In this post, I review the 2021 Surviving Sepsis Guidelines Update podcast notes By Dr Brit Long From EM Quick Hits 36. This section of the podcast is from 0:38 – 11:58. This is the link to the complete podcast.
A. EM Quick Hits 36 – Surviving Sepsis, Angle Closure Glaucoma, Bougies, Frostbite, Hot/Altered Patient, Central Cord Syndrome. Emergency Medicine Cases. March 2022. https://emergencymedicinecases.com/em-quick-hits-march-2022/. Accessed 3-6-2022.
Here are the notes from the above section of the podcast.
Surviving Sepsis Campaign: 2021 Updates relevant to EM
Screening for Sepsis
- New guidelines recommend against using qSOFA as a single screening agent
- Commentary: NEWS score is likely a better single screening tool that is easy to use and can be done at triage
- Guidelines now only suggest rather than recommend using 30 cc/kg of IV crystalloid within the first 30 minutes of resuscitation
- Balanced crystalloids such as Plasmalyte and Lactated Ringer’s recommended as a first line over normal saline
- In most patients, norepinephrine is the first-line vasopressor, followed by vasopressin, then epinephrine
- In patients with cardiac dysfunction, use norepinephrine as first line then dobutamine or epinephrine alone
- In septic shock resistant to vasopressors, guidelines now support using IV hydrocortisone
- Monitoring resuscitation
- Use dynamic parameters (e.g. passive leg raise, stroke volume/pulse pressure variation, ultrasound) rather than using static parameters
- Point-of-care ultrasound can be used to assess volume status (IVC, B-lines, cardiac activity)
- For patients in septic shock, target a MAP of 65 mmHg
- Adjunctive markers: use capillary refill, lactate to guide resuscitation
- Antimicrobial therapy
- In patients with possible sepsis without shock, consider investigating for other causes for up to 3 hours before starting antimicrobial therapy (adjusted from 1 hour from previous guidelines)
- Choice of antimicrobials in the empiric phase
- High risk of multi-drug resistant organisms: 2 agents with gram negative coverage
- Low risk of multi-drug resistant organisms: 1 agent with gram negative coverage
- High risk of MRSA: provide coverage for MRSA (eg. vancomycin)
- No risk factors for MRSA: no routine MRSA coverage
- IV vitamin C is not recommended in septic shock
Airway and ventilation
- High-flow nasal cannula (HFNC): in sepsis-induced hypoxemic respiratory failure, HFNC is recommended over non-invasive positive pressure ventilation
- Intubation: low tidal volume strategy and upper plateau pressure of 30 cm H2O; in ARDS, consider using higher PEEP
- V-V ECMO can be considered if conventional mechanical ventilation fails
Episode 122 Sepsis and Septic Shock – What Matters from EM Cases Course with Sara Gray
- 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 Nov 1;49(11):e1063-e1143.
- Evans L, Rhodes A, Alhazzani W, et al. Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):1974-1982.