# Fluid Resuscitation in Sepsis



## EpiEMS (Jan 20, 2017)

For those who are interested, a nice (open access) paper out of Australia takes a pretty interesting tack:


> Fluid resuscitation is recommended and widely used as the first-line resuscitative therapy for all patients presenting with septic shock. This practice seems mainly based on historical beliefs and an incomplete or incorrect understanding of the pathophysiology of sepsis.
> 
> Viewed as a whole, the bench-to-bedside evidence supporting fluid resuscitation as treatment for sepsis remains remarkably weak and highly conflicting. In addition, the indiscriminate use of fluid resuscitation, specifically beyond the initial resuscitation phase, has the potential to cause significant harm.



Curious what everybody thinks!


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## Handsome Robb (Jan 20, 2017)

I think that there is still a place for fluids in the initial resuscitation of septic shock patients. However the trend in seeing is that fluids with concurrent vasopressors is becoming the norm rather than "give them 30mL/kg and if it doesn't fix their pressure then start a pressor". 

The previous thought process was you need to fill the tank prior to squeezing it. However seeing as the issue with sepsis is massive vasodilation and increased vascular permeability secondary to that dilation it makes sense that we need to correct the vasodilation while we also replace the volume lost to the interstitial space. Without vasporessor support our fluid challenges are basically going directly to the interstitial space as well. 


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## VentMonkey (Jan 20, 2017)

I don't know that they're going to directly third space across the board. I think many factors may come into play. What was the initial cause of their septic state? How far along into the SIRS--->septic shock treatment algorithm, and bundle are we talking? 

There are many variables that go into treating septic patients in the prehospital setting. Realistically speaking, if you are in an urban environment, oftentimes many paramedics would not even know what markers to look for aside from having a protocol drawn out for them, let alone establish large bore access for IVF resuscitation; 2 large bores and you're an "animal" to some older, closed-minded, non progressive folks. Do we really want every paramedic with a reasonably short ETA to the ED jumping into fluids, and vasopressors simultaneously without much forethought? 

Sepsis is not septic shock, it will result in septic shock if left untreated. That's something that I feel often goes unnoticed. I think with these types of patients we (the paramedics) are better off being in-serviced with proper SIRS--->septic shock/ MODS treatment bundles often seen in the hospital, preferably by an intensivist, and/ or ICU nurse before delving into proper treatments for septic shock patients encountered in the field to include whatever tools we have available for us at ones particular service. Being that this is yet another form of shock, something worth comparing is this: oftentimes in trauma there aren't jumping directly to blood product unless there is a reasonably prudent reason to in the resus bay, the same would hold true for the cardiogenic shock patient who is symptomatically bradycardic, as is the DKA patient prior to Insulin gtts. Oftentimes the common denominator with these patients is the 1-2 liters of IVF prior to the "next step" in their therapies. Anymore than the 1-2 liters of IVF, then I would say there's arguably a good chance of third spacing (with the exception of the extremely dehydrated DKA/ HHNK patient listed above).

In the field, I am hard pressed to jump straight to a pressor because I _think_ I know they're in septic _shock_ despite the presence of other diagnostic tools at my hands, be it an iSTAT, glucometer, in-line ETCO2, and adequate temp reading, obviously V/S, and of course before an IVF challenge trial. I will say that aggressive IVF in any obviously septic patient can go a long ways, and is not without its merit, IMO.


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## EpiEMS (Jan 20, 2017)

@VentMonkey and @Handsome Robb, thanks for the insight on this. 

I think the key point the authors make is that there isn't really any conclusive (RCT, say) high-quality evidence on whether septic shock patients actually benefit from fluid administration, and could very well be harm (fluid overload, etc.).

Hopefully - maybe -  one of our fine colleagues on this forum will be involved in a trial or two!


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## Ensihoitaja (Jan 20, 2017)

VentMonkey said:


> Realistically speaking, if you are in an urban environment, oftentimes many paramedics would not even know what markers to look for aside from having a protocol drawn out for them, let alone establish large bore access for IVF resuscitation; 2 large bores and you're an "animal" to some older, closed-minded, non progressive folks. Do we really want every paramedic with a reasonably short ETA to the ED jumping into fluids, and vasopressors simultaneously without much forethought?


