1. R. Phillip Dellinger, MD, MCCM, FCCP
Acting Chair & Chief of Department of Medicine
Head, Division of Critical Care Medicine
Cooper University Hospital
Camden, New Jersey
Professor of Medicine Cooper Medical School of Rowan University

2. What’s new with the 2012 guidelines and associated changes in the database
R. Phillip Dellinger MD, MCCM
Christa A. Schorr RN, MSN, FCCM
Cooper Medical School Rowan University
Cooper University Hospital
Camden, NJ

3. Potential Conflicts of Interest
Neither has direct or indirect potential financial conflict of interest as to any material presented in this presentation
As to potential intellectual conflict of interest both hold leadership positions in Surviving Sepsis Campaign

4. management of severe sepsis and septic shock: 2012
Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock: 2012
R. Phillip Dellinger, Mitchell M. Levy, Andrew Rhodes, Djillali Annane, Herwig Gerlach, Steven M. Opal, Jonathan E. Sevransky, Charles L. Sprung, Ivor S. Douglas, Roman Jaeschke, Tiffany M. Osborn, Mark E. Nunnally, Sean R. Townsend, Konrad Reinhart, Ruth M. Kleinpell, Derek C. Angus, Clifford S. Deutschman, Flavia R. Machado,Gordon D. Rubenfeld, Steven A. Webb, Richard J. Beale, Jean-Louis Vincent, Rui Moreno, and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup.
Crit Care Med 2013; 41:
Intensive Care Medicine 2013; ..

5. Currently Funded with a Gordon and Betty Moore Foundation Grant No direct or indirect industry support for guidelines revision

6. Grading Quality of Evidence GRADE System
A- high quality
B- intermediate
C- low
D- very low
Case series or expert opinion
Upgrade capability
Ungraded (UG) recommendation

7. Grading Strength of Recommendation GRADE System
1- strong recommendation
We recommend
2- weak recommendation
We suggest

8. Early Screening and a Performance Improvement Program

9. Antibiotic Therapy
We recommend that intravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock (1B) and severe sepsis without septic shock (1C).
(Best Practice versus Stand of Care)

10. Resuscitation of Sepsis Induced Tissue Hypoperfusion
Recommend MAP 65 mm Hg

11. FLUID THERAPY

12. Fluid therapy
We recommend crystalloids be used in the initial fluid resuscitation of severe sepsis (Grade 1B).

13. Fluid therapy
We suggest the use of albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids (Grade 2C).

14. Fluid challenge Initial fluid challenge in sepsis-induced tissue
hypoperfusion (hypotension or elevated lactate)
A minimum of 30ml/kg of crystalloids
(a portion of this may be albumin equivalent). (1B)

15. Vasopressors

16. Vasopressors
We recommend norepinephrine as the first choice vasopressor (Grade 1 B).

17. Vasopressors
2. We suggest epinephrine (added to and potentially substituted for norepinephrine) when an additional agent is needed to maintain blood pressure (Grade 2B).

18. Vasopressors
3. Vasopressin .03 units/min can be added to norepinephrine with the intent of raising MAP to target or decreasing or decreasing norepinephrine dosage. (UG)

19. Phenylephrine
Pure vasopressor and in general not recommended

20. Sepsis Induced Tissue Hypoperfusion (Recommend Quantitative Resuscitation)
Requirement for vasopressors after fluid challenge or
Lactate ≥ 4 mg/dL
The initial resuscitation of the patient is of utmost importance and frequently occurs in the emergency department or on hospital wards.

21. Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion
Recommend
Insertion central venous catheter
Central venous pressure: 8–12 mm Hg
Higher with altered ventricular compliance or increased intrathoracic pressure
Grade 1C

22. Arterial Systolic Pressure Variation
Parry-Jones, et al. Int J Respir Crit Care Med 2003;2:67

23. Effect on Stroke Volume
Part A
Once the initial Arterial thermodilution Cardiac Output is obtained the system is now calibrated to do the PCCO measurement.
PCCO is the measurement of Continuous Cardiac Output which is measured beat to beat.
How many of you look at the arterial line wave form to determine if the patient has adequate vascular volume ?
Tall narrow and peaked waveform may be an indication of possible hypovolemia.
Wide and Fat may be an indication of low vascular volume.
The truth is that the area under the arterial wave form is proportional to stroke volume. We determine the stroke volume and multiply it buy the heart rate and get Cardiac Output. t

24. Effect on Stroke Volume

25. Effect on Cardiac Filling

26. Initial Resuscitation of Sepsis Induced Tissue Hypoperfusion
Recommend
Insertion central venous catheter
ScvO2 saturation (SVC)  70%
Grade 1C

27. Lactate Clearance In patients with elevated lactate levels as a
marker of tissue hypoperfusion we suggest
targeting resuscitation to normalize lactate as
rapidly as possible (grade 2C).