Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021

Key points

• Sepsis and septic shock are medical emergencies: treatment and resuscitation should begin immediately, hospitals should run sepsis performance improvement programmes with screening, and qSOFA should not be used as a single screening tool.
• For possible septic shock or a high likelihood of sepsis, antimicrobials should be given immediately, ideally within 1 hour; for possible sepsis without shock, a rapid investigation is suggested, with antimicrobials within 3 hours if concern for infection persists.
• For sepsis-induced hypoperfusion or septic shock, at least 30 mL/kg of IV crystalloid within the first 3 hours is suggested; crystalloids are first-line, balanced crystalloids are suggested over saline, and starches should not be used.
• In septic shock, an initial mean arterial pressure target of 65 mm Hg and norepinephrine as first-line vasopressor are recommended; vasopressin is suggested rather than escalating norepinephrine, and IV corticosteroids with an ongoing vasopressor requirement.
• For sepsis-induced ARDS, low tidal volume ventilation (6 mL/kg), plateau pressure limit of 30 cm H2O and prone ventilation for more than 12 hours a day in moderate to severe ARDS are recommended.

Overview

The 2021 Surviving Sepsis Campaign guidelines for adults update the 2016 version and cover screening, initial resuscitation, infection management, haemodynamics, ventilation, additional therapies and long-term outcomes and goals of care. They were published simultaneously in Critical Care Medicine and Intensive Care Medicine. This overview is based on the table of current recommendations.

Resuscitation and infection

Dynamic measures, falling lactate and capillary refill time are suggested to guide resuscitation, and albumin in patients who received large volumes of crystalloids. ICU admission within 6 hours is suggested when needed, and vasopressors may be started peripherally rather than delaying for central access. Antimicrobial dosing should follow PK/PD principles, sources needing emergent control should be identified quickly, and possibly infected intravascular devices removed. Daily assessment for de-escalation, shorter courses after adequate source control and procalcitonin with clinical evaluation to guide discontinuation are suggested.

Additional therapies

A restrictive transfusion strategy and pharmacological VTE prophylaxis with low molecular weight heparin are recommended, and insulin should be started at a glucose level of 180 mg/dL (10 mmol/L) or higher. Stress ulcer prophylaxis is suggested for patients with GI bleeding risk factors, and early enteral nutrition within 72 hours. The guidelines suggest against IV immunoglobulins, IV vitamin C, polymyxin B haemoperfusion, terlipressin and levosimendan; sodium bicarbonate is suggested only with severe metabolic acidaemia (pH 7.2 or lower) and AKI stage 2 or 3. High flow nasal oxygen is suggested over noninvasive ventilation, and VV-ECMO in experienced centres when conventional ventilation fails in severe ARDS.

Goals of care and recovery

Goals of care and prognosis should be discussed with patients and families, preferably within 72 hours, and palliative care principles integrated when appropriate. For survivors, referral to peer support groups, a handoff process at transitions of care and screening for economic and social support needs are advised.

FAQ

How quickly should antibiotics be given in sepsis?

Immediately, ideally within 1 hour, for possible septic shock or a high likelihood of sepsis; within 3 hours after rapid investigation for possible sepsis without shock if infection is still suspected.

Which vasopressor is first-line in septic shock?

Norepinephrine, targeting an initial mean arterial pressure of 65 mm Hg; vasopressin is added rather than escalating norepinephrine, then epinephrine if needed.

Which fluids should be used?

Crystalloids first-line, preferably balanced crystalloids over saline, with albumin after large crystalloid volumes; starches should not be used.

Source

Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021;49(11):e1063-e1143. DOI: 10.1097/CCM.0000000000005337. Copyright © 2021 by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. All Rights Reserved. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.