Cite this post as:
Scott Weingart, MD FCCM. 2012 Surviving Sepsis Campaign Guidelines. EMCrit Blog. Published on January 24, 2013. Accessed on May 28th 2023. Available at [https://emcrit.org/emcrit/2012-surviving-sepsis-campaign-guidelines/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
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Original Release: January 24, 2013
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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How to use albumin as part of fluid therapy in septic shock ?
What concentration (4-5% or 20% albumin) to be used ?
What is the “dosage” ?
– how much ?
– how fast (the rate) ?
Ever since we started talking about the glycocalyx and modified Starling’s equation concerning fluid transport across the capillary membrane, we have known that hyperoncotic solutions are BAD for the endothelial surface layer. So 20 %albumin is kinda out!!. Also, there is no evidence of any survival benefit with its use from the literature. 4-5% Albumin is safe, and the dose equivalence to crystalloids is 1:1.4ml.
( SAFE and VISEP studies…) Also, there is some evidence that albumin infact protects the glycocalyx a bit.
Hope this helps.
I was hoping for the guidelines to include something about “prehospital recognition and initial treatment”. Currently unappreciated in the prehospital realm and a push from the “guidelines” side could help move this along (e.g. wider adoption of something like the Denver Sepsis Alert program).
At our shop, patients usually get up to the ICU within 1-2 hours. I love starting central lines. However, the culture at my facility is to not start them in the ED in most cases, as frustrating as that sounds. Given that reality, has anyone looked at the safety and efficacy of giving norepinephrine peripherally in a concentration that is more dilute than standard? Instead of 8mg/250ml of D5W, why not 1 or 2mg/250ml and increase the flow rate? To provide 16mcg/min, instead of 30ml/hr the rate would be 120ml/hr for a 2mg/250ml preparation. I don’t see that this has… Read more »
That is exactly what Paul Mayo (of the RSI debate) has been doing in the MICU at Long Island Jewish. I assume he will publish his results. I think the ideal for this is to place a longer cath in the AC (peds central line or a femoral a-line kit). I will shoot him an email and see if he responds.
That is the issue we face, in a generally very busy community department. Our times to ICU are not bad, but having the time to place central lines in a truly optimal fashion is rare, and giving peripheral pressors creates a workflow benefit. The discussion previously had included using phenylephrine as a safer peripheral agent, but the skylines pretty much shoot that down.
Love to hear what Paul has to say, Scott!
thanks Scott. great way to review the new guidelines! Over the last few years, I have stopped recommending CVC line placement in prehospital and retrieval medicine. cause more trouble than they are worth usually in the retrieval setting. I advocate use of norepinephrine or preferably epinephrine infusions via secure PIV for the few hours or less a retrieval mission will take. Norepi drips I recommend as Joe says in a dilute preparation. One time during the H1N1 epidemic I had a flu patient in septic shock, SBP 60, turn up at a remote clinic I was working. For initial resus,… Read more »
This might be tedious but it’s something that had me thinking recently. There is no recommended dosage infusions for norepinephrine despite being the first choice pressor. I had been searching the literature on sepsis and found ranges that varies from 0.02 mcg/kg/min to 5 mcg/kg/min. I generally prefer weight based dosages but at my institution norepinephrine scheme has always been unrelated to patients’ weight. If I got it right you are not following a weight based scheme either. Do you have any suggestion on starting dose and maximum dose? Is there any particular advantage in your opinion in using a… Read more »
No I see no advantage and a number of disadvantages. Norepi is a titratable drug, so it really doesn’t matter if you dose by weight except for the starting dose; after that you are just moving up and down by MAP. The disadvantage to weight base dosing is you may start too high. Often, 1-2 mcg/min of norepi does the job. I will start at these low doses if the patient is not crashing and move up from there.
Let’s say it’s found that pressors, when appropriately diluted, are safe given peripherally. If this were found to be the case, do you think there could be a subset of patients manageable in the ICU without the need for a central line? It sounds like that is what Dr. Mayo is doing. There may be other advantages to having the central line in place that we in the ED aren’t aware of. If there are any research directors reading this-how about a randomized trial? Could study outcomes of ICU patients managed without a central line and administration of pressors by… Read more »
Would not even need an RCT, just a cohort trial to look for adverse events
Dr Weingart I would really like to thank you for your very precise remarks about the new SSC guidelines! I am a greek intensivist doctor and a new member of your blog.
I learned about your blog recently while I was in New York for an ED training program. Since then I am a real fan of you and your interesting
notes! Thank you!
Thanks my friend!
Always a good read on why CVP must be put to rest:
http://socmob.blogspot.ch/2012_10_01_archive.html
Scott, Love the podcast as always, couple questions/comments 1. Why is there so much stress on the need for blood cultures? I mean every time I am about to give abx, I get a call from pharmacy or nursing to ask if they need blood cultures first. In the guidelines it seems as though they recommend blood cultures for all septic patients, is this including patients without shock? It seems that the diagnostic utility of blood cultures in your run of the mill septic patient is low, and between 1-5% of patients will have a false positive, and rarely the… Read more »
Blood cultures matter a ton for hospital/health care assoc. infections; not as much for community. But when we are dealing with severe infection, it is nice to know the bug and especially the sensitivities. Often the yield is higher in the patients as well. If the pt has CA-MRSA as the cause of their severe sepsis pneumonia, I’d like to know. I would not wait one second to start abx though. If you can’t get cx with first draw, start abx and keep working to get cx while the abx is infusing. Have no idea on fever control. I have… Read more »
Septic dialysis pt with map 64 , lactate 7. Alert but confused. Airway patent. Med. effusions on ct long windows. None on cxr. What do you do with fluid resuscitation in the Ed over 1st 3 hrs
500 mls aliquots until IVC not collapsing.
