Expert consensus on the perioperative management of patients with sepsis

doi:10.5847/wjem.j.1920-8642.2015.04.001

Abstract

Chinese Association of Anesthesiologists. Expert consensus on the perioperative management of patients with sepsis[J]. World Journal of Emergency Medicine, 2015, 6(4): 245-260.

Figures/Tables 5

Table 1

Table 2

Table 3

Table 4

Recommendations	Grade
Diagnosis and definition of sepsis
1. The definitions of sepsis, severe sepsis and septic shock are based on the principles of definition and diagnosis proposed by the International Sepsis Definitions Conference held in 2001.	Class I
Preoperative evaluation and treatment
The cardiovascular system
1. Body temperature, skin color, urine volume, heart rate and blood pressure should be observed closely to assess cardiovascular condition and identify septic shock early.	Class I
2. At least two venous accesses should be for fluid infusion and some micro infusion pumps are prepared in addition to vasoactive agents such as noradrenaline, adrenaline, vasopressin, dopamine, dobutamine and phenylephrine.	Class I
3. Invasive artery blood pressure (IABP), central venous pressure (CVP) and blood lactate should be monitored to evaluate the effect of fluid management.	Class I
4. Central or mixed venous oxygen saturation should be monitored to assess tissue perfusion of the patients.	Class III
5. Cardiac ultrasound and test of FloTrac or PiCCO should be monitored to guide fluid management.	Class II
The respiratory system
1. Respiratory features, respiratory rate and SpO₂ should be closely observed to evaluate respiratory function.	Class I
2. Clinicians should perform arterial blood gas analysis and assess oxygenation status via oxygen index (PaO₂/FiO₂).	Class I
3. Imaging mordalities including chest radiography, chest CT, even lung ultrasonography (if it is available) could be used to assess lung injury.	Class II
4. Berlin definition of ARDS is used for diagnosis and assessment of severity of ARDS.	Class II
5. Oxygen inhalation with ordinary or oxygen masks, noninvasive positive pressure ventilation, even emergency tracheal intubation with mechanical ventilation as a respiratory treatment is based on the severity of the patients.	Class I
Renal function
1. Urine volume, serum creatinine and urea nitrogen should be measured routinely to evaluate the renal function before surgery.	Class I
2. Preoperative hyperkalemia (>5.5 mmol/L) should be adjusted using glucose combined with insulin, calcium supplement, sodium bicarbonate and furosemide.	Class II
3. Continuous renal replacement therapy (CRRT) is given to the patients with severe renal function injury or renal failure and intermittent coagulation function is monitored to evaluate the risk of bleeding.	Class II
Recommendations	Grade
Liver function
1. Liver function assessment is based on the level of bilirubin, alkaline phosphatase, ALT, AST, γ-GGTP, serum protein and coagulation function.	Class I
The blood system
1. Skin color, mucosal color, petechiae, purpura and ecchymoses should be closely monitored to predict the occurrence of severe anemia and coagulation dysfunction.	Class I
2. Testing of routine blood and coagulation function should be done before surgery. Thrombelastography is used to dynamically monitor coagulation function if necessary.	Class I
The nervous system
1. Whether patients have sepsis-induced dysfunction of the nervous system is determined according to their consciousness, cognition, response status and compliance with the instruction.	Class II
Other assessment and preparation
1. Blood glucose, water-electrolyte and acid-base balance should be assessed, and appropriate treatments are given to correct the abnormality before surgery.	Class I
2. To assess the occurrence of IAH and ACS, abdominal pressure should be monitored according to IAH and ACS Consensus Definitions and Clinical Guidelines published by the World Society of Abdominal Compartment Syndrome (WSACS).	Class II
Medical history
1. Medical history of the patients should be assessed in detail. If necessary, other departments should participate in evaluating the risk of anesthesia and surgery and making a plan of perioperative management.	Class II
Screening and control of infection source
1. Communication between anesthesiologists surgeons is necessary to obtain samples of suspicious focal infection for culture before a first-line anti-microbial treatment.	Class II
2. Bacteriological examination should be done for the patients who are suspicious of catheter-related infection (arteriovenous catheter, urethral catheter and pleural or abdominal drainage tube) before surgery.	Class I
