Recent surviving sepsis guidelines and apache score
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Surviving Sepsis Campaign (SSC) Guidelines & APACHE Score
Surviving Sepsis Campaign Guidelines
The Surviving Sepsis Campaign (SSC) is a multidisciplinary group publishing evidence-based sepsis treatment recommendations. The guidelines cover five major domains:
1. Initial Resuscitation & Diagnosis
- Begin resuscitation immediately in patients with hypotension or elevated serum lactate
- Give ≥30 mL/kg IV crystalloid in the first 3 hours
- Ongoing fluid administration guided by clinical variables: heart rate, blood pressure, urine output, and invasive/noninvasive monitoring
- Resuscitation goals:
- MAP >65 mmHg
- Urine output >0.5 mL/kg/h
- Mixed venous O₂ saturation >65%
- Normalize lactate in patients with elevated levels
- Obtain appropriate cultures before antibiotics, but do not delay antibiotic therapy
- Perform imaging promptly to confirm source of infection
2. Antibiotic Therapy & Source Control
- Begin IV antibiotics as early as possible, within the first hour of recognition of severe sepsis/septic shock
- Use broad-spectrum agents with penetration into the presumed source
- Reassess regimen daily; de-escalate as appropriate
- Discontinue antibiotics in 7–10 days for most infections
- Consider serial procalcitonin levels to allow earlier cessation
- Establish anatomic site of infection as rapidly as possible
- Implement source control measures ASAP after initial resuscitation
- Remove intravascular access devices if potentially infected
3. Hemodynamic Support & Vasopressors
- Fluid therapy: Crystalloids first; albumin as adjunct if large volumes required; avoid hydroxyethyl starch and gelatin-based fluids
- Vasopressors:
- Norepinephrine (centrally administered) = first-line choice
- Add vasopressin to raise MAP or reduce norepinephrine requirement
- Epinephrine is an alternative to vasopressin (risk: reduced splanchnic flow)
- Dopamine: appropriate only in select patients (bradycardia, low arrhythmia risk)
- Phenylephrine is NOT recommended
- No role for low-dose "renal protection" dopamine
- Insert arterial catheters for patients requiring vasopressors
- Consider dobutamine infusion for persistent hypoperfusion despite resuscitation
4. Steroids
- Consider IV hydrocortisone (<300 mg/day) for adult septic shock when hypotension responds poorly to fluids and vasopressors
5. Other Supportive Therapy
- Blood products: Transfuse RBCs when Hgb <7.0 g/dL (absent extenuating circumstances such as myocardial ischemia or active hemorrhage)
- FFP is not required to correct coagulopathy in the absence of bleeding or planned procedures
APACHE Score (Acute Physiology and Chronic Health Evaluation)
Overview
APACHE is one of the most widely used ICU severity-of-illness scoring systems. It has gone through four iterations: APACHE, APACHE II, APACHE III, and APACHE IV.
APACHE II Components
APACHE II score = Acute Physiology Score + Age Points + Chronic Health Points
| Component | Details |
|---|---|
| Acute Physiology Score | 12 routine physiologic measurements (vital signs, oxygenation, lab values) |
| Glasgow Coma Scale | Incorporated directly |
| Age | Points added by age range |
| Chronic Health | Points for severe organ insufficiency or immunocompromise |
- Worst values during the first 24 hours in the ICU are used
- Higher score = higher predicted mortality
The relationship between APACHE II score and mortality risk is well established — higher scores correlate with significantly increased ICU mortality.
