American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New sepsis guidelines redefine the condition and its treatment

OCTOBER 25, 2017
Clinical Congress Daily Highlights, Wednesday Second Edition

This year’s update to the 2016 sepsis guidelines offers a number of new recommendations and even redefines the disease. In a Wednesday session, experts reviewed the latest changes and presented new data regarding optimal management of patients with sepsis and septic shock. They also looked at new studies providing data about better resuscitation techniques, selection of appropriate vasopressors, and adjunctive treatments in septic patients.

Addressing changes in the guidelines regarding how to resuscitate sepsis patients, including what fluids to use, resuscitation targets, and vasopressors, John C. Marshall, MD, FRCSC, FACS, University of Toronto, ON, highlighted the following recommendations: 

  • Resuscitate with crystalloids, such as saline or Ringer’s lactate. Starches are not comparable and may be harmful. Avoid volume overload by checking fluid responsiveness. Fluids levels should be adjusted depending on the patient’s response.
  • To determine if resuscitation has been adequate, function is the ultimate test, making urine output a critical measure of how well the resuscitation has gone.
  • Vasopressors should be used with caution, and norepinephrine should be preferred to dopamine.

Robert G. Sawyer, MD, FACS, Western Michigan University, Kalamazoo, discussed source control and antibiotic management. Although a number of new antibiotics have come out in the last few years, he said, few are much use to surgeons.

“There are about four that are relevant — but you would be safe in using the same ones you’ve used in the past, as long as the indications make it appropriate.”

Timothy G. Buchman, Editor-In-Chief of Critical Care Medicine and deputy editor of the Journal of the American College of Surgeons, described the new definition of sepsis, which has changed repeatedly in recent decades.

Using a large patient database, the guidelines now define sepsis — or “sepsis-3” — as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.” To employ this definition at the bedside, physicians should ask themselves if they suspect infection. If so, they should ask if the patient is really sick — that is, does the patient have a sepsis-related organ failure assessment (SOFA) score equal or greater than 2?

Dr. Buchman added that the new guidelines define septic shock as a subset of sepsis in which “underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone.”

In the future, he said, the hope is that we will be able to identify sepsis-3 patients before they meet those criteria, so that antibiotics — the only therapy consistently demonstrated to save lives — can be begun earlier, he said.

Richard S. Hotchkiss, MD, Washington University in St. Louis, MO, discussed the future of precision medicine and immunoadjuvants in sepsis.

New immunotherapy drugs coming onto the market to treat cancer appear promising for sepsis as well, Dr. Hotchkiss said. He argued that patients with weakened immune systems (such as the elderly, those with co-morbidities, or alcoholics) have the highest incidence of sepsis and show evidence of early and protracted immunosuppression. In other words, sepsis evolves into an immunosuppressive condition with a correspondingly high incidence of secondary infections.

Boosting immunity through immunotherapy may decrease secondary infections, which are a major cause of morbidity and mortality, and will provide protection against a broad range of pathogens.

A number of immuno-adjuvants are likely to be successful in sepsis, but anti-PD-1 and IL-7 are particularly attractive because they are well tolerated, have broad effects on cells of both innate and adaptive immunity, and block lymphocyte depletion, Dr. Hotchkiss said.  

Additional Information:
The Panel Session, Sepsis Update 2017, was held October 25, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.

Return to Index