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## VentMonkey (Jan 20, 2017)

Ensihoitaja said:


>


If you're 5 minutes from an ED, what is it may I ask that hanging a vasopressor will do in that short amount of time that is so much more "life-saving" that IVF? Are we talking about a reasonably healthy young septic adult? Or are we referring to a long-standing diabetic with multiple co-morbidities such as ESRD who is at higher risk for interstitial fluid retention?

I ask, and made the quoted statement as a generalization. Even now, I am a big proponent of least to most with a reasonably clinical thought process behind why I would just hang a vasopressor because an article, abstract, or RCT said it's "possibly harmful" and in theory could fluid overload a patient. Are we talking a septic otherwise healthy adult, or are we talking about a long-term. 

Read more into my initial post, it wasn't aimed at knocking the clinical insight of many of my peers. It just seems to me many urban systems tailor their ALS providers to a pretty basic approach to patients in general. Obviously this doesn't hold true for every one urban EMS system, its providers, or their medical direction. With that, in a largely urban setting how often are paramedics actually justifiably moving from a patient truly refractory to 1-2 liters of IVF, then on to a pressor. I just don't like jumping the gun, collectively so to speak, without hard evidence for such just because another route, or treatment measure sounds "sexy". FWIW, I feel the same regarding taking away their airway electively, it says more about me as a provider and paramedic if I know when not to vs. taking it away "just because".

I have seen time and again, overzealous paramedics over treat things because it's new or "cool". All I am implying is that with this patient population us EMS (as a whole) providers are better off being in-serviced about the proper treatment modalities that go into a sepsis bundle from medical direction--preferably the aforementioned intensivist, or ICU folks. Honestly, we're clearly all better off being in-serviced on many other topics as well, but I refrain from more digression.

Typically the first thing indicated with these patients is IVF, which can be provided safely by EMS providers. That isn't to say we're incapable of caring for them hemodynamically via vasopressor support. Nor is that to say we shouldn't carry them for situations such a the rural providers who don't have many other options aside from ground transport to a tertiary center, for starters.

Clearly, that isn't the case. I just think, again, as a whole our knowledge of the truly septic patient is in its infancy, and so to that I say we need consistently concrete evidence as to why we should, or shouldn't reconsider our our train of thought regarding aggressive IVF in the initial management of truly septic work ups.


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## VFlutter (Jan 20, 2017)

EpiEMS said:


> @VentMonkey and @Handsome Robb, thanks for the insight on this.
> 
> I think the key point the authors make is that there isn't really any conclusive (RCT, say) high-quality evidence on whether septic shock patients actually benefit from fluid administration, and could very well be harm (fluid overload, etc.).
> 
> Hopefully - maybe -  one of our fine colleagues on this forum will be involved in a trial or two!



Sure, volume overload could cause harm and may increase your risks of complications such as ARDS however it seems less tangible than the very real consequences of inadequate volume resuscitation that are commonly seen. Hard to fix ATN and end organ dysfunction.


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## Ensihoitaja (Jan 20, 2017)

VentMonkey said:


> Read more into my initial post, it wasn't aimed at knocking the clinical insight of many of my peers. It just seems to me many urban systems tailor their ALS providers to a pretty basic approach to patients in general. Obviously this doesn't hold true for every one urban EMS system, its providers, or their medical direction. With that, in a largely urban setting how often are paramedics actually justifiably moving from a patient truly refractory to 1-2 liters of IVF, then on to a pressor. I just don't like jumping the gun, collectively so to speak, without hard evidence for such just because another route, or treatment measure sounds "sexy". FWIW, I feel the same regarding taking away their airway electively, it says more about me as a provider and paramedic if I know when not to vs. taking it away "just because".



I don't disagree with you on your clinical treatment points, generally. I can count one finger the number of septic shock patients I've needed to give a pressor to.

I do disagree with the gratuitous slam against urban medics.


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## VentMonkey (Jan 20, 2017)

Ensihoitaja said:


> I do disagree with the gratuitous slam against urban medics.


