Table 3.
Initial Resuscitation and Infection Issues
| Initial resuscitation (first 6 hours) |
| Strength of recommendation and quality of evidence have been assessed using the GRADE criteria, presented in brackets after each guideline. For added clarity: • Indicates a strong recommendation or “we recommend”; ○ indicates a weak recommendation or “we suggest” |
| • Begin resuscitation immediately in patients with hypotension or elevated serum lactate > 4mmol/l; do not delay pending ICU admission.(1C) |
| • Resuscitation goals:(1C) |
| – Central venous pressure (CVP) 8–12 mm Hg* |
| – Mean arterial pressure ≥ 65 mm Hg |
| – Urine output ≥ 0.5 mL.kg-1.hr-1 |
| – Central venous (superior vena cava) oxygen saturation ≥ 70%, or mixed venous ≥ 65% |
| ○ If venous O2 saturation target not achieved: (2C) |
| – consider further fluid |
| – transfuse packed red blood cells if required to hematocrit of ≥ 30% and/or |
| – dobutamine infusion max 20 μg.kg-1.min-1 |
| * A higher target CVP of 12–15 mm Hg is recommended in the presence of mechanical ventilation or pre-existing decreased ventricular compliance. |
| Diagnosis |
| • Obtain appropriate cultures before starting antibiotics provided this does not significantly delay antimicrobial administration.(1C) |
| – Obtain two or more blood cultures (BCs) |
| – One or more BCs should be percutaneous |
| – One BC from each vascular access device in place > 48 h |
| – Culture other sites as clinically indicated |
| • Perform imaging studies promptly in order to confirm and sample any source of infection; if safe to do so.(1C) |
| Antibiotic therapy |
| • Begin intravenous antibiotics as early as possible, and always within the first hour of recognizing severe sepsis (1D) and septic shock (1B). |
| • Broad-spectrum: one or more agents active against likely bacterial/fungal pathogens and with good penetration into presumed source.(1B) |
| • Reassess antimicrobial regimen daily to optimise efficacy, prevent resistance, avoid toxicity & minimise costs.(1C) |
| ○ Consider combination therapy in Pseudomonas infections.(2D) |
| ○ Consider combination empiric therapy in neutropenic patients.(2D) |
| ○ Combination therapy no more than 3–5 days and deescalation following susceptibilities.(2D) |
| • Duration of therapy typically limited to 7–10 days; longer if response slow, undrainable foci of infection, or immunologic deficiencies.(1D) |
| • Stop antimicrobial therapy if cause is found to be non-infectious.(1D) |
| Source identification and control |
| • A specific anatomic site of infection should be established as rapidly as possible(1C) and within first 6 hrs of presentation(1D). |
| • Formally evaluate patient for a focus of infection amenable to source control measures (eg: abscess drainage, tissue debridement).(1C) |
| • Implement source control measures as soon as possible following successful initial resuscitation.(1C) |
| Exception: infected pancreatic necrosis, where surgical intervention best delayed. (2B) |
| • Choose source control measure with maximum efficacy and minimal physiologic upset.(1D) |
| • Remove intravascular access devices if potentially infected.(1C) |