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

Intensive Care Medicine, Год журнала: 2021, Номер 47(11), С. 1181 - 1247

Опубликована: Окт. 2, 2021

Язык: Английский

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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

Critical Care Medicine, Год журнала: 2021, Номер 49(11), С. e1063 - e1143

Опубликована: Окт. 4, 2021

INTRODUCTION Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection (1). and septic shock are major healthcare problems, impacting millions of people around the world each year killing between one in three six those it affects (2–4). Early identification appropriate management initial hours after development sepsis improve outcomes. The recommendations this document intended provide guidance for clinician caring adult patients with or hospital setting. Recommendations from these guidelines cannot replace clinician's decision-making capability when presented unique patient's clinical variables. These reflect best practice (Table 1). TABLE 1. - Table Current Changes From Previous 2016 2021 Recommendation Strength Quality Evidence For hospitals health systems, we recommend using performance improvement program sepsis, including screening acutely ill, high-risk standard operating procedures treatment. Strong , moderate-quality evidence (for screening) Changed Best statement "We that systems have patients." very low-quality procedures) 2. We against qSOFA compared SIRS, NEWS, MEWS as single-screening tool shock. NEW 3. adults suspected having suggest measuring blood lactate. Weak low quality INITIAL RESUSCITATION 4. medical emergencies, treatment resuscitation begin immediately. 5. induced hypoperfusion at least 30 mL/kg IV crystalloid fluid should be given within first 3 hr resuscitation. Weak, DOWNGRADE sepsis-induced hypoperfusion, hr" 6. shock, dynamic measures guide resuscitation, over physical examination, static parameters alone. 7. guiding decrease serum lactate elevated level, not 8. capillary refill time an adjunct other perfusion. MEAN ARTERIAL PRESSURE 9. on vasopressors, target mean arterial pressure (MAP) 65 mm Hg higher MAP targets. ADMISSION TO INTENSIVE CARE 10. who require ICU admission, admitting 6 hr. INFECTION 11. but unconfirmed infection, continuously re-evaluating searching alternative diagnoses discontinuing empiric antimicrobials if cause illness demonstrated strongly suspected. 12. possible high likelihood administering immediately, ideally 1 recognition. (Septic shock) CHANGED previous: administration intravenous initiated soon recognition hour both a) b) without shock" (Sepsis strong recommendation moderate 13. rapid assessment infectious versus noninfectious causes acute illness. 14. time-limited course investigation concern persists, was recognized. 15. deferring while continuing closely monitor patient. 16. procalcitonin plus evaluation decide start antimicrobials, 17. risk MRSA, MRSA coverage coverage. broad-spectrum therapy more presenting cover all likely pathogens (including bacterial potentially fungal viral coverage." 18. coverage, 19. multidrug resistant (MDR) organisms, two gram-negative agent. 20. agents treatment, 21. double once causative pathogen susceptibilities known. 22. antifungal no therapy. 23. use " 24. make antiviral agents. No 25. prolonged infusion beta-lactams maintenance (after bolus) conventional bolus infusion. 26. optimising dosing strategies based accepted pharmacokinetic/pharmacodynamic (PK/PD) principles specific drug properties. 27. rapidly identifying excluding anatomical diagnosis requires emergent source control implementing any required intervention medically logistically practical. 28. prompt removal intravascular access devices vascular has been established. 29. daily de-escalation fixed durations reassessment de-escalation. 30. adequate control, shorter longer duration antimicrobial 31. where optimal unclear, AND discontinue HEMODYNAMIC MANAGEMENT 32. crystalloids first-line 33. balanced instead normal saline weak evidence. either 34. albumin received large volumes crystalloids. 35. starches high-quality 36. gelatin UPGRADE gelatins resuscitating shock." 37. norepinephrine agent vasopressors. Dopamine. High-quality Vasopressin. Moderate-quality Epinephrine. Low Selepressin. Angiotensin II. Very 38. inadequate levels, adding vasopressin escalating dose norepinephrine. 39. levels despite vasopressin, epinephrine. 40. terlipressin. 41. cardiac persistent volume status pressure, dobutamine epinephrine 42. levosimendan. 43. invasive monitoring noninvasive monitoring, practical resources available. 44. starting vasopressors peripherally restore rather than delaying initiation until central venous secured. 45. There insufficient restrictive liberal 24 still signs depletion VENTILATION 46.There conservative oxygen targets hypoxemic respiratory failure. 47. failure, flow nasal ventilation. 48. ventilation comparison 49. ARDS, tidal strategy (6 mL/kg), (> 10 mL/kg). 50. severe upper limit goal plateau pressures cm H2O, pressures. 