recent surviving sepsis guideline and apache scoring system
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Surviving Sepsis Campaign (SSC) Guidelines
Definition & Background
The Surviving Sepsis Campaign is a multidisciplinary initiative that develops evidence-based treatment guidelines for sepsis and septic shock. The most recent widely referenced guidelines were published in 2016 (with a 2021 update for some specific recommendations).
SSC Guidelines — Key Recommendations
(Summarized from Schwartz's Principles of Surgery, 11e, Table 6-10)
1. Initial Resuscitation
| Parameter | Target |
|---|---|
| Timing | Begin immediately in patients with hypotension or elevated lactate |
| Fluid volume | ≥30 mL/kg IV crystalloid in the first 3 hours |
| MAP | >65 mmHg |
| Urine output | >0.5 mL/kg/h |
| Mixed venous O₂ saturation | >65% |
| Lactate | Normalize elevated lactate levels |
Ongoing fluid administration guided by physiologic response (HR, BP, UO) and/or invasive/non-invasive monitoring.
2. Diagnosis
- Obtain appropriate cultures (blood, urine, wound) before starting antibiotics — but do not delay antibiotic therapy for cultures
- Perform imaging studies promptly to confirm the source of infection
3. Antibiotic Therapy
- Begin IV antibiotics as early as possible, ideally within the first hour of recognition of severe sepsis/septic shock
- Use broad-spectrum regimen with adequate penetration into the presumed source
- Reassess daily for de-escalation
- Duration: 7–10 days for most infections
- Discontinue if cause is non-infectious
- Serial procalcitonin levels may allow earlier cessation
4. Source Control
- Identify anatomic site as rapidly as possible
- Implement source control (drainage, debridement, definitive procedure) as soon as possible after initial resuscitation
- Remove infected intravascular access devices
5. Hemodynamic Support
Fluids:
- Crystalloid is first-line; continue challenges while patient remains fluid-responsive
- Albumin may be added if large volumes of crystalloid are required
- Avoid hydroxyethyl starch and gelatin-based fluids
Vasopressors/Inotropes:
| Agent | Role |
|---|---|
| Norepinephrine (central) | First-line vasopressor |
| Vasopressin | Add-on if MAP goal not met or to reduce NE requirement |
| Epinephrine | Alternative to vasopressin (↑ risk of splanchnic hypoperfusion) |
| Dopamine | Only in select patients (bradycardia, low arrhythmia risk) |
| Low-dose "renal" dopamine | Not recommended |
| Phenylephrine | Not recommended |
| Dobutamine | For persistent hypoperfusion despite fluids + vasopressors |
- Insert arterial catheter for all patients requiring vasopressors
6. Steroids
- IV hydrocortisone (dose <300 mg/day) for adult septic shock when hypotension responds poorly to fluids and vasopressors
7. Other Supportive Therapy
- RBC transfusion when Hb <7.0 g/dL (unless active myocardial ischemia or hemorrhage)
- FFP: not routinely indicated unless active bleeding or invasive procedure
- Mechanical ventilation (sepsis-induced ARDS): Low tidal volume strategy (6 mL/kg ideal body weight); plateau pressure <30 cmH₂O
- Glucose control: Target blood glucose <180 mg/dL (not <110 mg/dL); use validated protocol
- DVT prophylaxis with LMWH or UFH
- Stress ulcer prophylaxis in patients with risk factors
- Nutrition: Oral/enteral feeding as tolerated within 48 hours; avoid early parenteral nutrition in stable patients
APACHE II Scoring System
APACHE II = Acute Physiology and Chronic Health Evaluation II
Purpose
Developed for use in the ICU to predict hospital mortality using 15 variables. Higher scores = higher predicted mortality.
Variables Included
The APACHE II score consists of three components:
A. Acute Physiology Score (12 variables, 0–4 points each)
| Variable |
|---|
| 1. Rectal temperature |
| 2. Mean arterial pressure |
| 3. Heart rate |
| 4. Respiratory rate |
| 5. PaO₂ (or A-a gradient) |
| 6. Arterial pH |
| 7. Serum sodium |
| 8. Serum potassium |
| 9. Serum creatinine |
| 10. Hematocrit |
| 11. WBC count |
| 12. Glasgow Coma Scale (15 − GCS score) |
B. Age Points (0–6 points)
| Age | Points |
|---|---|
| <44 | 0 |
| 45–54 | 2 |
| 55–64 | 3 |
| 65–74 | 5 |
| ≥75 | 6 |
C. Chronic Health Points (2–5 points)
Assigned for severe chronic organ insufficiency (liver, cardiovascular, respiratory, renal) or immunocompromised state — weighted by admission type (elective vs. emergency surgery vs. medical).
