Resuscitation and Management Bundle Elements
The expert panel identified six interventions for implementation in severe sepsis and septic shock patients. Together, this is referred to as the resuscitation bundle or early goal directed intervention. Every bundle component was graded a 1 or "strongly" supported. Level of evidence ranged from A to C. This indicates that a need for continued research on each bundle element remains. The group postulated that implementation of each of these bundle elements was beneficial in mortality reduction in patients with severe sepsis or septic shock and thus, should occur in every case.
Initial Resuscitation
The Resuscitation Components are to be completed ASAP and all within the first 6 hours of identification :
1. Blood cultures are to be drawn prior to antibiotic administration.
2. A serum lactate should be drawn.
3. Broad spectrum antibiotics are to be administered within the first hour of recognizing severe sepsis/septic shock in hospitalized patients.
4a. An initial fluid bolus of 30 ml/kg IV of normal saline for:
- Hypotension (systolic <90 mmHg or MAP < 65 mmHg) or
- Lactate> 4mmol/L
- Goal of treatment = MAP > 65 mmHg
4b. Vasopressors for hypotension not responding to initial fluid.
- Levophed (norepinephrine) preferred
- Goal of treatment = MAP > 65 mmHg
5. Central Line- measure Central Venous Pressure (CVP) (monitor for goal of 8-12 mmHg) if fluid resuscitation does not result in goal blood pressures.
- Insert Central line if BP parameters not met after initial fluid bolus of 30 ml/kg and no evidence of further responsiveness and further fluids..
- Insert Central Line if Lactate > 4 mmol/L
- Measure CVP as soon as possible after Central Line insertion.
- Acceptable central lines to measure CVP: subclavian, jugular or PICC. Central lines not supported by research to measure CVP include: groshong, hickman, implanted ports and femoral
6. ScvO2 (suplin vena cava oxygen saturation goal >70%) or Svo2 (mixed venous oxygen saturation > 65%
- Measure as soon as possible.
- Periodic or continuous measurement recommended.
- Obtain blood sample from distal port of central line if periodic measurements are used.
*It is of note that serial lactates with a goal of >10% decrease was not inferin to.
