Introduction
Results and recommendations
Topic | Recommendation | Relationship to other guidelines |
---|---|---|
Corticosteroids | We suggest intravenous hydrocortisone (200 mg per day, or equivalent dose of another corticosteroid) in adult patients with septic shock, who despite both adequate fluid resuscitation and vasopressor support remain hemodynamically unstable (low quality of evidence)
Remarks Hemodynamic instability may be defined by systolic blood pressure less than 90 mmHg for more than 1 h despite adequate fluid and vasopressor therapy. Hydrocortisone can be administered by continuous infusion or boluses for 5–7 days, or up to the weaning of vasopressor therapy, followed by tapering of the dose as guided by the clinical response. Bolus dosing does not require an infusion pump and is therefore more feasible. Dosing and pharmacokinetic properties of various corticosteroids are presented in supplementary Table 3 | Same as SSC [1] |
Sedation | The group believes that continuous or intermittent sedation should be minimized in mechanically ventilated sepsis patients, targeting specific titration end points from sedation scales (ungraded good practice statement)
Remarks Management of intravenous sedation for mechanically ventilated septic patients requires attentive nursing and medical expertise and sufficient staffing to handle risks of agitated delirium and device removal. Adequate pain control should be attained in all patients where necessary (analgesia-first sedation), and lighter sedation targets aimed for in general | Same as SSC [1] |
Use of neuromuscular blocking agents | We suggest neuromuscular blockade for a maximum of 2 days in mechanically ventilated septic patients with ARDS and PaO2/FiO2 ratio <150 mmHg (SpO2/FiO2 ratio <190) (moderate quality of evidence)
Remarks Attentive nursing and medical care are essential requirements to care for patients on neuromuscular blockade. We suggest monitoring the depth of blockade through train-of-four-stimulation when neuromuscular blocking agents are administered by continuous infusion. The safety of continuous neuromuscular blockade in the absence of capnography or arterial blood gas analysis is not established | Same as SSC [1] |
The group believes that neuromuscular blocking agents should not be administered when sedation and analgesia can prevent patient–ventilator dyssynchrony (ungraded good practice statement) | Not addressed | |
The group believes that sedation and analgesia should be used before and during neuromuscular blockade to achieve deep sedation (ungraded good practice statement) | Same as recent guideline [14] | |
Venous thromboembolism prophylaxis | We recommend UFH or LMWH to prevent VTE in patients with no contraindications to these medications (moderate quality of evidence) | Same as SSC [1] |
We recommend LMWH over UFH in patients with no contraindications to LMWH, assuming availability of both medications (moderate quality of evidence) | Same as SSC [1] | |
We suggest mechanical VTE prophylaxis when UFH and LMWH are contraindicated or unavailable (low quality of evidence)
Remarks Mechanical prophylaxis includes GCS and IPC devices; GCS may be less effective that IPC devices but are far more likely to be available | Same as SSC [1] | |
We suggest a combination of mechanical and pharmacologic prophylaxis if possible (low quality of evidence)
Remarks Same as for previous recommendation | Same as SSC [1] | |
The group believes that VTE prophylaxis should be continued until the patient is fully mobile (ungraded good practice statement) | Similar to recent guideline [8] | |
Stress ulcer prophylaxis | We recommend that stress ulcer prophylaxis be given to patients with sepsis or septic shock with risk factors for GI bleeding (low quality of evidence)
Remarks Risk factors for GI bleeding include mechanical ventilation for ≥48 h, coagulopathy, renal replacement therapy, liver disease, multiple comorbidities, and higher organ failure score | Same as SSC [1] |
We suggest that either PPIs or H2RAs be used for stress ulcer prophylaxis (low quality of evidence) | Same as SSC [1] | |
Blood glucose management | We recommend a protocolized approach to blood glucose management in ICU patients with sepsis, commencing when blood glucose is >180 mg/dL (>10 mmol/L), with a target blood glucose value of ≤180 mg/dL (≤10 mmol/L) (high quality of evidence) | Same as SSC [1] |
The group believes that blood glucose levels obtained with finger stick blood glucose tests be interpreted with caution, as these measurements may not accurately estimate arterial blood or plasma glucose values (ungraded good practice statement) | Same as SSC [1] | |
The group believes that a simple protocol for blood glucose management should be implemented for all critically ill patients, but only if frequent blood glucose monitoring is feasible, safe, and affordable (ungraded good practice statement) | Same as recent guideline [7] | |
The group believes that insulin should be administered intravenously rather than subcutaneously in ICU patients with sepsis (ungraded good practice statement) | Not addressed | |
Enteral feeding | We suggest early enteral feeding as tolerated in patients with sepsis and septic shock (low quality of evidence)
Remarks Additional considerations include starting oral or enteral intake within 24–48 h in adequately resuscitated and hemodynamically stable patients; taking measures to reduce the risk of aspiration; and being aware of the refeeding syndrome in the first few days following enteral nutrition initiation in severely malnourished or starved patients. The risk of aspiration may be increased in enterally fed non-intubated comatose patients with inadequate nursing supervision | Same as SSC [1] |
We suggest either early trophic/hypocaloric or early full enteral feeding in critically ill patients with sepsis or septic shock; if trophic/hypocaloric feeding is the initial strategy, then feeds should be advanced according to patient tolerance (moderate quality of evidence)
Remarks We suggest advancing feeds over the first week of ICU stay and note that many patients in low-resource ICUs would be expected to be at high nutrition risk/malnourished, and therefore likely to benefit from full enteral feeding | Same as SSC [1] | |
We suggest establishing the energy and protein requirements to determine the goals of nutrition therapy using weight-based equations (low quality of evidence) | Consistent with recent guideline [15] | |
We suggest a feeding protocol to optimize delivery of EN (moderate quality of evidence) | Consistent with recent guideline [15] | |
Renal replacement therapy | We suggest that patients with sepsis-induced AKI requiring renal replacement therapy be supported with PD in centers with no current access to renal replacement therapy (very low quality of evidence; case series only)
Remarks In centers with functioning IHD programs, we suggest that this modality continue to be used | Not addressed |
Fluid administration | We suggest conservative fluid administration in patients with sepsis who are not in shock (low quality of evidence; indirect evidence from trials in other forms of critical illness)
Remarks Conservative fluid administration requires development of a protocol (e.g., incorporating shock, oliguria, jugular venous pressure, capillary refill; see supplement for reference to a sample resuscitation protocol incorporating some clinical signs). The protocol should specify the timing of re-evaluation between fluid interventions determined by patient stability. No de-resuscitation protocol has been tested in low-resource ICUs. The role of pressure monitoring via a central venous catheter to direct resuscitation and de-resuscitation is contentious. Conservative fluid administration may be associated with higher levels of blood urea nitrogen, bicarbonate, hemoglobin, and albumin | Not addressed |