Sepsis

Special Articles

Surviving Sepsis Campaign guidelines for management of severe
sepsis and septic shock
R. Phillip Dellinger, MD; Jean M. Carlet, MD; Henry Masur, MD; Herwig Gerlach, MD, PhD;
Thierry Calandra, MD; Jonathan Cohen, MD; Juan Gea-Banacloche, MD, PhD; Didier Keh, MD;
John C. Marshall, MD; Margaret M. Parker, MD; Graham Ramsay, MD; Janice L. Zimmerman, MD;
Jean-Louis Vincent,MD, PhD; Mitchell M. Levy, MD; for the Surviving Sepsis Campaign Management
Guidelines Committee
Sponsoring Organizations: American Association of Critical-Care Nurses, American College of Chest Physicians, American
College of Emergency Physicians, American Thoracic Society, Australian and New Zealand Intensive Care Society,
European Society of Clinical Microbiology and Infectious Diseases,European Society of Intensive Care Medicine, European
Respiratory Society, International Sepsis Forum, Society of Critical Care Medicine, Surgical Infection Society.
Objective: In 2003, critical care and infectious disease experts
representing 11 international organizations developed management
guidelines for severe sepsis and septic shock that would be of
practical use for the bedside clinician,under the auspices of the
Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.
Design: The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based
discussion among subgroups and among the entire committee.
Methods: Weused a modified Delphi methodology for grading
recommendations, built on a 2001 publication sponsored by the
International Sepsis Forum. We undertook a systematic review of the
literature graded along five levels to create recommendation grades
from A to E, with A being the highest grade. Pediatric considerations
were provided to contrast adult and pediatric management.
Results: Keyrecommendations, listed by category and not by
hierarchy, include early goal-directed resuscitation of the septic
patient during the first 6 hrs after recognition; appropriate diagnostic
studies to ascertain causative organisms before starting antibiotics;
early administration of broad-spectrum antibiotic therapy; reassessment of antibiotic therapy with microbiology and clinical data to
narrow coverage,when appropriate; a usual 7–10 days of antibiotic
therapy guided by clinical response; source control with attention to
the method that balances risks and benefits; equivalence of crystalloid and colloid resuscitation; aggressive fluid challenge to restore
mean circulating filling pressure; vasopressor preference for norepinephrine and dopamine; cautious use of vasopressin pending furtherstudies; avoiding low-dose dopamine administration for renal protection; consideration of dobutamine inotropic therapy in some clinical
situations; avoidance of supranormal oxygen delivery as a goal of
therapy; stress-dose steroid therapy for septic shock; use of recombinant activated protein C in patients with severe sepsis and high risk

for death; with resolution of tissue hypoperfusion and in theabsence
of coronary artery disease or acute hemorrhage, targeting a hemoglobin
of 7–9 g/dL; appropriate use of fresh frozen plasma and platelets; a low
tidal volume and limitation of inspiratory plateau pressure strategy for
acute lung injury and acute respiratory distress syndrome; application of
a minimal amount of positive end-expiratory pressure in acute lung
injury/acute respiratorydistress syndrome; a semirecumbent bed position unless contraindicated; protocols for weaning and sedation/analgesia, using either intermittent bolus sedation or continuous infusion sedation with daily interruptions/lightening; avoidance of neuromuscular
blockers, if at all possible; maintenance of blood glucose 7.15; use of deep vein thrombosis/stress ulcer prophylaxis; and
consideration of...