsis, and pediatric considerations.
Results: Key recommendations, listed by category, include early goal-directed
resuscitation of the septic patient during the first 6 hrs after recognition (1C);
blood cultures before antibiotic therapy (1C); imaging studies performed promptly
to confirm potential source of infection (1C); administration of broad-spectrum
antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis
without septic shock (1D); reassessment of antibiotic therapy with microbiology
and clinical data to narrow coverage, when appropriate (1C); a usual 7–10 days
of antibiotic therapy guided by clinical response (1D); source control with attention
to the balance of risks and benefits of the chosen method (1C); administration
of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore
mean circulating filling pressure (1C); reduction in rate of fluid administration with
rising filing pressures and no improvement in tissue perfusion (1D); vasopressor
preference for norepinephrine or dopamine to maintain an initial target of mean
arterial pressure >65 mm Hg (1C); dobutamine inotropic therapy when cardiac
output remains low despite fluid resuscitation and combined inotropic/vasopressor
therapy (1C); stress-dose steroid therapy given only in septic shock after blood
pressure is identified to be poorly responsive to fluid and vasopressor therapy
(2C); recombinant activated protein C in patients with severe sepsis and clinical
assessment of high risk for death (2B except 2C for postoperative patients). In the
absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage,
target a hemoglobin of 7–9 g/dL (1B); a low tidal volume (1B) and limitation of
inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory
distress syndrome (ARDS); application of at least a minimal amount of
positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in
mechanically ventilated patients unless contraindicated (1B); avoiding routine use
of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical
ventilation and ICU length of stay, a conservative fluid strategy for patients with
established ALI/ARDS who are not in shock (1C); protocols for weaning and
sedation/analgesia (1B); using either intermittent bolus sedation or continuous
infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular
blockers, if at all possible (1B); institution of glycemic control (1B),
targeting a blood glucose <150 mg/dL after initial stabilization (2C); equivalency
of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis
for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent
upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors
(1B); and consideration of limitation of support where appropriate (1D). Recommendations
specific to pediatric severe sepsis include greater use of physical
examination therapeutic end points (2C); dopamine as the first drug of choice for
hypotension (2C); steroids only in children with suspected or proven adrenal
insufficiency (2C); and a recommendation against the use of recombinant activated
protein C in children (1B).
Conclusions: There was strong agreement among a large cohort of international
experts regarding many level 1 recommendations for the best current care
of patients with severe sepsis. Evidenced-based recommendations regarding the
acute management of sepsis and septic shock are the first step toward improved
outcomes for this important group of critically ill patients

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