Objective:To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.Design:A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at ke

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008. A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao
 2/Fio
 2 ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao
 2/Fi
 o
 2 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C). Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

/pdf/surviving-sepsis-campaign-international-guidelines-for-229kg8suph.pdf

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Objective
To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, “Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock,” published in 2004.

/pdf/surviving-sepsis-campaign-international-guidelines-for-lbjfg8yybt.pdf

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, “Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock,” published in 2004. Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. We used the GRADE system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation [1] indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost), or clearly do not. Weak recommendations [2] indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. Key recommendations, listed by category, include: early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures prior to antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7–10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure ≥ 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for post-operative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7–9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B) targeting a blood glucose < 150 mg/dL after initial stabilization ( 2C ); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper GI bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include: greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); a recommendation against the use of recombinant activated protein C in children (1B). There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Surviving sepsis campaign: international guidelines for the management of severe sepsis and septic shock: 2008

Early goal-directed therapy in the treatment of severe sepsis and septic shock

1. Editor do Jornal de Pediatria. 2. Editor Associado do Jornal de Pediatria. Ha aproximadamente seis anos nos foi confiada a responsabilidade de coordenar o corpo editorial do Jornal de Pediatria. Durante esse periodo estabelecemos uma sequencia de objetivos que deveriam ser atingidos e ultrapassados de forma a colocar o Jornal de Pediatria no mesmo patamar das mais conceituadas revistas medicas de nosso pais e do exterior. Vemos hoje com satisfacao que a quase totalidade dessas etapas foi alcancada, dentre as quais destacamos: (a) regularidade e pontualidade na impressao e distribuicao da revista; (b) utilizacao de mecanismos objetivos, impessoais e padronizados para avaliacao de artigos (todos os artigos sao avaliados por dois revisores e por um membro do conselho editorial); (c) adocao de padroes internacionais (normas de Vancouver) na organizacao e apresentacao dos artigos (resumo e abstract semiestruturado, referencias bibliograficas padronizadas, etc.); (d) mudanca no leiaute com modificacoes na capa, na distribuicao e limitacao de paginas de anunciantes, utilizacao de papel de qualidade superior, assim como otimizacao no sistema de envelopagem da revista; (e) controle minucioso de todo o processo, monitorados atraves de planilhas de custo, de receitas e de prazos; (f) reorganizacao administrativa, com a adocao de um programa gerenciador especifico e complementado com a transferencia da secretaria para junto do conselho editorial; (g) reunioes quinzenais de todo o conselho editorial, com analise e discussao de todos os trabalhos submetidos a avaliacao, assim como definicao dos artigos a serem publicados; (h) impressao de dois numeros extras anuais (suplementos) destinados exclusivamente a artigos de revisao, mas obedecendo e submetendose ao mesmo padrao editorial dos demais numeros; (i) intercâmbio com outras revistas pediatricas do Cone Sul no sentido de ampliar a nossa capacidade de divulgacao; (j) desenvolvimento de secoes como carta ao editor, perguntas ao especialista, editoriais baseados em artigos publicados, secao Cone Sul, etc.

http://www.jped.com.br/conteudo/01-77-01-01/port.pdf

Eyes on the present and looking into the future

Objective:To study the relationship between serum glucose level and mortality in children with septic shock.Design:Prospective cohort study.Setting:Twelve-bed pediatric intensive care unit at the Hospital Sao Lucas da PUCRS, Porto Alegre, Brazil.Patients:All children admitted with septic shock refra

Glucose level and risk of mortality in pediatric septic shock.

Objective:To describe the incidence of extubation failure and its associated risk factors among mechanically ventilated children.Method:Prospective cohort study. Children who were mechanically ventilated for longer than 12 hrs were followed up to 48 hrs after extubation. Cases of upper airway obstru

Risk factors for extubation failure in mechanically ventilated pediatric patients.

Aim: To evaluate serum ferritin level in children with severe sepsis and septic shock and its association with mortality.

Method: A cohort study of 36 children aged 1 month–16 years with severe sepsis or septic shock requiring intensive care was conducted. Serum ferritin levels were measured at the time of diagnosis of sepsis and a ferritin index (FI = observed serum ferritin divided by the upper limit of normal ferritin for age and gender) was calculated.

Results: The median age (range) of the children was 6 (2–100) months. Ferritin was 500 ng/mL in 12 children. The mortality associated with these groups was 23%, 9% and 58%, respectively. A ferritin >500 ng/mL was associated with a 3.2 (1.3–7.9) relative risk of death (p = 0.01). FI of 1.7 was the best cutoff value for identifying those who died. In a logistic regression analysis, ferritin level and PRISM were independently associated with mortality.

Conclusions: Ferritin is raised in children with septic shock and high ferritin level is associated with poorer outcome.

Ferritin levels in children with severe sepsis and septic shock.

OBJETIVO: Comparar o desempenho do PRISM (Pediatric Risk of Mortality) e o PIM (Pediatric Index of Mortality) em uma unidade de terapia intensiva pediatrica geral investigando a relacao existente entre a mortalidade e a sobrevivencia observadas com a mortalidade e sobrevivencia estimadas pelos dois escores. METODOS: Estudo de coorte contemporâneo realizado entre 1° de junho de 1999 a 31 de maio de 2000 na unidade de terapia intensiva pediatrica do Hospital Sao Lucas da Pontificia Universidade Catolica do Rio Grande do Sul. Os criterios de inclusao no estudo e o calculo do PRISM e do PIM foram feitos conforme preconizado e utilizando as formulas de seus artigos originais. Para estatistica, utilizou-se o teste z de Flora, teste de ajuste de Hosmer-Lemeshow, area sob a curva tipica de um recebedor operador de caracteristicas (curva ROC) e teste de correlacao de Spearman. O estudo foi aprovado pelo Comite da instituicao. RESULTADOS: Internaram na unidade de terapia intensiva pediatrica 498 pacientes, sendo 77 excluidos. Dos 421 pacientes estudados, 33 (7,83%) foram a obito. A mortalidade estimada pelo PRISM foi de 30,84 (7,22%), com standardized mortality rate 1,07 (0,74-1,50), z = -0,45. Pelo PIM, foi de 26,13 (6,21%), com standardized mortality rate 1,26 (0,87-1,77), z = -1,14. O teste de ajuste de Hosmer-Lemeshow obteve um qui-quadrado 9,23 (p = 0,100) para o PRISM e 27,986 (p < 0,001) para o PIM. A area abaixo da curva ROC foi 0,870 (0,810-0,930) para o PRISM e 0,845 (0,769-0,920) para o PIM. Teste de Spearman r = 0,65 (p < 0,001). CONCLUSAO: Na analise dos testes podemos constatar que, embora o PIM apresente uma pior calibracao no conjunto dos resultados, tanto o PRISM como o PIM apresentaram boa capacidade de discriminar entre sobreviventes e nao sobreviventes, constituindo-se em ferramentas de desempenho comparaveis na avaliacao prognostica de pacientes pediatricos admitidos em nossa unidade.

https://www.scielo.br/pdf/jped/v81n3/en_v81n3a14.pdf

Jefferson Pedro Piva

Papers

Eyes on the present and looking into the future

Glucose level and risk of mortality in pediatric septic shock.

Risk factors for extubation failure in mechanically ventilated pediatric patients.

Ferritin levels in children with severe sepsis and septic shock.

Comparison of two prognostic scores (PRISM and PIM) at a pediatric intensive care unit