Scoring & Interpretation
| APACHE II Score | Significance |
|---|---|
| 0–4 | Very low mortality risk |
| ≥8 (pancreatitis context) | Predicts need for ICU, pancreatic necrosis, secondary infection, and increased mortality |
| ≥15 | Significant mortality risk in general ICU patients |
| ≥25 | High mortality (>50%) |
- Total score range: 0–71
- Used to stratify severity and compare outcomes across ICU populations
APACHE II in Sepsis
- APACHE II provides a validated severity score at ICU admission
- Combined with SSC bundles, it helps predict mortality and guide intensity of intervention
- A score of ≥15 in septic patients correlates with substantially increased mortality and ICU resource requirements
- Procalcitonin, lactate, and SOFA score (Sequential Organ Failure Assessment) are now more commonly used alongside APACHE II in contemporary sepsis protocols
SOFA Score (Modern Complement)
The 2016 Sepsis-3 consensus introduced the SOFA score as the preferred organ dysfunction scoring tool for defining sepsis, while qSOFA (quick SOFA: altered mentation, RR ≥22, SBP ≤100) is used for rapid bedside screening. APACHE II remains valuable for overall ICU severity stratification and mortality prediction.
Sources: Schwartz's Principles of Surgery, 11e — Table 6-10, pp. 203–205; Swanson's Family Medicine Review; Rosen's Emergency Medicine, 9e
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Surviving Sepsis Campaign (SSC) Guidelines — Extended
Evolution of the Guidelines
The SSC guidelines were first published in 2004, then updated in 2008, 2014, 2016, and most recently in 2021. The 2016 update represented a major conceptual shift — abandoning SIRS criteria in favor of SOFA-based definitions of sepsis (Sepsis-3). The 2021 guidelines further refined recommendations, including advising against qSOFA as a sole screening tool. — Sabiston Textbook of Surgery, 10e
Sepsis-3 Definitions (2016 Onwards)
Old Definition (Pre-2016) — SIRS-Based
Sepsis was previously defined as SIRS + suspected infection source.
SIRS Criteria (≥2 required):
| Parameter | Threshold |
|---|---|
| Body temperature | >38°C or <36°C |
| Heart rate | >90 beats/min |
| Respiratory rate | >20/min or PaCO₂ <32 mmHg |
| WBC count | >12,000/mm³, <4,000/mm³, or >10% bands |
Problem: Any noninfectious inflammatory process (e.g., pancreatitis, burns, major surgery) could mimic this — poor specificity.
New Definitions (Sepsis-3, 2016)
| Term | Definition |
|---|---|
| Sepsis | Life-threatening organ dysfunction caused by a dysregulated host response to infection; defined as SOFA score increase ≥2 from baseline |
| Septic Shock | Sepsis + hypotension despite adequate fluid resuscitation requiring vasopressors + serum lactate >2 mmol/L despite absence of hypovolemia |
The key distinction: septic shock identifies patients with circulatory, cellular, and metabolic abnormality severe enough to substantially increase mortality.
SOFA Score (Sequential Organ Failure Assessment)
Used to quantify organ dysfunction in the ICU. A SOFA score ≥2 above baseline = sepsis.
| System | Parameter | Score 0 | Score 1 | Score 2 | Score 3 | Score 4 |
|---|---|---|---|---|---|---|
| Respiratory | PaO₂/FiO₂ (mmHg) | ≥400 | <400 | <300 | <200 (on vent) | <100 (on vent) |
| Coagulation | Platelets (×10³/µL) | ≥150 | <150 | <100 | <50 | <20 |
| Liver | Bilirubin (mg/dL) | <1.2 | 1.2–1.9 | 2.0–5.9 | 6.0–11.9 | >12.0 |
| Cardiovascular | MAP/vasopressors | MAP ≥70 | MAP <70 | Dopamine <5 or dobutamine (any) | Dopamine 5.1–15 or epi/norepi ≤0.1 | Dopamine >15 or epi/norepi >0.1 |
| CNS | Glasgow Coma Scale | 15 | 13–14 | 10–12 | 6–9 | <6 |
| Renal | Creatinine (mg/dL) | <1.2 | 1.2–1.9 | 2.0–3.4 | 3.5–4.9 | >5.0 |
— Sabiston Textbook of Surgery, 10e, Table 33.6
qSOFA (Quick SOFA) — Bedside Screening
A bedside tool requiring no lab tests. Score ≥2 = high risk, prompt sepsis workup warranted.
| Criterion | Threshold | Points |
|---|---|---|
| Altered mental status | Any GCS <15 | 1 |
| Respiratory rate | ≥22 breaths/min | 1 |
| Systolic BP | ≤100 mmHg | 1 |
Important (2021 SSC update): The 2021 guidelines now recommend against using qSOFA alone over SIRS, NEWS (National Early Warning Score), or MEWS (Modified Early Warning Score) as a single screening tool for sepsis — due to insufficient sensitivity.