It's hardly a gratuitous slam. Again, I'm still very much an urban paramedic as well. 

_As a whole_, our knowledge of the process from SIRS--->septic shock, and even worse, MODS is generally speaking quite lacking.

I think (hope?) eventually it too will get the same sense of urgency as the cardiac and stroke campaigns have afforded specialty centers, and "activation" protocols nationally, not regionally, nationally.


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## TXmed (Jan 20, 2017)

I feel the need to chime in that not all septic/sirs patients are the same. Age, co-morbidities, type & length of infection, and how the wind is blowing all factor into the treatment. This is why SOME goal directed therapies are not working (notice i said some and not all) . While adding volume is a good thought process, also starting early catacholamine replacent has begun to prove benificial. Early low dose levo and epi can help improve blood flow (which is a goal) and also prevent capillary leakage.


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## TXmed (Jan 20, 2017)

Also the rate of administration is another important thing to look at. If you are giving a liter every 5-10 minutes its been show to accelerate the 3rd spacing of the fluids


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## E tank (Jan 20, 2017)

Giving "volume" in septic shock can't be reduced to a binary question of "do it/don't do it" and I don't think the authors of the review article meant it to be that way. Patients in septic shock need volume expansion, the question is how much and how do we decide how much is enough. And everyone knows it isn't just about iv fluid.

To give some historical perspective, norepinephrine earned the name "leave 'em dead" not in small part to the "old" practice of fluid restriction in septic patients with aggressive inopressor support. Patients CO was maintained by squeezing them until they died. When norepi came back into favor for routine use by many in CC and anesthesia,  gasps and guffaws were common among the more clueless. The difference was we were giving fluid with the NE.

Understanding of treatment of these folks is evolving as much as any other patient groups and I think (as the authors seem to) that the best answer lies somewhere in the middle with regard to the one element of early hemodynamic management. 

I think we're better at it than the authors let on and looking at factors like mean systemic filling pressure as it relates to CVP/RAP and volume responsiveness measures are pretty good ways to determine fluid requirements. 

Could be wrong about a lot of places,  but I don't see folks dumping fluid with wild abandon very often at all anymore. Just a biased editorial note, giving NS to these patients is dumb. My opinion/experience.


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## E tank (Jan 20, 2017)

TXmed said:


> Also the rate of administration is another important thing to look at. If you are giving a liter every 5-10 minutes its been show to accelerate the 3rd spacing of the fluids



Right...even in healthy patients, only 25% of a liter of crystalloid remains intravascular.


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## E tank (Jan 20, 2017)

VentMonkey said:


> I think (hope?) eventually it too will get the same sense of urgency as the cardiac and stroke campaigns have afforded specialty centers, and "activation" protocols nationally, not regionally, nationally.



You're undoubtedly familiar with the SCC, but for those not...

http://www.survivingsepsis.org/Pages/default.aspx


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## SpecialK (Jan 20, 2017)

New CPGs for septic shock in adults:

- Minimum of two litres of NaCl 
- Coamoxiclav (and gentamicin if uro or abdosepsis, or unknown cause)
- If shock is unresponsive to fluid loading administer IV adrenaline infusion (two drops/sec of 1:1,000,000 adrenaline)


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## Handsome Robb (Jan 20, 2017)

VentMonkey said:


> I think (hope?) eventually it too will get the same sense of urgency as the cardiac and stroke campaigns have afforded specialty centers, and "activation" protocols nationally, not regionally, nationally.



Starting April 1st we'll be calling "Sepsis Alerts" to facilities. They tend to take it pretty serious already if we say sepsis on the radio. 

Hopefully it'll spread! 


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## Nova1300 (Jan 20, 2017)

Yeesh.  I didn't read every word, but there is a lot of misunderstanding of study conclusions on the part of the authors of this opinion piece.  They are trying to draw a lot of black and white from studies that were neither powered, nor designed to look for definitive conclusions.  

There are a handful of frankly disingenuous proclamations throughout this article that I take exception to.


