Surviving Sepsis Campaign Bundle

THE SURVIVING SEPSIS CAMPAIGN BUNDLE:

2021 UPDATE


Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis and septic shock are major healthcare problems, impacting millions of people around the world each year and killing between one in three and one in six of those it affects. Early identification and appropriate management in the initial hours after the development of sepsis improve outcomes.

The recommendations in this document are intended to provide guidance for the clinician caring for adult patients with sepsis or septic shock in the hospital setting. Recommendations from these guidelines cannot replace the clinician’s decision-making capability when presented with a unique patient’s clinical variables. These guidelines are intended to reflect best practice (Table 1).

Recommendations 2021Recommendation Strength and Quality of EvidenceChanges From 2016 Recommendations
1. For hospitals and health systems, we recommend using a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients and standard operating procedures for treatment.Strong moderate-quality evidence (for screening)Changed from Best practice statement
“We recommend that hospitals and hospital systems have a performance improvement program for sepsis including sepsis screening for acutely ill, high-risk patients.”
Strong very low-quality evidence (for standard operating procedures)
2. We recommend against using qSOFA compared with SIRS, NEWS, or MEWS as a single-screening tool for sepsis or septic shock.Strong moderate-quality evidenceNEW
3. For adults suspected of having sepsis, we suggest measuring blood lactate.Weak low quality of evidence
INITIAL RESUSCITATION
4. Sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately.Best practice statement
5. For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of IV crystalloid fluid should be given within the first 3 hr of resuscitation.Weaklow quality of evidenceDOWNGRADE from Strong , low quality of evidence
“We recommend that in the initial resuscitation from sepsis-induced hypoperfusion, at least 30 mL/kg of IV crystalloid fluid be given within the first 3 hr”
6. For adults with sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation, over physical examination, or static parameters alone.Weak very low quality of evidence
7. For adults with sepsis or septic shock, we suggest guiding resuscitation to decrease serum lactate in patients with elevated lactate level, over not using serum lactate.Weak low quality of evidence
8. For adults with septic shock, we suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion.Weak low quality of evidenceNEW
MEAN ARTERIAL PRESSURE
9. For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets.Strong moderate-quality evidence
ADMISSION TO INTENSIVE CARE
10. For adults with sepsis or septic shock who require ICU admission, we suggest admitting the patients to the ICU within 6 hr.Weak low quality of evidence
INFECTION
11. For adults with suspected sepsis or septic shock but unconfirmed infection, we recommend continuously re-evaluating and searching for alternative diagnoses and discontinuing empiric antimicrobials if an alternative cause of illness is demonstrated or strongly suspected.Best practice statement
12. For adults with possible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials immediately, ideally within 1 hr of recognition.Strong low quality of evidence (Septic shock)CHANGED from previous: “We recommend that administration of intravenous antimicrobials should be initiated as soon as possible after recognition and within one hour for both a) septic shock and b) sepsis without shock”
Strong very low quality of evidence (Sepsis without shock)
strong recommendation moderate quality of evidence
13. For adults with possible sepsis without shock, we recommend rapid assessment of the likelihood of infectious versus noninfectious causes of acute illness.Best practice statement
14. For adults with possible sepsis without shock, we suggest a time-limited course of rapid investigation and if concern for infection persists, the administration of antimicrobials within 3 hr from the time when sepsis was first recognized.Weak very low quality of evidenceNEW from previous:
“We recommend that administration of IV antimicrobials should be initiated as soon as possible after recognition and within 1 hr for both a) septic shock and b) sepsis without shock”
strong recommendation moderate quality of evidence
15. For adults with a low likelihood of infection and without shock, we suggest deferring antimicrobials while continuing to closely monitor the patient.Weak very low quality of evidenceNEW from previous:
“We recommend that administration of IV antimicrobials should be initiated as soon as possible after recognition and within 1 hr for both a) septic shock and b) sepsis without shock“
strong recommendation moderate quality of evidence
16. For adults with suspected sepsis or septic shock, we suggest against using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone.Weak very low quality of evidence
17. For adults with sepsis or septic shock at high risk of MRSA, we recommend using empiric antimicrobials with MRSA coverage over using antimicrobials without MRSA coverage.Best practice statementNEW from previous:
“We recommend empiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens (including bacterial and potentially fungal or viral coverage.”
Strong recommendation moderate quality of evidence
18. For adults with sepsis or septic shock at low risk of MRSA, we suggest against using empiric antimicrobials with MRSA coverage, as compared with using antimicrobials without MRSA coverage.Weak low quality of evidenceNEW from previous:
“We recommend empiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens (including bacterial and potentially fungal or viral coverage.”
Strong recommendation moderate quality of evidence
19. For adults with sepsis or septic shock and high risk for multidrug resistant (MDR) organisms, we suggest using two antimicrobials with gram-negative coverage for empiric treatment over one gram-negative agent.Weak very low quality of evidence
20. For adults with sepsis or septic shock and low risk for multidrug resistant (MDR) organisms, we suggest against using two gram-negative agents for empiric treatment, as compared to one gram-negative agent.Weak very low quality of evidence
21. For adults with sepsis or septic shock, we suggest against using double gram-negative coverage once the causative pathogen and the susceptibilities are known.Weak very low quality of evidence
22. For adults with sepsis or septic shock at high risk of fungal infection, we suggest using empiric antifungal therapy over no antifungal therapy.Weak low quality of evidenceNEW from previous:
“We recommend empiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens (including bacterial and potentially fungal or viral coverage.”
Strong recommendation moderate quality of evidence