51. PEEP lower PEEP. 52. failure (without ARDS), 53. moderate-severe traditional recruitment maneuvers. 54. When maneuvers, incremental titration/strategy. 55. prone greater 12 daily. 56. intermittent NMBA boluses, continuous 57. Veno-venous (VV) ECMO mechanical fails experienced centers infrastructure place support its use. ADDITIONAL THERAPIES 58. ongoing requirement vasopressor corticosteroids. hydrocortisone treat able hemodynamic stability (see goals Initial Resuscitation). If achievable, 200 mg/day." 59. polymyxin B hemoperfusion. regarding purification techniques" 60. techniques. 61. (over liberal) transfusion strategy. 62. immunoglobulins. 63. factors gastrointestinal (GI) bleeding, stress ulcer prophylaxis. 64. pharmacologic thromboembolism (VTE) prophylaxis unless contraindication such exists. 65. molecular weight heparin unfractionated VTE 66. prophylaxis, addition pharmacological 67. In AKI, renal replacement 68. definitive indications therapy, 69. initiating insulin glucose level ≥ 180mg/dL (10 mmol/L). 70. vitamin C. 71. hypoperfusion-induced lactic acidemia, sodium bicarbonate hemodynamics reduce requirements. 72. metabolic acidemia (pH ≤ 7.2) kidney injury (AKIN score 2 3), 73. can fed enterally, early (within 72 hr) enteral nutrition. LONG-TERM OUTCOMES GOALS OF 74. discussing care prognosis families discussion. 75. addressing late (72 later). 76. there standardized criterion trigger 77. palliative (which may include consultation judgement) integrated into plan, appropriate, address patient family symptoms suffering. 78. routine formal judgement. 79. survivors their families, referral peer groups referral. 80. handoff process critically important information transitions process. 81. structured usual processes. 82. economic social housing, nutritional, financial, spiritual support), referrals available meet needs. 83. offering written verbal education (diagnosis, post-ICU/post-sepsis syndrome) prior discharge follow-up 84. team opportunity participate shared decision making post-ICU planning ensure plans acceptable feasible. 85. critical transition program, care, upon transfer floor. 86. reconciling medications discharge. 87. about stay, related diagnoses, treatments, common impairments summary. 88. developed new impairments, clinicians manage long-term sequelae. 89. post-hospital follow-up. 90. cognitive 91. physical, cognitive, emotional problems 92. post-critical 93. receiving > 48hr stay hr, rehabilitation program. (References 5–24 referred Methodology section which accessed Supplemental Digital Content: Methodology.) SCREENING EARLY TREATMENT Screening Patients With Septic Shock recommendation, screening. procedures. Rationale programs generally consist screening, education, measurement bundle performance, outcomes, actions identified opportunities (25,26). Despite some inconsistency, meta-analysis 50 observational studies effect showed were associated better adherence bundles along reduction mortality (OR, 0.66; 95% CI, 0.61–0.72) (27). components did appear presence included metrics. tools designed promote manual methods automated electronic record (EHR). wide variation diagnostic accuracy most poor predictive values, although improvements processes (28–31). A variety variables used systemic inflammatory syndrome (SIRS) criteria, vital signs, quick Sequential Organ Failure Score (qSOFA) Assessment (SOFA) National Warning (NEWS), Modified (MEWS) (26,32). Machine learning tools, 42,623 seven predicting acquired pooled area under curve (SAUROC) (0.89; 0.86−0.92); sensitivity (81%; 80−81), specificity (72%; 72−72) machine SAUROC SIRS (0.70), (0.50), SOFA (0.78) (32). various locations, in-patient wards, emergency departments, ICUs (28–30,32). analysis RCTs demonstrate benefit active (RR, 0.90; 0.51−1.58) (33–35). However, they component timely intervention. Standard set practices specify preferred circumstances (36). procedures, initially specified Goal Directed Therapy evolved "usual care" includes approach bundle, identification, lactate, cultures, antibiotics, fluids (37). study examined association implementation state-mandated protocols, compliance, mortality. retrospective cohort 1,012,410 admissions 509 United States before (27 months) (30 New York state regulations, concurrent population four states (38). comparative interrupted series, compliance achieving successfully. Lower resource countries experience different effect. Sub-Saharan Africa found 1.26; 1.00−1.58) decreased (adjusted hazard ratio [HR]; 0.55−0.98) (39). single uses predict death known sepsis: Glasgow Coma < 15, rate 22 breaths/min systolic 100 Hg. present simultaneously, considered positive. Data Third International Consensus Conference Definitions predictor outcome performed (5). Since numerous investigated potential (40–42). results contradictory usefulness. Studies shown less sensitive criteria (40–43). Neither nor ideal bedside needs understand limitations each. original derivation study, authors only 24% infected had 3, accounted 70% outcomes Similar findings also comparing warning (NEWS) (44). Although positive alert possibility settings; qSOFA, panel issued tool.