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## Tigger (Jan 21, 2017)

Handsome Robb said:


> Starting April 1st we'll be calling "Sepsis Alerts" to facilities. They tend to take it pretty serious already if we say sepsis on the radio.
> 
> Hopefully it'll spread!


Here's to hoping. Our medical director encourages us to call "Sepsis Alerts" despite that not being in the guidelines, which I appreciate. The last one I called in was for a transfer from the VA, mid 40s guy with pneumonia (horrid lung sounds), pressure in the 80s, tachycardia, tachypneic, febrile, EtCO2 of 52, and altered. After my patch (with all of that), I get "what makes you think this patient is septic?"

grrrrrrr.

We are supposed to start carrying levophed this year, but I am curious as to how they will write the sepsis protocol with it. Even with an hour transport, infusing 30ml/kg pre-pressor is probably not likely. The EmCrits I've been listening to seem to suggest low dose levophed early on, but I am not sure we'll be able to do that if the hospitals aren't.


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## StCEMT (Jan 21, 2017)

Tigger said:


> The EmCrits I've been listening to seem to suggest low dose levophed early on, but I am not sure we'll be able to do that if the hospitals aren't.


I'm gonna have to go find this and give it a listen. Honestly not sure what the hospitals out here are doing, it'd be something I would have to call and ask for since it's not something expressly written that I can do. Just picked up a septic guy yesterday, might have to ask one of the local docs and get an idea of how they work.


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## E tank (Jan 21, 2017)

Tigger said:


> Here's to hoping. Our medical director encourages us to call "Sepsis Alerts" despite that not being in the guidelines, which I appreciate. The last one I called in was for a transfer from the VA, mid 40s guy with pneumonia (horrid lung sounds), pressure in the 80s, tachycardia, tachypneic, febrile, EtCO2 of 52, and altered. After my patch (with all of that), I get "what makes you think this patient is septic?"
> 
> grrrrrrr.
> 
> We are supposed to start carrying levophed this year, but I am curious as to how they will write the sepsis protocol with it. Even with an hour transport, infusing 30ml/kg pre-pressor is probably not likely. The EmCrits I've been listening to seem to suggest low dose levophed early on, but I am not sure we'll be able to do that if the hospitals aren't.



What is "low dose levophed"? What is your target blood pressure? Also, with all of the apparent controversy, what is not controversial is  the need for some way to establish a basis for the dose of fluid. Does your system give any guidance in that respect?


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## Handsome Robb (Jan 21, 2017)

Tigger said:


> Here's to hoping. Our medical director encourages us to call "Sepsis Alerts" despite that not being in the guidelines, which I appreciate. The last one I called in was for a transfer from the VA, mid 40s guy with pneumonia (horrid lung sounds), pressure in the 80s, tachycardia, tachypneic, febrile, EtCO2 of 52, and altered. After my patch (with all of that), I get "what makes you think this patient is septic?"
> 
> grrrrrrr.
> 
> We are supposed to start carrying levophed this year, but I am curious as to how they will write the sepsis protocol with it. Even with an hour transport, infusing 30ml/kg pre-pressor is probably not likely. The EmCrits I've been listening to seem to suggest low dose levophed early on, but I am not sure we'll be able to do that if the hospitals aren't.



We're adding push dose epinephrine as a bridge to early levophed in these patients. We're giving 20mL/kg doses concurrently with levophed starting at 5mcg/min with a target SBP of 90mmHg and/or a MAP of 65. The big killer in Sepsis is MODS, from my understanding. Our MDs thought process is the shorter period of time those organs go un/under perfused the better chance they have. 

I'll see if I can track down the evidence they're using for you guys as we don't do anything without a decent amount of evidence. 


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## VentMonkey (Jan 21, 2017)

Quick thread derail...

You know if WilCo EMS moved to an all ALS intercept service, I'd call it just about as close to a unicorn as one could ask for. Even still, you all have what I consider a career-service for paramedics down enticingly well.

...back to the sepsis talk.


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## MackTheKnife (Jan 21, 2017)

EpiEMS said:


> For those who are interested, a nice (open access) paper out of Australia takes a pretty interesting tack:
> 
> 
> Curious what everybody thinks!