23. For adults with sepsis or septic shock at low risk of fungal infection, we suggest against empiric use of antifungal therapyWeak low quality of evidenceNEW from previous:
“We recommend empiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens (including bacterial and potentially fungal or viral coverage. “
Strong recommendation moderate quality of evidence
24. We make no recommendation on the use of antiviral agents.No recommendation
25. For adults with sepsis or septic shock, we suggest using prolonged infusion of beta-lactams for maintenance (after an initial bolus) over conventional bolus infusion.Weak moderate-quality evidence
26. For adults with sepsis or septic shock, we recommend optimising dosing strategies of antimicrobials based on accepted pharmacokinetic/pharmacodynamic (PK/PD) principles and specific drug properties.Best practice statement
27. For adults with sepsis or septic shock, we recommend rapidly identifying or excluding a specific anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical.Best practice statement
28. For adults with sepsis or septic shock, we recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established.Best practice statement
29. For adults with sepsis or septic shock, we suggest daily assessment for de-escalation of antimicrobials over using fixed durations of therapy without daily reassessment for de-escalation.Weak very low quality of evidence
30. For adults with an initial diagnosis of sepsis or septic shock and adequate source control, we suggest using shorter over longer duration of antimicrobial therapy.Weak very low quality of evidence
31. For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear, we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone.Weak low quality of evidence
HEMODYNAMIC MANAGEMENT
32. For adults with sepsis or septic shock, we recommend using crystalloids as first-line fluid for resuscitation.Strong moderate-quality evidence
33. For adults with sepsis or septic shock, we suggest using balanced crystalloids instead of normal saline for resuscitation.Weak low quality of evidenceCHANGED from weak recommendation low quality of evidence.
“We suggest using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock”
34. For adults with sepsis or septic shock, we suggest using albumin in patients who received large volumes of crystalloids.Weak moderate-quality evidence
35. For adults with sepsis or septic shock, we recommend against using starches for resuscitation.Strong high-quality evidence
36. For adults with sepsis and septic shock, we suggest against using gelatin for resuscitation.Weak moderate-quality evidenceUPGRADE from weak recommendation low quality of evidence
“We suggest using crystalloids over gelatins when resuscitating patients with sepsis or septic shock.”
37. For adults with septic shock, we recommend using norepinephrine as the first-line agent over other vasopressors.Strong
Dopamine. High-quality evidence
Vasopressin. Moderate-quality evidence
Epinephrine. Low quality of evidence
Selepressin. Low quality of evidence
Angiotensin II. Very low-quality evidence
38. For adults with septic shock on norepinephrine with inadequate mean arterial pressure levels, we suggest adding vasopressin instead of escalating the dose of norepinephrine.Weak moderate quality evidence
39. For adults with septic shock and inadequate mean arterial pressure levels despite norepinephrine and vasopressin, we suggest adding epinephrine.Weak low quality of evidence
40. For adults with septic shock, we suggest against using terlipressin.Weak low quality of evidence
41. For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we suggest either adding dobutamine to norepinephrine or using epinephrine alone.Weak low quality of evidence
42. For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, we suggest against using levosimendan.Weak low quality of evidenceNEW
43. For adults with septic shock, we suggest invasive monitoring of arterial blood pressure over noninvasive monitoring, as soon as practical and if resources are available.Weak very low quality of evidence
44. For adults with septic shock, we suggest starting vasopressors peripherally to restore mean arterial pressure rather than delaying initiation until a central venous access is secured.Weak very low quality of evidenceNEW
45. There is insufficient evidence to make a recommendation on the use of restrictive versus liberal fluid strategies in the first 24 hr of resuscitation in patients with sepsis and septic shock who still have signs of hypoperfusion and volume depletion after the initial resuscitation.No recommendationNEW
“We suggest using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock”
Weak recommendation low quality of evidence
“We suggest using crystalloids over gelatins when resuscitating patients with sepsis or septic shock.”
Weak recommendation low quality of evidence
VENTILATION
46.There is insufficient evidence to make a recommendation on the use of conservative oxygen targets in adults with sepsis-induced hypoxemic respiratory failure.No recommendation
47. For adults with sepsis-induced hypoxemic respiratory failure, we suggest the use of high flow nasal oxygen over noninvasive ventilation.Weak low quality of evidenceNEW
48. There is insufficient evidence to make a recommendation on the use of noninvasive ventilation in comparison to invasive ventilation for adults with sepsis-induced hypoxemic respiratory failure.No recommendation
49. For adults with sepsis-induced ARDS, we recommend using a low tidal volume ventilation strategy (6 mL/kg), over a high tidal volume strategy (> 10 mL/kg).Strong high-quality evidence
50. For adults with sepsis-induced severe ARDS, we recommend using an upper limit goal for plateau pressures of 30 cm H2O, over higher plateau pressures.Strong moderate-quality evidence
51. For adults with moderate to severe sepsis-induced ARDS, we suggest using higher PEEP over lower PEEP.Weak moderate-quality evidence
52. For adults with sepsis-induced respiratory failure (without ARDS), we suggest using low tidal volume as compared with high tidal volume ventilation.Weak low quality of evidence
53. For adults with sepsis-induced moderate-severe ARDS, we suggest using traditional recruitment maneuvers.Weak moderate-quality evidence
54. When using recruitment maneuvers, we recommend against using incremental PEEP titration/strategy.Strong moderate-quality evidence
55. For adults with sepsis-induced moderate-severe ARDS, we recommend using prone ventilation for greater than 12 hr daily.Strong moderate-quality evidence
56. For adults with sepsis induced moderate-severe ARDS, we suggest using intermittent NMBA boluses, over NMBA continuous infusion.Weak moderate-quality evidence
57. For adults with sepsis-induced severe ARDS, we suggest using Veno-venous (VV) ECMO when conventional mechanical ventilation fails in experienced centers with the infrastructure in place to support its use.Weak low quality of evidenceNEW
ADDITIONAL THERAPIES