The APACHE II score is the sum of the acute physiology score (vital signs, oxygenation, laboratory values), the Glasgow coma score, age, and chronic health points. The worst values during the first 24 h in the ICU should be used. — Harrison's Principles of Internal Medicine 22E, p. 311
SOFA & qSOFA (Current Sepsis-3 Emphasis)
Per Sepsis-3 consensus guidelines, SOFA (Sequential Organ Failure Assessment) is now central to sepsis diagnosis and monitoring:
SOFA Score — 6 organ systems, each scored 0–4:
| System | Parameters |
|---|---|
| Respiration | PaO₂/FiO₂ (mmHg): ≥400=0, <400=1, <300=2, <200+support=3, <100+support=4 |
| Coagulation | Platelets (×10³/μL): ≥150=0, <150=1, <100=2, <50=3, <20=4 |
| Liver | Bilirubin mg/dL: <1.2=0, 1.2–1.9=1, 2.0–5.9=2, 6.0–11.9=3, >12=4 |
| Cardiovascular | MAP/vasopressor doses (see full table) |
| CNS | Glasgow Coma Scale: 15=0, 13–14=1, 10–12=2, 6–9=3, <6=4 |
| Renal | Creatinine mg/dL / urine output |
- An increase of ≥2 SOFA points from baseline = diagnostic of sepsis in the setting of suspected/documented infection
qSOFA (quick SOFA) — bedside screening, ≥2 of:
- Respiratory rate ≥22 breaths/min
- Altered mental status
- Systolic BP ≤100 mmHg
qSOFA is intended to screen patients outside the ICU for risk of poor outcomes from sepsis.
Key Distinction: APACHE vs. SOFA in Sepsis
| Feature | APACHE II | SOFA |
|---|---|---|
| Primary use | General ICU mortality prediction | Organ dysfunction tracking in sepsis |
| Timing | Based on worst 24-h values | Can be recalculated daily |
| Sepsis diagnosis | Not used for this | ≥2-point rise = sepsis (Sepsis-3) |
| Bedside version | None (complex calculation) | qSOFA (3 criteria) |
Sources:
- Schwartz's Principles of Surgery, 11th Ed. — Table 6-10 (Summary of SSC Guidelines)
- Harrison's Principles of Internal Medicine, 22E — Ch. 311 (APACHE II, SOFA, qSOFA)
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Surviving Sepsis Campaign (SSC) — Detailed Guidelines & APACHE Score
PART 1: SURVIVING SEPSIS CAMPAIGN — DETAILED GUIDELINES
Background
The SSC published its first evidence-based guidelines in 2004, with major updates in 2008, 2012, 2016, and the most recent update in 2021. Recommendations are bundled into time-based targets. The core principles of management are:
- Source control
- Restoration of end-organ perfusion
- Appropriate antimicrobial therapy
THE 1-HOUR BUNDLE (SSC 2018/2021)
The SSC bundle consolidates initial interventions. The original goal was completion within 3 hours; subsequent evidence has pushed toward a 1-hour completion target:
- Measure lactate (repeat if initial >2 mmol/L)
- Obtain blood cultures before antibiotics
- Administer broad-spectrum antibiotics
- Begin fluid resuscitation (30 mL/kg IV crystalloid) for hypotension or lactate ≥4 mmol/L
- Initiate vasopressors if hypotension persists despite fluids (MAP target ≥65 mmHg)
Faster bundle completion is associated with lower in-hospital mortality. However, criticism exists: only a minority of patients who screen positive receive a confirmed diagnosis of sepsis, raising concerns about overuse of antibiotics and overly aggressive fluid resuscitation.
1. FLUID RESUSCITATION (Detailed)
Initial bolus:
- 30 mL/kg balanced crystalloid (e.g., lactated Ringer's) within the first 3 hours for hypotension or lactate ≥4 mmol/L
- Balanced crystalloids (vs. normal saline) are associated with decreased mortality, less need for renal replacement therapy, and less renal dysfunction
What NOT to use:
- Colloids (albumin): Not recommended for initial resuscitation
- Hydroxyethyl starches: Associated with increased need for RRT — do not use in septic patients
- Gelatin-based fluids: Should not be used
Beyond initial resuscitation:
- Ongoing fluids guided by dynamic assessment — no longer target a static CVP of 8–12 mmHg
- Use passive leg raise test: If SBP increases within 60 seconds of raising legs 45°, the patient is likely fluid-responsive (best detected with intra-arterial monitoring)
- On mechanical ventilation: Pulse pressure variation (PPV) predicts fluid responsiveness
- Bedside point-of-care ultrasound: IVC collapsibility, ventricular size/function, aortic flow variation
- Sustained positive fluid balance in the ICU has negative consequences — avoid over-resuscitation
Resuscitation endpoints:
- MAP ≥65 mmHg
- Urine output ≥0.5 mL/kg/h
- Normalization of serum lactate
- Mixed venous O₂ saturation >65%
Delaying resuscitation by as little as 3 hours has been shown to worsen outcomes. — Schwartz's Principles of Surgery, 11th Ed.