Preoperative preparation
1. Continuous monitoring is necessary for the patients during the process of transportation, and attention should be paid to the handover of personnel, facilities and drugs.	Class I
Intraoperative monitoring and management
Anesthetic methods
1. Local infiltration anesthesia, regional blocking anesthesia and general anesthesia are suitable to septic patients, which should be selected individually after preoperative evaluation.	Class I
2. Intravertebral anesthesia is not suitable for septic patients if their hemodynamics is instable.	ClassII
3. Reflux and aspiration should be avoided in the patients with full stomach.	Class II
Anesthetic agents
1. Titration method of drug delivery is used in the process of anesthetic induction to avoid hemodynamic fluctuations.	Class I
2. Midazolam, propofol, ketamine and etomidate as intravenous anesthetics are suitable for septic patients, but etomidate is not indicated for patients with adrenal insufficiency.	Class II
3. Fentanyl, sufentanil and remifentanil as opioid analgesics are suitable for septic patients.	Class I
4. Cisatracurium, atracurium, rocuronium and vecuronium as muscle relaxants are suitable for septic patients.	Class II
5. N₂O, isoflurane, sevoflurane and desflurane as volatile anesthetics are feasible for septic patients, but N₂O is not indicated for patients with pneumothorax or intestinal obstruction.	Class II
6. Dexmedetomidine as an adjuvant agent is indicated for septic patients during anesthetic induction and maintenance.	Class II
Recommendations	Grade
Intraoperative monitoring
1. Routine monitoring including electrocardiogram, blood pressure, SpO₂, PETCO₂, pressure of airway, respiratory waveform, body temperature and urine output is necessary for septic patients.	Class I
2. Invasive blood pressure and central venous pressure should be monitored for patients with hemodynamic instability.	Class I
3. FloTrac, PiCCO, Swan-Ganz and cardiac ultrasound could be used for septic patients, and the parameters of stroke volume variation (SVV), pulse pressure variation (PPV), cardiac index (CI), and corrected flow time (FTc) can be ued to guide fluid therapy during operation.	Class II
4. Blood glucose, arterial blood gas, blood lactate, blood routine, blood electrolyte, coagulation function, BNP and troponin should be monitored during operation.	Class I
5. Depth of anesthesia and muscle relaxation should be monitored during operation.	Class II
Management of the circulatory system
1. The first objective of fluid management: MAP≥65 mmHg, CVP 8-12 mmHg, urine output≥0.5 mL/kg per hour, arterial blood lactate<4.0 mmol/L.	Class I
2. The second objective of fluid management: ScvO₂≥70% or SvO₂≥65%.	Class III
3. Crystalloid solution such as acetated Ringer's solution or lactated Ringer's solution could be used as the first-choice fluid for septic patients, whereas hydroxyethyl starch is not used for the treatment of patients with severe sepsis during operation. If colloid solution is available, albumin could be used as the first choice.	Class II
4. Norepinephrine can be used as the first-choice vasopressor, then epinephrine, vasopressin, dopamine, dobutamine and phenylephrine could also be used according to the condition of the patient.	Class I
5. Fresh frozen plasma (FFP) is not applicable for the increase of blood volume in septic patients.	Class II
6. Platelet count should exceed 50×10⁹/L during operation.	Class II
7. The level of hemoglobin should exceed 70 g/L during operation.	Class II
8. Intravenous hydrocortisone at a dose of 200 mg per day is prescribed as a treatment for septic patients when adequate fluid resuscitation and vasopressor therapy fail to restore the stable hemodynamics.	Class II
Management of the respiratory system
1. LPVS is used as a treatment for septic patients with ARDS (including low tidal volume, PEEP and lung recruitment maneuver, etc.).	Class I
Regulation of the immune system
1. Intravenous immunoglobulin is not suitable for septic patients during operation.	Class II
2. Intravenous ulinastain is suitable for the treatment of septic patients during operation.	Class II
3. Subcutaneous injection of thymosin and intravenous drip of Xuebijing could be used for the treatment of septic patients during operation.	Class III
Treatment in intensive care unit (ICU)
1. Patients with severe sepsis and septic shock should be transferred to the ICU for advanced treatment after surgery.	Class I