58. For adults with septic shock and an ongoing requirement for vasopressor therapy we suggest using IV corticosteroids.Weak moderate-quality evidenceUPGRADE from Weak recommendation low quality of evidence
“We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (see goals for Initial Resuscitation). If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg/day.”
59. For adults with sepsis or septic shock we suggest against using polymyxin B hemoperfusion.Weak low quality of evidenceNEW from previous: “We make no recommendation regarding the use of blood purification techniques”
60. There is insufficient evidence to make a recommendation on the use of other blood purification techniques.No recommendation
61. For adults with sepsis or septic shock we recommend using a restrictive (over liberal) transfusion strategy.Strong moderate-quality evidence
62. For adults with sepsis or septic shock we suggest against using IV immunoglobulins.Weak low quality of evidence
63. For adults with sepsis or septic shock, and who have risk factors for gastrointestinal (GI) bleeding, we suggest using stress ulcer prophylaxis.Weak moderate-quality evidence
64. For adults with sepsis or septic shock, we recommend using pharmacologic venous thromboembolism (VTE) prophylaxis unless a contraindication to such therapy exists.Strong moderate-quality evidence
65. For adults with sepsis or septic shock, we recommend using low molecular weight heparin over unfractionated heparin for VTE prophylaxisStrong moderate-quality evidence
66. For adults with sepsis or septic shock, we suggest against using mechanical VTE prophylaxis, in addition to pharmacological prophylaxis, over pharmacologic prophylaxis alone.Weak low quality of evidence
67. In adults with sepsis or septic shock and AKI, we suggest using either continuous or intermittent renal replacement therapy.Weak low quality of evidence
68. In adults with sepsis or septic shock and AKI, with no definitive indications for renal replacement therapy, we suggest against using renal replacement therapy.Weak moderate-quality evidence
69. For adults with sepsis or septic shock, we recommend initiating insulin therapy at a glucose level of ≥ 180mg/dL (10 mmol/L).Strong moderate-quality evidence
70. For adults with sepsis or septic shock we suggest against using IV vitamin C.Weak low quality of evidenceNEW
71. For adults with septic shock and hypoperfusion-induced lactic acidemia, we suggest against using sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements.Weak low quality of evidence
72. For adults with septic shock and severe metabolic acidemia (pH ≤ 7.2) and acute kidney injury (AKIN score 2 or 3), we suggest using sodium bicarbonate therapyWeak low quality of evidence
73. For adult patients with sepsis or septic shock who can be fed enterally, we suggest early (within 72 hr) initiation of enteral nutrition.Weak very low quality of evidence
LONG-TERM OUTCOMES AND GOALS OF CARE
74. For adults with sepsis or septic shock, we recommend discussing goals of care and prognosis with patients and families over no such discussion.Best practice statement
75. For adults with sepsis or septic shock, we suggest addressing goals of care early (within 72 hr) over late (72 hr or later).Weak low quality of evidence
76. For adults with sepsis or septic shock, there is insufficient evidence to make a recommendation on any specific standardized criterion to trigger goals of care discussion.No recommendation
77. For adults with sepsis or septic shock, we recommend that the principles of palliative care (which may include palliative care consultation based on clinician judgement) be integrated into the treatment plan, when appropriate, to address patient and family symptoms and suffering.Best practice statement
78. For adults with sepsis or septic shock, we suggest against routine formal palliative care consultation for all patients over palliative care consultation based on clinician judgement.Weak low quality of evidence
79. For adult survivors of sepsis or septic shock and their families, we suggest referral to peer support groups over no such referral.Weak very low quality of evidence
80. For adults with sepsis or septic shock, we suggest using a handoff process of critically important information at transitions of care over no such handoff process.Weak very low quality of evidence
81. For adults with sepsis or septic shock, there is insufficient evidence to make a recommendation on the use of any specific structured handoff tool over usual handoff processes.No recommendation
82. For adults with sepsis or septic shock and their families, we recommend screening for economic and social support (including housing, nutritional, financial, and spiritual support), and make referrals where available to meet these needs.Best practice statement
83. For adults with sepsis or septic shock and their families, we suggest offering written and verbal sepsis education (diagnosis, treatment, and post-ICU/post-sepsis syndrome) prior to hospital discharge and in the follow-up setting.Weak very low quality of evidence
84. For adults with sepsis or septic shock and their families, we recommend the clinical team provide the opportunity to participate in shared decision making in post-ICU and hospital discharge planning to ensure discharge plans are acceptable and feasible.Best practice statement
85. For adults with sepsis and septic shock and their families, we suggest using a critical care transition program, compared with usual care, upon transfer to the floor.Weak very low quality of evidence
86. For adults with sepsis and septic shock, we recommend reconciling medications at both ICU and hospital discharge.Best practice statement
87. For adult survivors of sepsis and septic shock and their families, we recommend including information about the ICU stay, sepsis and related diagnoses, treatments, and common impairments after sepsis in the written and verbal hospital discharge summary.Best practice statement
88. For adults with sepsis or septic shock who developed new impairments, we recommend hospital discharge plans include follow-up with clinicians able to support and manage new and long-term sequelae.Best practice statement
89. For adults with sepsis or septic shock and their families, there is insufficient evidence to make a recommendation on early post-hospital discharge follow-up compared with routine post-hospital discharge follow-up.No recommendation
90. For adults with sepsis or septic shock, there is insufficient evidence to make a recommendation for or against early cognitive therapy.No recommendation
91. For adult survivors of sepsis or septic shock, we recommend assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge.Best practice statement
92. For adult survivors of sepsis or septic shock, we suggest referral to a post-critical illness follow-up program if available.Weak very low quality of evidence
93. For adult survivors of sepsis or septic shock receiving mechanical ventilation for > 48hr or an ICU stay of > 72 hr, we suggest referral to a post-hospital rehabilitation program.Weak very low quality of evidence