Hospital- 30ml/kg IVF for Sepsis Alert even if they have cardiac issues. The idea is you can manage (diurese) later.

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## Handsome Robb (Jan 21, 2017)

VentMonkey said:


> Quick thread derail...
> 
> You know if WilCo EMS moved to an all ALS intercept service, I'd call it just about as close to a unicorn as one could ask for. Even still, you all have what I consider a career-service for paramedics down enticingly well.
> 
> ...back to the sepsis talk.



Come join us...we have cookies! 


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## Tigger (Jan 21, 2017)

Handsome Robb said:


> We're adding push dose epinephrine as a bridge to early levophed in these patients. We're giving 20mL/kg doses concurrently with levophed starting at 5mcg/min with a target SBP of 90mmHg and/or a MAP of 65. The big killer in Sepsis is MODS, from my understanding. Our MDs thought process is the shorter period of time those organs go un/under perfused the better chance they have.
> 
> I'll see if I can track down the evidence they're using for you guys as we don't do anything without a decent amount of evidence.
> 
> ...


Is there some sort of criteria for who gets pressor support + fluids and who gets fluids?

That's what I struggle with.


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## Tigger (Jan 21, 2017)

E tank said:


> What is "low dose levophed"? What is your target blood pressure? Also, with all of the apparent controversy, what is not controversial is  the need for some way to establish a basis for the dose of fluid. Does your system give any guidance in that respect?


I was listening to this http://emcrit.org/podcasts/vasopressor-basics/.
The idea I guess is to start with smaller (can't remember the number and am too tired to relisten) doses at the same time as fluids resuscitation begins. If you need it great, turn it up. If not, well it's probably well tolerated anyway.


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## VentMonkey (Jan 21, 2017)

Handsome Robb said:


> The big killer in Sepsis is MODS


The way I learned it was SIRS-->sepsis-->severe sepsis-->septic shock-->MODS. Once you're in MODS (2+ more end organ failure) your chances of mortality drastically increase; even more so with 3, 4, 5 organs. MODS is a very late manifestation, and ominous sign of the sepsis "chain".

http://emedicine.medscape.com/article/169640-overview#a3


Tigger said:


> Is there some sort of criteria for who gets pressor support + fluids and who gets fluids?


My guess is it's the often adopted SIRS criteria coupled with reasonable suspicion to believe said patient has an port of entry (e.g., recent infection, weeping wound, etc.), but Robb can elaborate.


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## Handsome Robb (Jan 22, 2017)

Tigger said:


> Is there some sort of criteria for who gets pressor support + fluids and who gets fluids?
> 
> That's what I struggle with.



Anyone who's hypotensive and doesn't rapidly respond to fluids. The answer I got is that if they haven't improved in the time it takes you to mix the levo then hang the levo. 

Basically it's suspected infection then 2 of the following 
HR >90
RR >20 or EtCO2 <25mmHg
Temp >100.4 or < 96.8
If they're normotensive they just get 20mL/kg. If they're hypotensive they get 20mL/kg and levophed with profoundly hypotensive patients getting push dose epi to bridge the gap while we mix the levo. 




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## StCEMT (Jan 22, 2017)

What are yall's experience with using epi in this case? No levo here, so epi would be the only decent option I would have.


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## SpecialK (Jan 22, 2017)

StCEMT said:


> What are yall's experience with using epi in this case? No levo here, so epi would be the only decent option I would have.



Adrenaline works well.  It's the only vasopressor carried.  I'm told there is no convincing evidence noradrenaline or one of the dopamine like drugs is better.  Easy, cheap, simple to make up and administer (1 mg in one litre NaCl run at 2 drops a second initially) and no fart arseing around with syringe boluses.


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## Tigger (Jan 22, 2017)

StCEMT said:


> What are yall's experience with using epi in this case? No levo here, so epi would be the only decent option I would have.


The research I did in class brought me to the conclusion that I'd rather give epi than dope. Dopamine does not have great outcomes for sepsis.