2. ANTIMICROBIAL THERAPY (Detailed)
- Initiate IV antibiotics within 1 hour of recognition — each hour of delay is independently associated with increased mortality
- Broad-spectrum coverage: gram-positive, gram-negative, and anaerobic organisms
- Consider antifungals in high-risk situations (immunocompromised, prolonged ICU stay, prior antibiotics, candidemia risk)
- Obtain blood, urine, sputum, and site-specific cultures (peritoneal fluid, abscess fluid, etc.) before antibiotics — but do not delay antibiotics for cultures
- Consider serial procalcitonin levels to allow earlier cessation
- Reassess daily for de-escalation once culture sensitivities available
- Duration: 7–10 days for most infections; stop for non-infectious processes
- Choice influenced by: patient history, chronic organ dysfunction, immunocompromise, prior antibiotic exposure, indwelling devices, suspected source
- AI-based early detection algorithms (accuracy ~80%) are under development
3. SOURCE CONTROL (Detailed)
The third crucial component — many sepsis etiologies cannot be managed without a surgeon.
Common surgically manageable sources:
- Cholecystitis / Cholangitis
- Intestinal ischemia / Bowel perforation / Perforated appendicitis
- Pyelonephritis with obstruction
- Abscess formation
- Necrotizing soft tissue infections
- Contaminated implanted devices / catheters
Key principles:
- Establish anatomic source as rapidly as possible; implement source control ASAP after initial resuscitation
- Observation studies show lower mortality when source control is achieved early, even when resuscitation or antibiotics are delayed
- Prolonged medical stabilization before source control is not advised
- Patients who appear "too sick" to tolerate surgery may in fact be "too sick NOT to have" surgery
- Use the least invasive intervention adequate to achieve source control
- If no clinical improvement after intervention → evaluate whether source control has truly been achieved (may need reoperation)
- Remove intravascular access devices if potentially infected
4. VASOPRESSORS / HEMODYNAMIC SUPPORT (Detailed)
| Agent | Role | Notes |
|---|---|---|
| Norepinephrine | First-line | Centrally administered; target MAP ≥65 mmHg |
| Vasopressin | Second-line adjunct | 0.04 units/min; added when norepinephrine >~5 mcg/min; reduces NE requirements; may decrease sepsis-induced pulmonary inflammation |
| Epinephrine | Alternative if NE+vasopressin insufficient | Can cause falsely elevated lactate — complicates monitoring |
| Dobutamine | Adjunct for low CO or cardiac dysfunction | Add to NE in patients with septic cardiomyopathy |
| Dopamine | Avoid routinely | Higher rates of arrhythmias; use only if bradycardia + low arrhythmia risk |
| Phenylephrine | Do NOT use | Associated with higher in-hospital mortality in septic shock |
MAP target debate:
- Standard target: MAP ≥65 mmHg
- MAP >85 mmHg showed no mortality benefit overall, but in patients with chronic systolic hypertension, higher MAP was associated with less organ failure and reduced need for RRT
- Higher MAP target requires more vasopressors → more arrhythmias; individualize
Septic cardiomyopathy:
- Sepsis can cause both systolic and diastolic dysfunction
- Distinguish type of shock (distributive vs. cardiogenic vs. concurrent) — guides treatment