2018 UPDATE

The “sepsis bundle” has been central to the implementation of the Surviving Sepsis Campaign (SSC) from the first publication of its evidence-based guidelines in 2004 through subsequent editions. In response to the publication of “Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016”, a revised “hour-1 bundle” has been developed in 2018. The elements of the 2018 bundle, intended to be initiated within the first hour. The most important change in the revision of the SSC bundles is that the 3-h and 6-h bundles have been combined into a single “hour-1 bundle”. This reflects the clinical reality at the bedside of these seriously ill patients. Obtaining blood for measuring lactate and blood cultures, administration of fluids and antibiotics, and in the case of life-threatening hypotension, initiation of vasopressor therapy, are all begun immediately. It is important to note that there are no published studies that have evaluated the efficacy in important subgroups, including burns and immunocompromised patients.



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SURVIVING SEPSIS CAMPAIGN: INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEPSIS AND SEPTIC SHOCK: 2016

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, and killing as many as one in four (and often more). These clinical practice guidelines are a revision of the
2012 Surviving Sepsis Campaign (SSC) guidelines for the
management of severe sepsis and septic shock. These guidelines are appropriate for the sepsis patient in a
hospital setting. These guidelines are intended to be
best practice and not created to represent standard
of care. 
Following table shows the comparison of recommendations from 2012 to 2016








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