Язык: Английский

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Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU

Critical Care Medicine, Год журнала: 2016, Номер 45(1), С. 103 - 128

Опубликована: Дек. 17, 2016

To provide clinicians with evidence-based strategies to optimize the support of family critically ill patients in ICU. We used Council Medical Specialty Societies principles for development clinical guidelines as framework guideline development. assembled an international multidisciplinary team 29 members expertise development, evidence analysis, and family-centered care revise 2007 Clinical Practice Guidelines patient-centered conducted a scoping review qualitative research that explored Thematic analyses were Population, Intervention, Comparison, Outcome question Patients families validated importance interventions outcomes. then systematic using Grading Recommendations, Assessment, Development Evaluations methodology make recommendations practice. Recommendations subjected electronic voting pre-established thresholds. No industry funding was associated The yielded 683 studies; 228 thematic analysis search 4,158 reports after deduplication 76 additional studies added from alerts hand searches; 238 met inclusion criteria. made 23 moderate, low, very low level on topics of: communication members, presence, support, consultations ICU operational environmental issues. future work-tools translation into These identify base best practices All weak, highlighting relative nascency this field most effective improve important aspect care.

Язык: Английский

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Burn injury

Nature Reviews Disease Primers, Год журнала: 2020, Номер 6(1)

Опубликована: Фев. 13, 2020

Burn injuries are under-appreciated that associated with substantial morbidity and mortality. injuries, particularly severe burns, accompanied by an immune inflammatory response, metabolic changes distributive shock can be challenging to manage lead multiple organ failure. Of great importance is the injury affects not only physical health, but also mental health quality of life patient. Accordingly, patients burn cannot considered recovered when wounds have healed; instead, leads long-term profound alterations must addressed optimize life. care providers are, therefore, faced a plethora challenges including acute critical management, rehabilitation. The aim this Primer give overview update about care, raise awareness ongoing stigmata injuries.

Язык: Английский

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European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care

Intensive Care Medicine, Год журнала: 2015, Номер 41(12), С. 2039 - 2056

Опубликована: Окт. 13, 2015

Язык: Английский

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Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults

Critical Care Medicine, Год журнала: 2018, Номер 47(1), С. 3 - 14

Опубликована: Окт. 18, 2018

Objective: Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance patient-centered outcomes in critical care. Design: Prospective, multicenter, cohort study from a national quality improvement collaborative. Setting: 68 academic, community, federal ICUs collected data during 20-month period. Patients: 15,226 adults with at least one day. Interventions: defined (our main exposure) two ways: 1) complete (patient received every eligible element on any given day) 2) proportional (percentage of elements performed day). explored association three sets outcomes: patient-related (mortality, hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), system-related (ICU readmission, discharge destination). All models were adjusted for minimum 18 priori determined potential confounders. Measurements Results: Complete was associated lower likelihood seven death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17–0.62), next-day mechanical ventilation odds ratio [AOR], 0.28; 0.22–0.36), coma (AOR, 0.35; 0.22–0.56), delirium 0.60; 0.49–0.72), physical use 0.37; 0.30–0.46), readmission 0.54; 0.37–0.79), facility other than home 0.64; 0.51–0.80). There consistent dose-response higher improvements each above-mentioned clinical (all p < 0.002). Significant pain more frequently reported as proportionally increased ( = 0.0001). Conclusions: showed significant clinically meaningful survival, use, restraint-free care, readmissions, post-ICU disposition.