- Echocardiography is essential for assessment
Insert arterial catheter for all patients requiring vasopressors (continuous BP monitoring + fluid responsiveness assessment)
5. CORTICOSTEROIDS (Detailed)
- Use low-dose IV hydrocortisone (200 mg/day — not >300 mg/day) in vasopressor-dependent, volume-replete septic shock refractory to initial therapy
- ADRENAL trial: Low-dose steroids did not decrease 90-day mortality, but showed faster resolution of shock and shorter duration of mechanical ventilation
- HAT therapy (Hydrocortisone + Ascorbic acid + Thiamine): Recent RCTs failed to show mortality benefit; some evidence of faster shock resolution — not routinely recommended
- Do NOT use corticosteroids routinely in all septic patients
6. MECHANICAL VENTILATION IN SEPSIS
- Lung-protective ventilation:
- Tidal volume: 6 mL/kg ideal body weight
- Plateau pressure: <30 cmH₂O
- PEEP: Higher PEEP recommended if ARDS develops
- Permissive hypercapnia tolerated if pH >7.2
- Sepsis-induced ARDS with PaO₂/FiO₂ <150: Use prone ventilation (over supine or HFOV)
- Pulmonary artery catheter: Not indicated for routine monitoring
- Sedation: Minimize; use specific titration endpoints; daily sedation holidays
- Spontaneous breathing trials (SBT): Daily, part of weaning protocol
- VAP prevention: HOB elevation 30–45°; oral decontamination with chlorhexidine gluconate
7. BLOOD PRODUCTS
| Product | Threshold | Conditions |
|---|---|---|
| RBCs | Hgb <7.0 g/dL | Absent myocardial ischemia, active hemorrhage, or severe anemia (old EGDT threshold of <10 g/dL when ScvO₂ <70% is no longer supported) |
| FFP | Only if active bleeding or planned procedure | No RCT data in sepsis; not for routine INR correction |
| Platelets | <50,000 if bleeding/procedure; <20,000 if no bleeding risk | Thrombocytopenia often transient (consumptive) |
For DOAC reversal in surgical source control: use Prothrombin complex concentrate (PCC) — faster acting, avoids large FFP volumes in patients with cardiomyopathy.
8. ADDITIONAL SUPPORTIVE CARE
- Glucose control: Protocolized management; target upper blood glucose ≤180 mg/dL (avoid hypoglycemia)
- Stress ulcer prophylaxis: PPI or H2 blocker
- DVT prophylaxis: Low-dose unfractionated or LMWH heparin
- Goals of care: Discuss advance care planning with patients and families; set realistic expectations; limitation of support if appropriate
EGDT — What Changed?
Early Goal-Directed Therapy (EGDT) originally included CVP targets, ScvO₂ targets, and early transfusion to Hgb 10. Subsequent RCTs (ProCESS, ARISE, ProMISe) showed little additional benefit over standard care. The current consensus:
- Underlying principles of metric-guided resuscitation remain valid
- What has changed: dynamic monitoring (not static CVP), Hgb threshold lowered to 7, de-emphasis on ScvO₂
- The control groups improved because EGDT principles became standard care
PART 2: APACHE SCORE — DETAILED
Overview of APACHE Versions
| Version | Notes |
|---|---|
| APACHE | Original (rarely used now) |
| APACHE II | Most widely used in North America; most validated |
| APACHE III | Published; more variables |
| APACHE IV | Most recent version |
APACHE II — Full Scoring Details
APACHE II Score = Acute Physiology Score (APS) + Age Points + Chronic Health Points
Uses the worst values in the first 24 hours of ICU admission.
