AUG 08, 2017 | JESSICA BURCHETTE, PHARMD, BCPS, AND DAVID CLUCK, PHARMD, BCPS, AAHIVP
Another highlight of the 2016 guidelines is the use of different variables to assess fluid responsiveness. Previous iterations of the guidelines suggested that clinicians target a central venous pressure (CVP) of 8 to 12 mmHg (12-15 mmHg if mechanically ventilated) for fluid resuscitation goals. This shift away from using CVP as a marker of responsiveness was based on findings from the FENICE study, among others, which revealed little clinical utility of this static factor when CVP is within normal range.7-9
The FENICE findings also highlighted the need to promptly discontinue fluids once they are deemed no longer beneficial, as poor patient outcomes are a proven consequence of excess net fluids.9
From this, the 2016 guidelines shifted to a resuscitation approach more focused on measurements in the individual patient, with assessment based on dynamic variables such as pulse or stroke volume.
Source control and timing of antimicrobial therapy is reiterated in the 2016 guidelines. Regarding timing, several observational studies have demonstrated increased risk of mortality when antimicrobial therapy is delayed.10,11
The guidelines reemphasize the 1-hour time threshold to initiate appropriate therapy after sepsis or septic shock is recognized, noting that feasibility has not been directly assessed and may be challenging for some centers. Although the timing of therapy is important, selection and dose are equally important. The 2016 guidelines highlight the use of pharmacokinetic/pharmacodynamic principles when selecting and dosing antimicrobials. Clinical pharmacists should be able to assist clinicians in doing both, and clinicians should strongly consider consulting them.
Other recommendations remain from the 2012 guidelines, including appropriate de-escalation, the use of procalcitonin to expedite de-escalation or discontinuation, and appropriate durations of therapy. The emphasis on appropriate de-escalation and antimicrobial stewardship, in general, in this iteration of the guidelines is particularly noteworthy, as those areas have become key initiatives in all health care facilities in 2017.12