SSC 2021 — Key Updated Recommendations
Hour-1 Bundle (replacing the old 3-hour and 6-hour bundles)
The 2021 SSC introduced the "Hour-1 Bundle" to be initiated within the first hour of recognition:
- Measure lactate — re-measure if initial lactate >2 mmol/L
- Blood cultures — before antibiotics
- Broad-spectrum antibiotics
- 30 mL/kg IV crystalloid for hypotension or lactate ≥4 mmol/L
- Vasopressors if MAP <65 mmHg despite fluid resuscitation
Initial Resuscitation (2021 Updates)
- Targeting lactate normalization is preferred over targeting ScvO₂ alone
- Dynamic measures of fluid responsiveness (pulse pressure variation, stroke volume variation) are preferred over static measures (CVP) for guiding fluid therapy
- CVP alone is no longer recommended as a primary guide for resuscitation
- Routine use of Swan-Ganz catheter: not recommended (excessive hemodynamic monitoring shown to be of no added benefit in controlled trials)
Antibiotic Therapy (2021 Updates)
| Recommendation | Detail |
|---|---|
| Timing | Within 1 hour of recognition |
| Spectrum | Broad-spectrum covering likely organisms and penetrating suspected source |
| De-escalation | Reassess daily; narrow as culture results become available |
| Duration | 7–10 days for most infections |
| Procalcitonin | Use serial levels to guide early cessation of antibiotics |
| Combination therapy | Consider for septic shock; not routinely for all sepsis |
Vasopressor Therapy (2021 — Hierarchy)
| Priority | Agent | Indication |
|---|---|---|
| 1st line | Norepinephrine (central IV) | All septic shock |
| 2nd line | Vasopressin (0.03–0.04 units/min) | Add-on to reduce NE dose or meet MAP target |
| 3rd line | Epinephrine | Alternative to vasopressin; caution: splanchnic hypoperfusion |
| Selected patients only | Dopamine | Only if bradycardia + low arrhythmia risk |
| Not recommended | Phenylephrine, "renal dose" dopamine | — |
| Adjunct | Angiotensin II | Can be used in refractory vasodilatory shock |
| Inotrope | Dobutamine | Persistent hypoperfusion after adequate fluids + vasopressors |
Steroid Therapy (2021)
- IV Hydrocortisone 200 mg/day (as continuous infusion or divided doses) for septic shock when:
- Adequate fluid resuscitation has been given AND
- Vasopressor requirement remains high
- Dose update: reduced from the previous threshold of <300 mg/day to 200 mg/day
- Duration: typically 5–7 days with tapering
Ventilatory Support in Sepsis-Induced ARDS
| Parameter | Target |
|---|---|
| Tidal volume | 6 mL/kg ideal body weight |
| Plateau pressure | <30 cmH₂O |
| PEEP | Higher PEEP in moderate-to-severe ARDS |
| Prone positioning | ≥12 hours/day for severe ARDS (PaO₂/FiO₂ <150) |
| Neuromuscular blockade | Can be used for severe ARDS refractory to other measures |
| Target SpO₂ | 92–96% (avoid hyperoxia) |
Glucose Control
- Target: Blood glucose <180 mg/dL (not <110 mg/dL — tight control increases hypoglycemia risk)
- Use a validated insulin protocol
- Monitor glucose every 1–2 hours until stable, then every 4 hours
Renal Support
- Continuous renal replacement therapy (CRRT) or intermittent hemodialysis equivalent in hemodynamically stable patients
- CRRT preferred in hemodynamically unstable patients
- Avoid nephrotoxins; adjust drug doses for renal impairment
Nutrition
- Oral/enteral feeding within 48 hours of ICU admission if tolerated
- Avoid early parenteral nutrition in patients who can be fed enterally
- No benefit to supplemental parenteral nutrition in first 7 days if enteral route is partially functioning
EGDT — Historical Context
Rivers et al. (2001) showed that a 6-hour Early Goal-Directed Therapy (EGDT) protocol — targeting CVP 8–12, MAP ≥65, ScvO₂ ≥70%, and UO ≥0.5 mL/kg/h — reduced mortality from 46.5% to 30.5%. This formed the basis of the original SSC bundles.
Subsequent trials (ProCESS, ARISE, ProMISe) showed no additional benefit of protocol-mandated central venous monitoring over standard care — largely because standard care had already incorporated EGDT principles. What persists is the underlying philosophy: early recognition, early antibiotics, early hemodynamic support.