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## VentMonkey (Jan 22, 2017)

While a few years old, this seems to be the mainstay when talking norepi vs. dopamine with the septic patient, so I'll leave this here: 

https://www.ncbi.nlm.nih.gov/m/pubmed/22036860/

And yes, many providers seem to be leaning  more, and more on Epi as opposed to Dopamine as an option for septic shock patients in need of vasoactive medications.


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## TXmed (Jan 22, 2017)

Dopamine looses its effectiveness the lower the PH is. B-Hydroxyesterase ( i think) is an enzyme dopamine uses that is not apparent in a very acidotic enviroment.


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## E tank (Jan 22, 2017)

TXmed said:


> Dopamine looses its effectiveness the lower the PH is. B-Hydroxyesterase ( i think) is an enzyme dopamine uses that is not apparent in a very acidotic enviroment.



Any pressor or inopressor is less effective the more acidotic the patient is. Dopamine is not a very predictable drug compared with epi  in the best of conditions. Early on, the most potent mediator of fall in CO is loss of vasomotor tone, not contractility which is  why NE (mostly alpha mild beta) is used and Epi or dopamine isn't. As things progress, if contractility becomes impaired, epi is added as opposed to dopamine because of it's greater dose/response predictability.


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## VentMonkey (Jan 22, 2017)

E tank said:


> Any pressor or inopressor is less effective the more acidotic the patient is. Dopamine is not a very predictable drug compared with epi  in the best of conditions. Early on, the most potent mediator of fall in CO is loss of vasomotor tone, not contractility *which is  why NE (mostly alpha mild beta) is used and Epi or dopamine isn't*. As things progress, if contractility becomes impaired, epi is added as opposed to dopamine because of it's greater dose/response predictability.


@E tank I want to say this is what, and why our CCP instructor emphasized and was such a Levophed proponent. Basically its added benefits as it possesses both ino- and chronotropic properties.


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## StCEMT (Jan 22, 2017)

Tigger said:


> The research I did in class brought me to the conclusion that I'd rather give epi than dope. Dopamine does not have great outcomes for sepsis.


That's what I am seeing too. Trying to learn more about epi, not sure how keen the docs are on letting us hang it.


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## Tigger (Jan 22, 2017)

StCEMT said:


> That's what I am seeing too. Trying to learn more about epi, not sure how keen the docs are on letting us hang it.


Our guidelines are super vague about pressures (edit: ironically autocorrect changed that from "pressors"). "Refractory shock" is the indication for epi for both drip and 0.1mg push doses, refractory to what might I ask?


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## E tank (Jan 22, 2017)

VentMonkey said:


> @E tank I want to say this is what, and why our CCP instructor emphasized and was such a Levophed proponent. Basically its added benefits as it possesses both ino- and chronotropic properties.


 
The greatest advantage is the vasopressor property because that's what most of the problem is when you guys contact the patient. It's only a mild inotrope, but that isn't what is called for in vasoplegia 2/2 septic shock. A rise in heart rate comes at higher doses and isn't what it's used for. Raising the heart rate as a goal isn't an advantage.


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## StCEMT (Jan 22, 2017)

Tigger said:


> Our guidelines are super vague about pressures. "Refractory shock" is the indication for epi for both drip and 0.1mg push doses, refractory to what might I ask?


That is kinda vague. It's non-existent here. Dopamine with cardiogenic shock, but that's it.


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## VentMonkey (Jan 22, 2017)

We have our choice of Epi or Dopamine in regards to cardiogenic shock in our protocol. I doubt if push came to shove on a truly septic patient that spun the right way a hospital wouldn't ok the Epi gtt in a severely symptomatic septic patient, but again, from my standpoint it seems like we're all in need of some more education, and in my case re-education regarding the pearls of EGDT.

I am seeing a lot of uncertainty, and "not sure" type answers. I'm not knocking anyone whatsoever, I'm just saying as paramedics without sounding too crude, we need to be educated to the point where we run these calls with the same sense of comfort, and confidence in treatment making as the ones that have been drilled into our heads.


