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Surviving Sepsis Campaign (SSC) Guidelines & APACHE II Score

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🔴 Surviving Sepsis Campaign Guidelines

1. Initial Evaluation & Resuscitation

• Ongoing fluid administration guided by physiologic variables (HR, BP, UO) or invasive/non-invasive monitoring.

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2. Diagnosis

• Obtain appropriate cultures before antibiotics — but do not delay antibiotic therapy.
• Perform imaging promptly to confirm source of infection.

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3. Antibiotic Therapy

• Begin IV broad-spectrum antibiotics as early as possible, within 1 hour of recognizing severe sepsis/septic shock.
• Antibiotic regimen should have penetration into the presumed source.
• Reassess daily for de-escalation as culture data returns.
• Duration: 7–10 days for most infections.
• Stop antibiotics if no infectious etiology is identified.
• Serial procalcitonin levels may allow earlier cessation.

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4. Source Control

• Establish anatomic source of infection as rapidly as possible.
• Implement source control (drainage, debridement) as soon as possible after initial resuscitation.
• Remove intravascular access devices if potentially infected.

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5. Hemodynamic Support & Vasopressors

• Norepinephrine is the first-line vasopressor (MAP target ≥65 mmHg).
• Vasopressin (up to 0.03 units/min) may be added to norepinephrine to raise MAP or to reduce norepinephrine dose.
• Epinephrine can be added when additional agent is needed.
• Dopamine as an alternative to norepinephrine only in select patients (low risk of tachyarrhythmia, relative bradycardia).
• Dobutamine (up to 20 μg/kg/min) for patients with myocardial dysfunction with low cardiac output/filling pressures.
• Avoid dopamine use in septic shock unless specific indications exist.

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6. Corticosteroids

• IV hydrocortisone 200 mg/day — only if hemodynamic instability persists despite adequate fluid resuscitation and vasopressor therapy.
• Do not use corticosteroids to treat sepsis in the absence of shock.
• Taper steroids once vasopressors are no longer required.
• Do not use dexamethasone if hydrocortisone is available.

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7. Blood Products

• Transfuse RBCs when Hgb <7.0 g/dL in the absence of:
  • Myocardial ischemia
  • Severe hypoxemia
  • Acute hemorrhage
• No erythropoietin for treatment of sepsis-related anemia.
• FFP only for active bleeding or planned invasive procedure with coagulopathy.
• Platelets transfused when <10,000/mm³ (no bleeding), <20,000/mm³ (significant bleeding risk), <50,000/mm³ (active bleeding, surgery, or invasive procedures).

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8. Mechanical Ventilation (Sepsis-Induced ARDS)

• Target tidal volume 6 mL/kg predicted body weight.
• Plateau airway pressures <30 cmH₂O.
• Apply PEEP to prevent alveolar collapse.
• Prone positioning in severe ARDS (PaO₂/FiO₂ <100 mmHg).
• HOB elevation 30–45° to reduce aspiration/VAP risk.
• Minimize continuous or intermittent sedation; target specific titration endpoints.
• Avoid neuromuscular blockade when possible; if required in ARDS, use ≤48 hours.
• Avoid routine use of β₂-agonists unless bronchospasm is present.

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9. Sedation & Delirium

• Minimize sedation; use titrated protocols.
• Assess for and manage ICU delirium.

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10. Glucose Control

• Initiate insulin when blood glucose >180 mg/dL.
• Target blood glucose ≤180 mg/dL (not <110 mg/dL — avoid hypoglycemia).
• Monitor glucose every 1–2 hours until stable, then every 4 hours.

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11. Renal Replacement Therapy (RRT)

• Continuous or intermittent RRT are equivalent in severe AKI.
• Use continuous RRT for hemodynamically unstable patients.

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12. Bicarbonate Therapy

• Do not use sodium bicarbonate for lactic acidosis from hypoperfusion if pH ≥7.15.

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13. DVT Prophylaxis

• Use unfractionated heparin (UFH) or LMWH unless contraindicated.
• If heparin contraindicated, use mechanical prophylaxis (graduated compression stockings / intermittent pneumatic compression).

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14. Stress Ulcer Prophylaxis

• Administer H₂ blocker or PPI to patients with bleeding risk factors.
• Do not provide prophylaxis in patients without risk factors.

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15. Nutrition

• Administer oral/enteral (not parenteral) nutrition as tolerated within the first 48 hours.
• Avoid mandatory full caloric replacement in the first week.
• Use IV glucose + enteral nutrition rather than full parenteral nutrition alone.
• Avoid supplemental selenium, glutamine, or arginine (no benefit shown).

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📊 APACHE II Scoring System

Components of APACHE II Score

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12 Physiologic Variables (APS) — Score 0 to +4 each

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Age Points

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Chronic Health Points

• +5 points for non-operative or emergency postoperative patients
• +2 points for elective postoperative patients

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Scoring Interpretation & Mortality Prediction

1. APACHE II score
2. Whether emergency surgery was required
3. A disease-specific diagnostic category weight

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Updated Versions

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Key Clinical Uses

• Prognosis and risk stratification on ICU admission
• Research: benchmarking ICU performance and comparing study populations
• Sepsis severity: APACHE II ≥25 in sepsis indicates high mortality risk
• Pancreatitis: APACHE-II ≥8 within 24 hours indicates severe acute pancreatitis

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• Schwartz's Principles of Surgery, 11th Ed. — Table 6-10 (Surviving Sepsis Campaign)
• Harrison's Principles of Internal Medicine, 22nd Ed. — Table 311-2 (APACHE II)