Sepsis: Updated Guidelines

The Surviving Sepsis Campaign has released it’s new guidelines for the management of sepsis (Fulltext PDF available here)

So what is new and relevant for paramedics?  Read on to find out.

Well, sadly, not much is new for paramedics.  I’ll summarise a few points for adults.

  • Diagnostic criteria:  No real change to clinical criteria for identification of sepsis. Some lab values like procalcitonin are different/new, but not relevant to most paramedics.
  • Initial resuscitation in sepsis and sepsis induced hypotension should be with crystalloids.  Resuscitation should be aggressive (minimum of 30ml/kg of crystalloids as an initial challenge, possibly more/faster in some patients)
  • Albumin may be used if patients need large volumes of crystalloids.
  • Starches should not be used (greater mortality in patients resuscitated with starches)
  • Noradrenaline is the pressor of choice.  Adrenaline may be added or substituted.
  • Dopamine should be avoided except in a very select patient population.  “Renal Dose” dopamine should not be used (that myth has been busted anyway)
  • Initial target for resuscitation is a MAP >65mmHg (other criteria such as lactate clearance and CVP are not relevant to most paramedics.  For those lucky enough to have an iStat,  normalisation of lactate in 6 hours is the goal)
  • Steroids should not routinely be used unless hypoperfusion persists despite adequate fluid resuscitation and pressor use.
  • Antibiotic therapy should start within 1 hour of identification of sepsis, but only after cultures are drawn.
  • Ventilation:  If the patient is intubated, tidal volumes of 6ml/kg should be targeted.
  • PEEP must be used to avoid alveolar collapse.  High levels of PEEP may be required, but a plateau pressure of <30cmH2O is preferable.
  • Elevate the stretcher head 35 degrees.
  • Aim for minimal use of sedation and avoid neuromuscular blockade if possible.

Ok, so those are probably the main points.  Nothing really new in terms of initial resuscitation, just the reinforcement that it should be early, aggressive and with crystalloids.  I’m not personally aware of any services using hetastarch or the like (I believe they are expensive) but if you are, don’t use them.

Noradrenaline is not that common on ambulances down-under, although some air services definitely use it.  However, not to worry as adrenaline can be substituted and doesn’t seem to be inferior.  There are some concerns with increased lactate production and decreased splanchnic blood flow, but this does not seem to translate into worse outcomes in humans.  Peripheral administration is acceptable until central access can be gained.  Try to use a large, proximal vein though.

Stress does steroid use seems to come and go.  They have entered and exited my protocols a number of times in the last few years as consensus has shifted.  The recommendation for steroids when they are used is for hydrocortisone.  I’m not sure what this means for those of us carrying dexamethasone.  A couple of studies (here and here) suggest a decrease in mortality and a decrease in length of hospital stay when low dose dex is used.

Early antibiotics post cultures remains a constant.  I am still vexed by the question of whether we should be giving any in the field.  Our service carries ceftriaxone which seems a reasonable choice, and transport times from rural areas can often be well in excess of 1 hour.  I’m not sure whether we should be going ahead with cef, or waiting.  I shall try to find an answer to this, but if anyone has any ideas, please comment.

None of the ventilation strategies should be particularly different for paramedics.  There are recommendations for trying prone ventilation, but this is not practical in an ambulance.  All the rest of the recommendations should really be followed with most or all of your intubated patients anyway.  I have a post on ventilation in the pipeline that will discuss these things, so stay tuned.

Paediatrics

For paediatric sepsis patients:

  • In respiratory distress or hypoxemia use high flow nasal cannula delivered O2.
  • Fluid resuscitate aggressively (boluses of 20ml/kg over 5-10 minutes, possibly exceeding 60mls/kg unless rales are present)
  • Aim for normal vital signs or capilaary refill <2 seconds.
  • Do not delay the use of inotropes in patients who do not respond to fluid.  Delay results in increased mortality.  Peripheral IV or IO routes are ok.
  • Timely steroid use in catecholamine resistant paeds is encouraged.

When you break this down for adults or kids it is really just a matter of optimising the ABCs.  There are some other strategies involved but many of these are not entirely relevant to paramedics.  As such sepsis is something we should be able to address with a fair degree of success.  Whilst the literature regarding prehospital specific intervention is rather sparse I think this is a condition where the early goals for treatment, and largely the means of achieving these goals, should be consistent with in hospital treatment.

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