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Variables	Acute respiratory distress syndrome
Timing	Within 1 week of a known clinical insult or new or worsening respiratory symptoms
Chest imaging	Bilateral opacities-not fully explained by effusions, labor/lung collapse, or nodules
Origin of edema	Respiratory failure not fully explained by cardiac failure or fluid overload Need objective assessment (e.g., echocardiography) to exclude hydrostatic edema if no risk factor present
PaO₂/FiO₂
Mild	200 mmHg﹤PaO₂/FiO₂≤300 mmHg (PEEP≥5 mmHg or CPAP≥5 mmHg
Moderate	100 mmHg﹤PaO₂/FiO₂≤200 mmHg (PEEP≥5 mmHg)
Severe	PaO₂/FiO₂≤100 mmHg (PEEP≥5 mmHg)

Expert consensus on the perioperative management of patients with sepsis

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Infection, documented or suspected, and some of the following:
General variables
Fever (>38.3 °C)
Hypothermia (core temperature<36.0 °C)
Heart rate>90/minute or more than two SD above the normal value for age
Tachypnea (>30/minute)
Altered mental status
Significant edema or positive fluid balance (>20 mL/kg over 24 hours)
Hyperglycemia (plasma glucose>140 mg/dL or 7.7 mmol/L) in the absence of diabetes
Inflammatory variables
Leukocytosis (WBC count>12×10⁹/L)
Leukopenia (WBC count<4×10⁹/L)
Normal WBC count with greater than>10% immature forms
Plasma C-reactive protein more than two SD above the normal value
Plasma procalcitonin more than two SD above the normal value
Hemodynamic variables
Arterial hypotension (SBP<90 mmHg, MAP<70 mmHg, or an SBP decrease>40 mmHg in adults or less than two SD below normal for age)
Mixed venous oxygen saturation>70%
Cardiac index>3.5 L·min^-1·m^-2
Organ dysfunction variables
Arterial hypoxemia (PaO₂/FiO₂<300)
Acute oliguria (urine output<0.5 mL·kg^-1·h^-1for at least 2 hours despite adequate fluid resuscitation)
Creatinine increase≥0.5 mg/dL or 44.2 μmol/L
Coagulation abnormalities (INR>1.5 or APTT>60 seconds)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count<100×10⁹/L)
Hyperbilirubinemia (plasma total bilirubin>4 mg/dL, or 70 μmol/L)
Tissue perfusion variables
Hyperlactatemia (>2 mmol/L)
Decreased capillary refill or mottling

Severe sepsis is defined as sepsis-induced tissue hypoperfusion or organ dysfunction (any of the following thought to be due to the infection):
Sepsis-induced hypotension^a
Lactate above upper limits laboratory normal
Urine output<0.5 mL·kg^-1·h^-1 for more than 2 hours despite adequate fluid resuscitation
Acute lung injury with PaO₂/FiO₂<250 in the absence of pneumonia as infection source
Acute lung injury with PaO₂/FiO₂<200 in the presence of pneumonia as infection source
Creatinine>2.0 mg/dL (176.8 μmol/L)
Bilirubin>2.0 mg/dL (34.2 μmol/L)
Platelet count<100×10⁹/L
Coagulopathy (international normalized ratio >1.5)
Septic shock is defined as persistent arterial hypotension or hyperlactatemia in spite of adequate fluid resuscitation.

Diminished abdominal wall compliance
Abdominal surgery
Major trauma
Major burns
Increased intra-luminal contents
Gastroparesis/gastric distention/ileus
Ileus
Colonic pseudo-obstruction
Volvulus
Increased intra-abdominal contents
Acute pancreatitis
Distended abdomen
Hemoperitoneum/pneumoperitoneum or intra-peritoneal fluid
Intra-abdominal infection/abscess
Intra-abdominal or retroperitoneal tumors
Laparoscopy with excessive insufflations pressures
Liver dysfunction/cirrhosis with ascites
Peritoneal dialysis
Capillary leak/fluid resuscitation
Acidosis
Damage control laparotomy
Hypothermia
Increased APACHE II or SOFA score
Massive fluid resuscitation or positive fluid balance
Polytransfusion
Others/miscellaneous
Age
Bacteremia
Coagulopathy
Increased head of bed angel
Massive incisional hernia repair
Mechanical ventilation
Obesity or increased body mass index
PEEP>10 mmHg
Peritonitis
Pneumonia
Sepsis
Shock or hypotension