Recent surviving sepsis guidelines & apache score
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Surviving Sepsis Campaign (SSC) Guidelines — Summary
Source: Schwartz's Principles of Surgery, 11th Ed. | Harrison's Principles of Internal Medicine, 22nd Ed. (2025)
Initial Resuscitation
- Begin immediately in patients with hypotension or elevated serum lactate
- Administer ≥30 mL/kg IV crystalloid within the first 3 hours
- Ongoing fluids guided by physiologic response (HR, BP, urine output, dynamic monitoring/ultrasound)
- Goals:
- MAP ≥65 mmHg
- Urine output ≥0.5 mL/kg/hr
- Mixed venous O₂ saturation >65%
- Normalization of serum lactate
- Delaying resuscitation by even 3 hours worsens outcomes
Diagnosis
- Obtain appropriate cultures before antibiotics — but do NOT delay antibiotic therapy for culture collection
- Perform imaging promptly to confirm source of infection
Antibiotic Therapy
- Start IV antibiotics within 1 hour of recognition of severe sepsis/septic shock
- Use broad-spectrum agents with penetration into presumed source
- Reassess regimen daily and de-escalate appropriately
- Duration: 7–10 days for most infections
- Consider serial procalcitonin to guide earlier cessation
Source Control
- Identify anatomic infection site as rapidly as possible
- Implement source control measures (drainage, debridement) as soon as possible after initial resuscitation
- Remove potentially infected intravascular access devices
Hemodynamic Support & Vasopressors
| Agent | Role |
|---|---|
| Norepinephrine (central IV) | First-line vasopressor |
| Vasopressin | Add to raise MAP or reduce NE dose |
| Epinephrine | Alternative to vasopressin; risk of reduced splanchnic flow |
| Dopamine | Only in select patients (bradycardia, low arrhythmia risk) |
| Phenylephrine | Not recommended |
| Dobutamine | For persistent hypoperfusion despite fluids + vasopressors |
- Insert arterial catheter for patients requiring vasopressors
- Titrate to mixed venous O₂ saturation and plasma lactate to reduce perfusion deficits
Steroids
- Consider IV hydrocortisone (<300 mg/day) only when septic shock hypotension responds poorly to fluids and vasopressors
Other Supportive Therapies
| Domain | Recommendation |
|---|---|
| Blood products | Transfuse RBC if Hgb <7.0 g/dL (except myocardial ischemia/hemorrhage); platelets <10,000/mL prophylactically; <50,000 if active bleeding or procedure |
| Mechanical ventilation | Tidal volume 6 mL/kg; plateau pressure <30 cm H₂O; use PEEP; conservative fluids; prone ventilation for PaO₂/FiO₂ <150 |
| Sedation | Minimize; use titration endpoints |
| Glucose | Target upper blood glucose ≤180 mg/dL using protocolized approach |
| Prophylaxis | Stress ulcer (PPI or H2 blocker) + DVT prophylaxis (LMWH or UFH) |
| Goals of care | Discuss advance care planning and realistic expectations with patient/family |
APACHE II Score (Acute Physiology and Chronic Health Evaluation II)
Source: Harrison's Principles of Internal Medicine, 22nd Ed. | Schwartz's Principles of Surgery | Swanson's Family Medicine Review
APACHE II is the most widely used ICU severity-of-illness scoring system. It is calculated from the worst values in the first 24 hours of ICU admission.
Components
1. Acute Physiology Score (APS) — 12 variables, each scored 0–4 (creatinine gets up to +8 in acute renal failure):
| Variable | Score range |
|---|---|
| Rectal temperature (°C) | 0–4 |
| Mean arterial pressure (mmHg) | 0–4 |
| Heart rate (beats/min) | 0–4 |
| Respiratory rate (breaths/min) | 0–4 |
| Arterial pH | 0–4 |
| Oxygenation: A-aDO₂ (if FiO₂ >0.5) or PaO₂ (if FiO₂ ≤0.5) | 0–4 |
| Serum sodium (mEq/L) | 0–4 |
| Serum potassium (mEq/L) | 0–4 |
| Serum creatinine (mg/dL) | 0–8 (doubled in acute renal failure) |
| Hematocrit (%) | 0–4 |
| White blood cell count (×10³/mm³) | 0–4 |
| Glasgow Coma Scale | 15 minus actual GCS |
Max APS = 60 points
2. Age Points
| Age (years) | Points |
|---|---|
| <44 | 0 |
| 45–54 | 2 |
| 55–64 | 3 |
| 65–74 | 5 |
| ≥75 | 6 |
3. Chronic Health Points — 2 points (elective surgery) or 5 points (emergency surgery / non-surgical) if the patient has severe organ insufficiency or is immunocompromised (liver, cardiovascular, respiratory, renal, or immune system)
Total APACHE II Score = APS + Age Points + Chronic Health Points
Maximum = 71 points
Clinical Interpretation
| Score | Significance |
|---|---|
| <8 | Low severity |
| ≥8 | High risk — associated with need for ICU, pancreatic necrosis, secondary infection, increased mortality |
| ≥15 | High severity of illness (used as a threshold in antimicrobial guidelines for escalating coverage) |
| ≥16 | Significantly increased ICU mortality in trauma/sepsis |
| Higher scores | Progressively higher predicted mortality |
- In sepsis, APACHE II ≥16 is associated with substantially higher mortality — Harrison's Principles of Internal Medicine, 22nd Ed.
- In acute pancreatitis, APACHE II ≥8 at 24 hours predicts need for ICU, secondary infection, necrosis, and death — Swanson's Family Medicine Review
Key Relationship: Sepsis + APACHE II
APACHE II is used in sepsis to:
- Risk-stratify patients at ICU admission
- Guide antimicrobial intensity (e.g., APACHE II ≥15 triggers broader coverage)
- Predict mortality and guide goals-of-care discussions
- Benchmark outcomes for quality improvement
The Surviving Sepsis Campaign recommends using objective severity scores like APACHE II alongside lactate, SOFA, and clinical signs to guide resuscitation and ongoing management.
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