Bicarbonate Therapy

1. Bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor requirements is not recommended for treatment of hypoperfusion-induced lactic acidemia with pH >7.15. The effect of bicarbonate administration on hemodynamics and vasopressor requirement at lower pH, as well as the effect on clinical outcome at any pH, has not been studied.

   Grade of Recommendation: C

Deep Vein Thrombosis Prophylaxis

1. Severe sepsis patients should receive deep vein thrombosis (DVT) prophylaxis with either low-dose unfractionated heparin or low-molecular weight heparin. For septic patients who have a contraindication for heparin use (i.e., thrombocytopenia, severe coagulopathy, active bleeding, recent intracerebral hemorrhage), the use of a mechanical prophylactic device (graduated compression stockings or intermittent compression device) is recommended (unless contraindicated by the presence of peripheral vascular disease). In very high-risk patients such as those who have severe sepsis and history of deep vein thrombosis, a combination of pharmacologic and mechanical therapy is recommended.

   Grade of Recommendation: A

Stress Ulcer Prophylaxis

1. Stress ulcer prophylaxis should be given to all patients with severe sepsis. H₂ receptor inhibitors are more efficacious than sucralfate and are the preferred agents. Proton pump inhibitors have not been assessed in a direct comparison with H₂ receptor antagonists and, therefore, their relative efficacy is unknown. They do demonstrate equivalency in ability to increase gastric pH.

   Grade of Recommendation: A