Язык: Английский

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European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care

Intensive Care Medicine, Год журнала: 2021, Номер 47(4), С. 369 - 421

Опубликована: Март 25, 2021

Язык: Английский

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The Stanford Hall consensus statement for post-COVID-19 rehabilitation

British Journal of Sports Medicine, Год журнала: 2020, Номер 54(16), С. 949 - 959

Опубликована: Май 31, 2020

The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the system, evidence indicates multisystem disease which is frequently often results in death. Long-term sequelae of are unknown, but from previous CoV outbreaks demonstrates impaired pulmonary physical function, reduced quality life emotional distress. Many survivors who require critical care may develop psychological, cognitive impairments. There clear need for guidance on rehabilitation survivors. This consensus statement was developed by an expert panel fields rehabilitation, sport exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology specialist pain, working at Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised following domains relating to requirements: pulmonary, cardiac, SEM, musculoskeletal, neurorehabilitation medical. A chair combined recommendations generated within teams. writing committee prepared accordance with appraisal guidelines research evaluation criteria, grading all levels evidence. Authors scored their level agreement each recommendation scale 0–10. Substantial (range 7.5–10) reached 36 chaired meeting that attended authors. provides overarching framework assimilating likely requirements multidisciplinary post illness, target population active individuals, including military personnel athletes.

Язык: Английский

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The immune system's role in sepsis progression, resolution, and long‐term outcome

Immunological Reviews, Год журнала: 2016, Номер 274(1), С. 330 - 353

Опубликована: Окт. 26, 2016

Summary Sepsis occurs when an infection exceeds local tissue containment and induces a series of dysregulated physiologic responses that result in organ dysfunction. A subset patients with sepsis progress to septic shock, defined by profound circulatory, cellular, metabolic abnormalities, associated greater mortality. Historically, sepsis‐induced dysfunction lethality were attributed the complex interplay between initial inflammatory later anti‐inflammatory responses. With advances intensive care medicine goal‐directed interventions, early 30‐day mortality has diminished, only steadily escalate long after “recovery” from acute events. As so many survivors succumb persistent, recurrent, nosocomial, secondary infections, investigators have turned their attention long‐term alterations cellular immune function. clearly alters innate adaptive for sustained periods time clinical recovery, suppression, chronic inflammation, persistence bacterial representing such alterations. Understanding sepsis‐associated cell defects correlate mortality, more investigations centered on potential modulatory therapy improve patient outcomes. These efforts are focused defining effectively reversing persistent

Язык: Английский

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Estimated Global Proportions of Individuals With Persistent Fatigue, Cognitive, and Respiratory Symptom Clusters Following Symptomatic COVID-19 in 2020 and 2021

JAMA, Год журнала: 2022, Номер 328(16), С. 1604 - 1604

Опубликована: Окт. 10, 2022

Some individuals experience persistent symptoms after initial symptomatic SARS-CoV-2 infection (often referred to as Long COVID).To estimate the proportion of males and females with COVID-19, younger or older than 20 years age, who had COVID in 2020 2021 their symptom duration.Bayesian meta-regression pooling 54 studies 2 medical record databases data for 1.2 million (from 22 countries) infection. Of studies, 44 were published 10 collaborating cohorts (conducted Austria, Faroe Islands, Germany, Iran, Italy, Netherlands, Russia, Sweden, Switzerland, US). The participant derived from (10 501 hospitalized 42 891 nonhospitalized individuals), cohort 526 1906), US electronic (250 928 846 046). Data collection spanned March January 2022.Symptomatic infection.Proportion at least 1 3 self-reported clusters (persistent fatigue bodily pain mood swings; cognitive problems; ongoing respiratory problems) months 2021, estimated separately aged by sex both sexes age.A total included (mean 4-66 years; males, 26%-88%). In modeled estimates, 6.2% (95% uncertainty interval [UI], 2.4%-13.3%) experienced including 3.2% UI, 0.6%-10.0%) swings, 3.7% 0.9%-9.6%) problems, 2.2% 0.3%-7.6%) problems adjusting health status before comprising an 51.0% 16.9%-92.4%), 60.4% 18.9%-89.1%), 35.4% 9.4%-75.1%), respectively, cases. more common women (10.6% [95% 4.3%-22.2%]) men (5.4% 2.2%-11.7%]). Both age be affected 2.8% 0.9%-7.0%) infections. mean cluster duration was 9.0 7.0-12.0 months) among 4.0 3.6-4.6 individuals. Among infection, 15.1% 10.3%-21.1%) continued 12 months.This study presents estimates

Язык: Английский

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