Surviving sepsis 2017

Great update on sepsis by JournalWatch. For those who do not have access:

Daniel M. Lindberg, MD Reviewing Rhodes A et al., Intensive Care Med 2017 Jan 18;
This revision of the 2012 guidelines focuses on early management in adults.
Sponsoring Organizations: Surviving Sepsis Campaign, Society of Critical Care Medicine, and European Society of Intensive Care Medicine
Target Population: Clinicians who care for adult patients with sepsis and septic shock in a hospital setting.
Background and Objective
Sepsis remains incompletely understood, imperfectly defined, underrecognized, and exceptionally lethal. The Surviving Sepsis Campaign convened 55 experts from 25 organizations to undertake a systematic review and grading of evidence to update guidelines for the management of sepsis and septic shock in adult patients (NEJM JW Emerg Med Apr 2013 and Crit Care Med 2013; 41:580). This revision was conducted before publication of the Sepsis-3 definitions and does not incorporate them (NEJM JW Gen Med Mar 15 2016 and JAMA 2016 Feb 23; 315:801).
Key Recommendations
  • Patients with hypoperfusion should receive at least 30 mL/kg of IV crystalloid within 3 hours (strong recommendation, low quality of evidence), and should be re-assessed frequently (best practice statement).
  • For patients who require vasopressors, the initial target mean arterial pressure should be 65 mm Hg (strong recommendation, moderate quality of evidence).
  • IV antibiotics should be started within 1 hour of sepsis recognition (strong recommendation, moderate quality of evidence), and should include combination therapy (at least two classes of antibiotics to cover a known or suspected pathogen) for patients with septic shock. Combination therapy should not routinely be used for patients without shock.
  • Norepinephrine is the first choice for patients who need vasopressors. Vasopressin or epinephrine can be added. For patients who remain unstable, dobutamine is recommended.
  • IV hydrocortisone (200 mg/day) is suggested for patients who are hemodynamically unstable despite fluids and vasopressors.
  • Blood transfusion should be reserved for patients with hemoglobin concentration <7.0 g/dL, except in special circumstances such as hemorrhage and myocardial ischemia (strong recommendation, high quality of evidence). Platelets should be given if the platelet count is <10,000/mm3 or <20,000/mmwith bleeding.
  • Sodium bicarbonate should not be used for most patients with pH ≥7.15.
What's Changed
With publication of the PROCESS and ARISE trials, these guidelines de-emphasize protocolization of care and invasive monitoring, instead suggesting that patients be re-evaluated frequently.
We continue to search for new definitions, diagnostic tests, antimicrobials, and treatments for patients with sepsis. However, improving outcomes probably has as much to do with increasing adherence to the practices we already know are effective and embedding automated passive alerting functions in the electronic medical record. For patients with sepsis, provide early, aggressive treatment with fluids and antibiotics, coupled with frequent re-assessment.

  1. Rhodes A et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 2017 Jan 18; [e-pub]. (

CT after CA… worth it?

Here's a good nugget of food for thought from Medscape. We do this too. Outcomes are yet to be viewed though.


January 13, 2017
Daniel M. Lindberg, MD Reviewing Reynolds AS et al., Resuscitation 2017 Jan 3;
Many computed tomography scans showed abnormalities in this retrospective study, but it's not clear that performing early head CT improved care.
Neurological emergencies can result in cardiac arrest, and neurological injury can occur as a result of cardiac arrest. These authors retrospectively assessed the utility of head computed tomography (CT) in patients with out-of-hospital cardiac arrest who survived for at least 24 hours at a single academic center from 2007 to 2015.
Of 213 patients in the analysis, 115 (54%) underwent head CT within 24 hours. In 43 patients (20% of all patients; 37% of those who underwent head CT), head CT showed abnormalities, such as loss of gray-white differentiation, global cerebral edema, and ischemic stroke. The authors note that head CT findings led to changes in management in 15 patients. These changes included transfer to the neurological intensive care unit, repeat head CT, and neurosurgical consultation alone; only one patient underwent neurological surgery. Of patients for whom CT findings changed management, only one survived, in a persistent vegetative state.
The limited clinical significance of the CT findings and of the resulting management changes does not make a compelling case to expand the use of CT scans. In patients stable enough for imaging, head CT should be obtained if pre-arrest symptoms or the neurological exam suggest a neurological source for the arrest or if the patient had significant head trauma.

When a lot fails, then what?

Here's a difficult case that one of our EM residents, Dr Conne Lau,  encountered. What would you do?
73 y/o
PMhx:  DM , HTN , HL
Presented to the ED for palpitations , non vertiginous giddiness and chest discomfort. \

Decision was made for trial of vagal manoeuvres as standby adenosine was being prepared.
Post vagal manoeuvres patient became hypotensive . However patient was still alert.
ECG repeated showed persistent SVT.
IV fluids was given and trial of adenosine was given 6mg–>12mg –>12mg ,
However patient reverted back to SVT after a few seconds post adenosine.
Repeat BP was  80/60 and patient was still alert.
What would you do now?

With failure of adenosine , decision  was made for synchronised cardioversion with sedation.
50J –>100J–>100J , each time the patient reverted back to SVT within a few seconds and remained hypotensive.
Repeat  BP 70/50  despite IV fluids . HR ranged between 180-200.
Cardiology on call was consulted:

  • IV diltiazem (bolus) + IV fluids + electrical cardioversion was given
  • Patient again reverted back to SVT after a few seconds and remained hypotensive.
  • A second attempt of diltiazem  ( infusion) + IV fluids  + electrical cardioversion was given.
  • With the continuous diltiazem infusion patient converted to sinus rhythm.

Q1 :How to correct the hypotension? Is noradrenaline or dobutamine an option ?
Ans :
Management of hypotension always starts with fluid resuscitation. Rate control agents are all vasodilatory and therefore some fluid resuscitation would be helpful.
If decision is made to start vasopressors . Aim is to maintain good blood pressure but not counteract the rate controlling drugs. i.e. amiodarone.
Noradrenaline can be used as a temporising measure , as it has vasoconstriction with limited impact on heart rate (chronotropy) .
Dobutamine is a potent ionotrope with weak chronotropy but it significantly increases myocardial oxygen consumption ,
BOTTOMLINE : Fluids remains the first line of treatment ,and if decision is made to start vasopressors noradrenaline is the drug of choice for most physicians.

Q2 What is the drug of choice when adenosine and electrical cardioversion fails and patient remains hypotensive?
Ans :
Amiodarone is considered first line in this case , as it is believed to have less hypotensive effects compared to calcium channel blockers (CCB). Also CCB should be used in caution in those with unknown EF.
If amiodarone fails, CCB can be tried  and diltiazem is preferred to verapamil .
Use diltiazem , not as a push but a slow bolus . Drip it in at 2.5 mg/minute until HR < 100 or you get to 50 mg. Diltiazem can be converted to a conventional dose when patient is more stable.
Reference of local evidence of slow infusion CCB in termination of SVT :