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## TXmed (Jan 22, 2017)

I think alot of uncertainty comes from the fact we are learning more and more about sepsis and constantly changing our algorithms and definitions, i mean intensivists dont exactly have the best handle on this stuff either judging from the podcasts ive listened too. In the end we are all probably wrong one way or another, and i suspect the most correct answer is not with a pressor or fluids but more recognition and specific treatment of the source of the sepsis.


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## Tigger (Jan 22, 2017)

TXmed said:


> I think alot of uncertainty comes from the fact we are learning more and more about sepsis and constantly changing our algorithms and definitions, i mean intensivists dont exactly have the best handle on this stuff either judging from the podcasts ive listened too. In the end we are all probably wrong one way or another, and i suspect the most correct answer is not with a pressor or fluids but more recognition and specific treatment of the source of the sepsis.


Pretty much. I don't want to be the cookbook guy, but I can't really just fly from the seat of my pants either. I don't possess the education nor stature to do so. Tell me what is effective and I will learn it and try to implement it, but when you have ICU docs talking about how they just "know" what sort of dose of levo is needed...well that's not gonna fly in EMS.


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## VentMonkey (Jan 22, 2017)

TXmed said:


> I think alot of uncertainty comes from the fact we are learning more and more about sepsis and constantly changing our algorithms and definitions.


I think this is what I was getting at. The sense of urgency it's (thankfully) now being treated with by like minded people on this forum, for example, is definitely a step in the right direction.

I just think as far as it goes with EMS, being that it's severity is something that is becoming more emphatic, it will eventually draw _prehospital _goal directed therapies tried, and true. 

Basically, right now we (EMS) still very much seem to be in the "testing phase" of what works best for these patient before getting them to definitive care. Will they change? I don't doubt they will, but have we _universally_ adopted a protocol for sepsis like we have for the standard work ups found in just about every system protocol throughout the country? 

Good discussion all around.


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## ERDoc (Jan 23, 2017)

I will admit I didn't read the entire thread so forgive me if I'm repeating something.  Hospitals are very much taking sepsis/SIRS very seriously these days, including the development of things such as the previous mentioned sepsis alert.  Why?  Because it has become a CMS core measure, or to put it differently affects reimbursement.  Our system has event created an alert in the computer that pops up if the pt meets certain criteria.  If the alert pops us, a nurse has to document that he/she told the doc about it and the doc has to click a check box acknowledging they are aware of the alert and what they are doing about it.  The problem becomes that the core measures don't take into account anything else about the pt such as CHF/ESRD history and require a 30cc/kg bolus (or about 3L in your average pt).  There are so many pts not meeting the core measures because we try not to kill the pts by drowning but CMS doesn't care about that.

EDIT:  Here is the core measures from the ACEP website
https://www.acep.org/content.aspx?id=104615


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## EpiEMS (Jan 23, 2017)

ERDoc said:


> There are so many pts not meeting the core measures because we try not to kill the pts by drowning but CMS doesn't care about that.


Perverse incentives run amok.

Doc, thanks very much for your insight!


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## Handsome Robb (Jan 23, 2017)

Handsome Robb said:


> Anyone who's hypotensive and doesn't rapidly respond to fluids. The answer I got is that if they haven't improved in the time it takes you to mix the levo then hang the levo.
> 
> Basically it's suspected infection then 2 of the following
> HR >90
> ...



I stand corrected. I made the corrects in the quote. They're bolded.


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## E tank (Jan 23, 2017)

I wonder if we're not talking about 2 different things. Sure, there is the actual disease that is causing all of the mayhem that the infectious disease people treat and advise on, then there is oxygen delivery problem that is related but distinct. In the acute die/don't die phase, the approach is pretty straight forward with respect to mechanical ventilation and cardiac output for most of the folks that read this forum.  Those principles don't change too much across diagnoses. Getting oxygen to tissues is a trauma problem, burn problem, cardiac, sepsis etc. and it's pretty much approached the same way with some variation on the  specific themes.  Cardiac output has very specific elements that go sideways and it doesn't matter if the cause is a spinal cord injury or sepsis initially. The treatment follows the same basic process/algorithm.

The real differences tho, are the assessment tools that are available as the patient moves from the field to the ER to the ICU.


