Thread by @MereLOlsen

As #MedTwitter regulars, you may have already heard that the #SurvivingSepsis Campaign has released the updated 2021 version of the International #Guidelines for Management of #Sepsis and #SepticShock!

But have you gone thru the updates yet?

A #Tweetorial (1/x):

There are 93 #recommendations made in the new publication. I don’t have time to write (or read) that kind of #Tweetorial and neither do you. That’s what the publication is for -> journals.lww.com/ccmjournal/Cit… !

But let’s hit the ✨highlights✨ starring Table 1: (2/x)

Why we care (and we care so much!): Sepsis and septic shock affect millions of people globally each year, and kills somewhere between 1/6 and 1/3 of those diagnosed with the #syndrome. 1/3!!! 😳😢 (3/x)

Some refreshment: Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to #infection. Guidelines do not replace your 🧠 when confronted by unique patients’ clinical variables, but they are intended to reflect current best practice. (4/x)

For hospitals & health systems, #SSC recommends having a performance improvement program for sepsis, including screening for appropriate pts and SOPs for treatment. 💪 rec, former BPS. (5/x)

NEW: #SSC now recommends AGAINST using qSOFA compared with SIRS, NEWS, or MEWS as a single-screening tool for sepsis or septic shock. 💪 (6/x)

Best Practice Statement: Sepsis and septic shock are medical #emergencies, and it is *recommended* that treatment and #resuscitation begin immediately. 🔥🚒‼️ (7/x)

DOWNGRADED: It is now *suggested* rather than *recommended* that pts with sepsis driven hypoperfusion or shock receive at least 30ml/kg IV crystalloid, within the first 3 hrs of resuscitation. (8/x)

Fluid suggestions: use BALANCED crystalloids over normal saline, and consider albumin in pts who have received large volumes of crystalloids. Eat your starches 🥖🥔🍝 and your gelatin, as #SSC recommends AGAINST using them to resuscitate people intravenously. (9/x)

Checking a lactate is *suggested*. If high, it’s so nice you should consider checking it twice 🎅 You know, later, after the initial resus, to see if it’s going down. As a surrogate marker of perfusion. This is a weak recommendation. (10/x)

Consider using dynamic measures and capillary refill time to guide fluid resuscitation OVER physical exam or static parameters alone. (11/x)

In the words of a podcast (@PulmCrit) I like to listen to (but certainly don’t speak for ☺), DEFEND THE MAP! If pts w septic shock are on vasopressors, #SSC recommends an initial target #MAP of 65mmHg over higher MAP targets. 💪 (12/x)

Try to get the patients into the ICU within 6 hours *laugh/cries in COVID*.

Don’t hurt me, #MedTwitter (13/x)

From the ID perspective: find the bug 🦠. If you can’t find it, & another cause for illness is more likely, consider d/cing empiric antimicrobials (BPS). If pt has a low likelihood of infxn & is w/o shock, suggest deferring antimicrobials in favor of continued monitoring (14/x)

CHANGE: For pts w high likelihood for sepsis/septic shock, #SSC *recommends* antimicrobials immediately, ideally within ONE HOUR (after cultures, of course) 💪 If no shock is present, recommend rapid assessment of the acute illness. If c/f infxn persists, abx w/in 3 hrs. (15/x)

BPS: If pt is at high risk for MRSA, use empiric antimicrobials that include coverage for MRSA. Conversely, if the patient is at low risk for MRSA, #SSC *suggests* AGAINST empiric MRSA coverage. Turns out vancosyn is not the right answer for everybody 🙃 (16/x)

Please apply the above logic in terms of fungal infection and antifungal coverage. 🍄 (17/x)

#SSC makes *no recommendation* for use of antiviral agents. (18/x)

Norepinephrine first, vasopressin second & *early* rather than escalating the dose of norepi. Follow that up with some epinephrine if you need it, then maybe some dobutamine. Consider early invasive monitoring. SSC suggests against using terlipressin & levosimendan. (19/x)

NEW: starting peripheral #pressors to restore the MAP is *suggested*, rather than delaying initiation in favor of obtaining central access. (20/x)

Ventilation: New recommendations include using HFNC over NIV for sepsis-induced hypoxemic respiratory failure, and for sepsis-induced severe ARDS, use VV ECMO* when conventional MV fails. (21/x)

*in experienced centers with the infrastructure in place to support its use

UPGRADE: Steroids! For adults with septic SHOCK and ongoing requirement for vasopressors, IV corticosteroids are suggested. 💪 However, #SSC suggests AGAINST IV Vitamin C. 🍊 (22/x)

Goals of Care Synopsis: Address GOC early with patients and family, and incorporate the principles of palliative care into these discussions. Consult your palliative care specialists 👼 based on your clinical judgment. (23/x)

Thanks for hanging with me, folks 🙏 There are lots more details in the pub journals.lww.com/ccmjournal/Cit…

All kinds of smart groups and people have weighed in on & endorsed this publication, but there is SO MUCH WORK LEFT TO BE DONE! (24/FIN)

#survivingsepsis #SCCM #ESICM #AACCN #ACCP #ACEP #ATS and many others ♥️

@Paul_Wischmeyer @ilanaPICUdoc @PICU_UAE
@aartisarwal @SCCMPresident @SCCM @CritCareMed @accpchest @virenkaul @chungk1031 @jessica_bunin @KFabsMD @joshuadhartzell