A. Acute Physiology Score (12 Variables, each scored 0–4)
| Variable | +4 | +3 | +2 | +1 | 0 | +1 | +2 | +3 | +4 |
|---|---|---|---|---|---|---|---|---|---|
| Rectal Temp (°C) | ≥41 | 39–40.9 | — | 38.5–38.9 | 36–38.4 | 34–35.9 | 32–33.9 | 30–31.9 | ≤29.9 |
| Mean BP (mmHg) | ≥160 | 130–159 | 110–129 | — | 70–109 | — | 50–69 | — | ≤49 |
| Heart Rate (bpm) | ≥180 | 140–179 | 110–139 | — | 70–109 | — | 55–69 | 40–54 | ≤39 |
| Respiratory Rate | ≥50 | 35–49 | — | 25–34 | 12–24 | 10–11 | 6–9 | — | ≤5 |
| Oxygenation (FiO₂ <0.5: use A-a gradient; ≥0.5: use PaO₂) | varies | — | — | — | — | — | — | — | — |
| Arterial pH | ≥7.7 | 7.6–7.69 | — | 7.5–7.59 | 7.33–7.49 | — | 7.25–7.32 | 7.15–7.24 | <7.15 |
| Serum Na (mEq/L) | ≥180 | 160–179 | 155–159 | 150–154 | 130–149 | — | 120–129 | 111–119 | ≤110 |
| Serum K (mEq/L) | ≥7 | 6–6.9 | — | 5.5–5.9 | 3.5–5.4 | 3–3.4 | 2.5–2.9 | — | <2.5 |
| Serum Creatinine | ≥3.5 | 2–3.4 | 1.5–1.9 | — | 0.6–1.4 | — | <0.6 | — | — |
| Hematocrit (%) | ≥60 | — | 50–59.9 | 46–49.9 | 30–45.9 | — | 20–29.9 | — | <20 |
| WBC (×10³/mm³) | ≥40 | — | 20–39.9 | 15–19.9 | 3–14.9 | — | 1–2.9 | — | <1 |
| Glasgow Coma Scale | Score = 15 minus actual GCS |
B. Age Points
| Age | Points |
|---|---|
| ≤44 | 0 |
| 45–54 | 2 |
| 55–64 | 3 |
| 65–74 | 5 |
| ≥75 | 6 |
C. Chronic Health Points
For patients with severe organ insufficiency or immunocompromise (liver cirrhosis, portal hypertension, Class IV heart failure, severe COPD, chronic dialysis, immunocompromise):
- +5 points for nonoperative or emergency postoperative patients
- +2 points for elective postoperative patients
APACHE II Score → Predicted Mortality
| APACHE II Score | Approximate ICU Mortality |
|---|---|
| 0–4 | ~4% |
| 5–9 | ~8% |
| 10–14 | ~15% |
| 15–19 | ~25% |
| 20–24 | ~40% |
| 25–29 | ~55% |
| 30–34 | ~75% |
| ≥35 | >80% |
Predicted hospital mortality = derived from a formula incorporating:
- APACHE II score
- Need for emergency surgery
- A weighted, disease-specific diagnostic category
SOFA vs. APACHE II in Sepsis Context
| Feature | APACHE II | SOFA |
|---|---|---|
| Purpose | Overall ICU mortality prediction | Organ dysfunction scoring; sepsis diagnosis |
| Variables | 12 physiology + age + chronic health | 6 organ systems |
| Timing | Worst values, first 24h (static snapshot) | Can be recalculated daily |
| Sepsis diagnosis | Not used | ≥2-point rise = sepsis (Sepsis-3) |
| Trend value | Not designed for trending | Rising scores = increasing mortality |
| ICU use | General severity, triage, research | Daily monitoring, clinical decision-making |
| Bedside version | None | qSOFA (3 criteria) |
qSOFA — Bedside Screening Tool
≥2 of the following = high risk for poor outcomes (screen outside ICU):
- Respiratory rate ≥22 breaths/min
- Altered mental status (GCS <15)
- Systolic BP ≤100 mmHg
Note: The most recent SSC guidelines recommend against using qSOFA alone over SIRS or other criteria for sepsis screening — it has lower sensitivity than SIRS for identifying sepsis, though higher specificity. — Sabiston Textbook of Surgery
Electronic & AI-Based Scoring (Emerging)
- Electronic health record (EHR)-based scoring systems are being developed to incorporate larger, real-time datasets
- AI algorithms for early sepsis detection currently achieve ~80% accuracy in studies
- These may eventually supplement or replace static scoring systems like APACHE
Sources:
- Current Surgical Therapy, 14th Ed.
- Sabiston Textbook of Surgery (Biological Basis of Modern Surgical Practice)
- Schwartz's Principles of Surgery, 11th Ed.
- Harrison's Principles of Internal Medicine, 22nd Ed. (2025)
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