APACHE II Scoring System — Extended
Full Overview
APACHE II was developed by Knaus et al. (1985) to quantify illness severity for ICU patients and predict hospital mortality. It remains one of the most widely used and validated ICU scoring systems globally.
Total score range: 0 to 71 (higher = worse prognosis)
Component A — Acute Physiology Score (APS)
12 physiologic variables, each scored 0–4 based on deviation from normal:
| # | Variable | Worst value in first 24h |
|---|---|---|
| 1 | Temperature (rectal, °C) | |
| 2 | Mean arterial pressure (mmHg) | |
| 3 | Heart rate (beats/min) | |
| 4 | Respiratory rate (breaths/min) | |
| 5 | Oxygenation: PaO₂ (if FiO₂ <50%) or A-a gradient (if FiO₂ ≥50%) | |
| 6 | Arterial pH | |
| 7 | Serum sodium (mEq/L) | |
| 8 | Serum potassium (mEq/L) | |
| 9 | Serum creatinine (mg/dL) — doubled if acute renal failure | |
| 10 | Hematocrit (%) | |
| 11 | WBC count (×10³/mm³) | |
| 12 | Glasgow Coma Scale — points = 15 − actual GCS |
Each variable scored 0 (normal) → 1 → 2 → 3 → 4 (most abnormal in either direction).
Component B — Age Points
| Age (years) | Points |
|---|---|
| ≤44 | 0 |
| 45–54 | 2 |
| 55–64 | 3 |
| 65–74 | 5 |
| ≥75 | 6 |
Component C — Chronic Health Points
Assigned if patient has severe organ insufficiency or is immunocompromised (documented prior to admission):
| Admission Type | Points |
|---|---|
| Nonoperative or emergency postoperative | 5 |
| Elective postoperative | 2 |
Qualifying conditions:
- Liver: Cirrhosis with portal hypertension; hepatic encephalopathy history
- Cardiovascular: NYHA Class IV
- Respiratory: Chronic restrictive/obstructive/vascular disease; chronic hypoxia, hypercapnia, polycythemia, or pulmonary hypertension
- Renal: Receiving chronic dialysis
- Immunocompromised: Immunosuppressive therapy, radiation, long-term steroids, leukemia, lymphoma, AIDS
Final Score Calculation
APACHE II = APS + Age Points + Chronic Health Points
Mortality Prediction
| APACHE II Score | Predicted ICU Mortality |
|---|---|
| 0–4 | ~4% |
| 5–9 | ~8% |
| 10–14 | ~15% |
| 15–19 | ~25% |
| 20–24 | ~40% |
| 25–29 | ~55% |
| 30–34 | ~75% |
| ≥35 | >85% |
APACHE II — Clinical Applications
| Condition | Significance of Score |
|---|---|
| Sepsis/Septic shock | Score ≥15 correlates with high mortality; guides intensity of intervention |
| Acute pancreatitis | Score ≥8 at 24 hours predicts need for ICU, pancreatic necrosis, secondary infection, and mortality |
| Acute liver failure | Used alongside King's College Criteria to assess prognosis |
| Cirrhosis | Predicts postoperative mortality in non-hepatic surgery (used alongside Child-Pugh) |
| ARDS | Stratifies severity; higher scores guide escalation to prone positioning or ECMO |
APACHE II vs. Other ICU Scoring Systems
| Score | Basis | Purpose | Bedside? |
|---|---|---|---|
| APACHE II | 12 physiology + age + chronic health | Mortality prediction; ICU stratification | No (needs labs) |
| SOFA | 6 organ systems | Organ dysfunction; defines sepsis (Sepsis-3) | Partial |
| qSOFA | RR, SBP, GCS | Rapid sepsis screening | Yes |
| SIRS | Temp, HR, RR, WBC | Old sepsis screening (largely abandoned) | Yes |
| MEWS/NEWS | Vital signs | Early warning; deterioration detection | Yes |
| SAPS II | 17 variables | Alternative to APACHE; simpler | No |
Key Points to Remember
- APACHE II uses the worst values in the first 24 hours of ICU admission
- Serum creatinine is doubled if the patient has acute (not chronic) renal failure
- The GCS component = 15 minus the actual GCS score (i.e., normal GCS = 0 points)
- APACHE II scores are used for ICU audit, benchmarking, research, and to compare predicted vs. actual mortality across units
- It does not replace clinical judgment and should not be used as the sole basis for triage or withdrawal decisions
Sources: Sabiston Textbook of Surgery, 10e — Tables 33.5–33.7, pp. 577–582; Schwartz's Principles of Surgery, 11e — Table 6-10, pp. 203–205; Swanson's Family Medicine Review; Rosen's Emergency Medicine, 9e
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