400	M. Kharbanda and S. Ramasubban

•This can also be given by continuous infusion for better glycemic control.

•Close monitoring of glucose control needs to be maintained during steroid therapy.

•Steroid therapy may be continued till the patient is on vasopressor and gradually tapered off over a week.

•Replacement dose of steroid should be continued in patients on chronic steroid therapy.

•ACTH (adrenocorticotropic hormone) stimulation test is not routinely recommended.

Step 14: Following therapies are no more recommended in the management of severe sepsis

•Activated protein C

•Immunoglobulins

•Intravenous selenium

Step 15: Achieve sepsis management bundle goals within 24 h of hospital admission (Table 50.4)

•After initial resuscitation, the focus should be on further stabilization and starting adjunctive therapy for sepsis, which can be achieved by attaining the management bundle goals.

Table 50.4 Severe sepsis management bundle (24-h bundle): complete tasks within 24 h of identifying severe sepsis

Administer low-dose steroids for septic shock in accordance with a standardized hospital policy

Maintain glucose control (110–180 mg/dL)

Maintain inspiratory plateau pressure (IPP) £30 cm H2O for mechanically ventilated patients

Step 16: Organ support

•Organ support such as ventilator and renal support should be instituted as and when necessary as per the ICU protocol (see Chap. 70).

Step 17: General support

•General ICU support such as nutrition, stress ulcer prophylaxis, and deep vein thrombosis prophylaxis should be instituted (see Chap. 70).

Suggested Reading

1.Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36(1):296–327.

Evidenced-based recommendations regarding the acute management of sepsis and septic shock, consensus conference of 55 international experts.

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2.Kortgen A, Niederprum P, Bauer M, Implementation of an evidence-based “standard operating procedure” and outcome in septic shock. Crit Care Med. 2006;34:943–9.

The implementation of a “sepsis bundle” can be facilitated by a standardized protocol while significantly reducing the time until the defined therapeutic measures are realized in daily practice.

3.Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, et al. Duration of hypotension prior to initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589–96.

Effective antimicrobial administration within the first hour of documented hypotension was associated with increased survival to hospital discharge in adult patients with septic shock. Despite a progressive increase in mortality rate with increasing delays, only 50% of septic shock patients received effective antimicrobial therapy within 6 h of documented hypotension.

4.Hollenberg SM, Ahrens TS, Annane D, et al. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med. 2004;32:1928–48.

Updated guidelines for hemodynamic support of adult patients with sepsis—specific recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of sepsis in adult patients.

5.Rivers E, Nguyen B, Havstad S, Early Goal-Directed Therapy Collaborative Group, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–77.

The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit.

6.Maitland K, Kiguli S, Opoka RO, et al. Mortality after Fluid Bolus in African Children with Severe Infection. N Engl J Med 2011;364:2483–2495.