What are the new updates from the 2021 Surviving Sepsis Campaign guidelines?

Comment by InpharmD Researcher

Surviving sepsis campaign international guidelines for management of sepsis and septic shock was most recently updated in October 2021. There are 21 new or revised statements (see Table 1). Among the changes are a suggestion of using capillary refill time to guide resuscitation, additional ventilation statements, and discouragement on using empiric MRSA antibiotics or antifungals when risk of infection is low.

Background

Surviving sepsis campaign international guidelines for management of sepsis and septic shock was most recently updated in October 2021. The previous update was in 2016. The updated guidelines emphasize the statements 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." [1], [2] For a complete summary of statement changes, please see Table 1.

References:

[1] Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 [published online ahead of print, 2021 Oct 2]. Intensive Care Med. 2021;10.1007/s00134-021-06506-y. doi:10.1007/s00134-021-06506-y
[2] Rhodes, A., Evans, L.E., Alhazzani, W. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 43, 304–377. https://doi.org/10.1007/s00134-017-4683-6
Literature Review

A search of the published medical literature revealed 1 study investigating the researchable question:

What are the new updates for 2021 Sepsis guidelines?

Please see Table 1 for your response.

New and updated recommendations within the 2021 guidelines for management of sepsis and septic shock
Recommendation 2021 statement

Previous 2016 statement (if any)
1: Screening for Patients with Sepsis and Septic Shock 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. 1. Recommended that hospitals and hospital systems have a performance improvement program for sepsis including sepsis screening for acutely ill, high-risk patients.
4,5,8: Initial Resuscitation

4. Sepsis and septic shock are medical emergencies and we recommend that treatment and resuscitation begin immediately. 

5. For patients with sepsis induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of intravenous (IV) crystalloid fluid should be given within the first 3 hours of resuscitation.

8. For adults with septic shock, we suggest using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion.

4. New recommendation

5. Recommended that in the initial resuscitation from sepsis-induced hypoperfusion, at least 30 mL/kg of intravenous crystalloid fluid should be given within the first 3 hours.

8. New recommendation
12, 14, 15, 17, 18, 22, 23: Infection

12. For adults with possible septic shock or a high likelihood for sepsis, we recommend administering antimicrobials immediately, ideally within one hour of recognition. 

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 hours from the time when sepsis was first recognized. 

15. For adults with a low likelihood of infection and without shock, we suggest deferring antimicrobials while continuing to closely monitor the patient.

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. 

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. 

22. For adults with sepsis or septic shock at high risk of fungal infection, we suggest using empiric antifungal therapy over no antifungal therapy. 

23. For adults with sepsis or septic shock at low risk of fungal infection, we suggest against empiric use of antifungal therapy.

12. Recommended 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. 

14. Recommended 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. 

15. Recommended 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. 

17. Recommended 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).

18. Recommended 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).

22. Recommended 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). 

23. Recommended 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). 
33, 36, 42, 44, 45: Hemodynamic Management

33. For adults with sepsis or septic shock, we suggest using balanced crystalloids instead of normal saline for resuscitation.

36. For adults with sepsis and septic shock, we suggest against using gelatin for resuscitation.

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.

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. 

45. There is insufficient evidence to make a recommendation on the use of restrictive versus liberal fluid strategies in the first 24 hours of resuscitation in patients with sepsis and septic shock who still have signs of hypoperfusion and volume depletion after the initial resuscitation.

33. Suggested using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock.

36. Suggested using crystalloids over gelatins when resuscitating patients with sepsis or septic shock.

42. New recommendation

44. New recommendation

45. Suggested using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock and using crystalloids over gelatins when resuscitating patients with sepsis or septic shock. 
47, 57: Ventilation 

47. For adults with sepsis-induced hypoxemic respiratory failure, we suggest the use of high flow nasal oxygen over non-invasive ventilation. 

57. For adults with sepsis-induced severe acute respiratory distress syndrome (ARDS), we suggest using Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) when conventional mechanical ventilation fails in experienced centers with the infrastructure in place to support its use. 

47. New recommendation

57. New recommendation 
58, 59, 70: Additional Therapies

58. For adults with septic shock and an ongoing requirement for vasopressor therapy we suggest using IV corticosteroids.

59. For adults with sepsis or septic shock we suggest against using polymyxin B hemoperfusion. 

70. For adults with sepsis or septic shock we suggest against using IV vitamin C.

58. Suggested against using intravenous hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this was not achievable, suggested intravenous hydrocortisone at a dose of 200 mg per day. 

59. Made no recommendation regarding the use of blood purification techniques. 

70. New recommendation
References:

Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 [published online ahead of print, 2021 Oct 2]. Intensive Care Med. 2021;10.1007/s00134-021-06506-y. doi:10.1007/s00134-021-06506-y

Rhodes, A., Evans, L.E., Alhazzani, W. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 43, 304–377. https://doi.org/10.1007/s00134-017-4683-6