Hi. I’m very interested in changes you have made to comply with the new recommendations for Sepsis Campaign, as well as what barriers you anticipate. Does your facility use a sepsis database?
Are art lines always necessary for patients on pressors? http://resus.me/non-invasive-bp-in-shock/
(Crit Care Med 2013;41:34)
Scott,
Great review thanks. A few quick questions:
– In Marik’s study a significant number of his patients were post-CABG: how does this effect the extension of this study’s findings to septic MICU patients?
– Marik’s “responders” and “non-responders” had CVPs of 8.7 and 9.7 respectively: what’s the likelihood these guys are already on the flat part of the startling curve?
– Lactate vs. Scv02: what about the significant number of initially lactate negative patients that go on to vasopressor dependent shock? Might seeing a (pre-dysoxic state) falling Scv02 have promoted more aggressive, potentially life-saving, resuscitation?
Thanks!
Insightful points. We all believe that when the cvp is very low<5 they pt likely will be fluid responsive. Most of the CABG pts were fluid replete in the OR, so the cohort cuts out the easy patients, but this is a better test of a test. THis si the opposite of a case-control conundrum, If CVP works great for profoundly dehydrated patients and pts in cardiogenic pulm edema but no well for the middle ground, then it is a failure as a test. Sort of like BNP. What the literature is showing in 3 separate trials now is that… Read more »
Scott, We are working on an institution wide sepsis protocol in anticipation that CMS will soon require it.(most of our ed folks have been following the EGDT guidlines already) I agree that the non invasive strategy is a great option for many patients and would love to avoid central lines if possible. The question came up about using PICC lines for cvp monitoring. I have found conflicting information about this. Just wondering what you thought about it? Thanks for the great material. Mike
I find the diagnosis section confusing. “Sepsis is defined as the presence (probable or documented) of infection together with systemic manifestations of infection.” Okay got it. SIRS now includes a plethora of new variables and the statement in Table 1 “Infection, documented or suspected, and some of the following:” is wooly but presumably increases sensitivity. “Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion”. Table 2 has organ dysfunction variables that are different from the organ dysfunction variables in table 1 (Bilirubin, Creatinine, acute lung injury). The threshold for bilirubin is higher for use as a… Read more »
Couldn’t agree more. Unless someone validates these, I have no use for them.
Thanks for a great review. You mentioned you wouldn’t wait for blood cultures to start antibiotics. Do you know of data on how long after starting antibiotics valid blood cultures can be obtained ? I would be very curious to see data on that… However, the literature finds that most blood cultures obtained in the ED are not helpful. They are almost as likely to be false positive (contaminants) as true positive, true positives may not be noted by the inpatient team, and even if they are, culture results are less likely to influence management than the patient’s “clinical picture.”… Read more »
I wrote the blood cx policy for ACEP, so I think I’m probably goig to agree with you : )
Scott: Surviving Sepsis Campaign is dear to my heart, and as an advanced practitioner Paramedic we are looking to implement as much of the reccomended bundles as appropriate and practical for EMS. The problem on our end is cost and reimbursements…. trying to sell administration on training/screening/Finger stick lactate levels/ Sepsis Alert –> Any literature you are aware of that may help with this? Thanks!
Scott: I know that you advocate the use of lactate clearance as a resuscitation goal. I was wondering if you have had the chance to take a look at this article by PE Marik? It is suggesting that lactate clearance is a flawed concept and that lactic acidosis in fact is no associated with anaerobic metabolism. Pretty controversial stuff I would say! Must I unlearn all that I have learned??? Do you have any thoughts or comments?
http://www.oapublishinglondon.com/article/431
Nothing controversial about this at all. Most of lactate in severe sepsis is not from anaerobic metabolism, it is from the cytokine-storm induced changes in metabolism. Paul’s facts are all true, the conclusion doesn’t follow. When Jones performed the LACTATE study it was with full knowledge that what we are seeing is not anaerobic metabolism. This was discussed way back in the all about lactate podcast.
Dear Sir,
I’m a medical doctor, and I desperately need your help about one question. The question is:
Solutions of choice in the treatment of sepsis and septic shock are (one answer is correct):
a. crystalloid solutions;
b. colloidal solutions;
c. there is no evidence that one type of solution has the advantage over the other, and can both can be aplied
My dilemma is: are the crystalloids recommended as initial fluid due to hard clinical evidence, or just because of their lower cost? What would you answer on this question? Thanks in advance
The only colloid that may have a role in sepsis is albumin. The data is not clear how advantageous it is over crystalloid if at all, and it is radically more expensive. Based on that you make your choices.
We can draw a continuum in sepsis: infection -> sepsis -> severe sepsis -> septic shock. Where does “Sepsis Induced Tissue Hypoperfusion” fit? By other words, what´s the difference between “Sepsis Induced Tissue Hypoperfusion” and “Septic Shock”?
shock is being used to refer to hypotension as opposed to the better definition of tissue hypoperfusion. So severe sepsis is the better term.
Thanks for your reply!
As a far as I know that was a term introduced in the new SSC Guidelines 2012 and I was having trouble understanding it. To my opinion, I patient with hyperlactatemia > 4mmol/L after fluid-challenge is also in shock – cryptic shock, to be more precisely.
I too survived SEPSIS… http://www.chickenscratchonacocktailnapkin.com/archives/2013/03/one_of_the_longest_most_diffic.html