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## StCEMT (Jan 23, 2017)

Tigger said:


> Pretty much. I don't want to be the cookbook guy, but I can't really just fly from the seat of my pants either. I don't possess the education nor stature to do so. Tell me what is effective and I will learn it and try to implement it, but when you have ICU docs talking about how they just "know" what sort of dose of levo is needed...well that's not gonna fly in EMS.


This sums up my thoughts really well. I've picked up multiple people starting down the septic path, but my experience with the VERY sick septic people is limited.


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## ERDoc (Jan 30, 2017)

I came across this today and thought it would be appropriate to post here:

http://emcrit.org/pulmcrit/sepsis-myths/


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## reaper (Jan 30, 2017)

https://www.ncbi.nlm.nih.gov/pubmed/?term=27918869

Showing very good results so far.

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## ERDoc (Jan 30, 2017)

reaper said:


> https://www.ncbi.nlm.nih.gov/pubmed/?term=27918869
> 
> Showing very good results so far.
> 
> Sent from my VS985 4G using Tapatalk



Fixed it:

*BACKGROUND:*

To improve patient outcomes find a way to decrease reimbursement, the Center for Medicare and Medicaid Services (CMS) implemented core measures that outline the initial treatment of the septic patient, which have been shown to have no effect on outcome or may cause harm. These measures include initial blood culture collection prior to antibiotics, adequate one size fits all, even when it is inappropriate intravenous fluid resuscitation, and unnecessarily early administration of broad spectrum antibiotics. We sought to determine if Paramedics can initiate the CMS sepsis core measure bundle in the prehospital field reliably so the hospital has someone else to blame when they don’t meet inappropriate benchmarks.


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## Summit (Jan 30, 2017)

ERDoc said:


> Fixed it:
> 
> *BACKGROUND:*
> 
> To improve patient outcomes find a way to decrease reimbursement, the Center for Medicare and Medicaid Services (CMS) implemented core measures that outline the initial treatment of the septic patient, which have been shown to have no effect on outcome or may cause harm. These measures include initial blood culture collection prior to antibiotics, adequate one size fits all, even when it is inappropriate intravenous fluid resuscitation, and unnecessarily early administration of broad spectrum antibiotics. We sought to determine if Paramedics can initiate the CMS sepsis core measure bundle in the prehospital field reliably so the hospital has someone else to blame when they don’t meet inappropriate benchmarks.


Winner winner


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## reaper (Jan 30, 2017)

With a major decrease in mortality and ICU admissions, it must just be a fluke.

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## ERDoc (Jan 30, 2017)

reaper said:


> With a major decrease in mortality and ICU admissions, it must just be a fluke.
> 
> Sent from my VS985 4G using Tapatalk



I'm not sure what you are talking about but the article you posted has nothing to do with mortality or ICU admissions.


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## reaper (Jan 30, 2017)

Sorry about that. It was in the PowerPoint presentation I was reading. I cannot figure out how to post it here.

It stated that the hospital system had the lowest mortality rates from sepsis in their history. ICU admissions dropped dramaticly. In hospital costs dropped along with it.

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## reaper (Jan 30, 2017)

https://www.dropbox.com/s/rzf6mwxibduiwbe/Walchok_EMS ABX_2016_Short.pdf?dl=0

See if that works?

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## ERDoc (Jan 30, 2017)

There is a difference between developing a sepsis protocol and following a CMS guidelines.  In the article I posted earlier it stated that just having a protocol in place would be beneficial, but following the CMS guidelines could be harmful.


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## reaper (Jan 30, 2017)

I understand that. But they have seen good outcomes with this pilot. It was a trial pilot, which is now going statewide. It has been presented at multiple medical conferences with a lot of good feedback on it. 
Is this for every system, that I do not know. I just thought I would share this for others to look at.

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## ERDoc (Jan 30, 2017)

My last post posted before I read the powerpoint.  I'm not saying there isn't some promise in EMS interventions, my criticism is the rigid CMS guidelines that penalize you if you think (or practice medicine) and go outside the guidelines.  The thing with the PP though is that many of the things they measure have been shown NOT to affect outcomes (see the article I posted).  Obviously, they have some promising results so it would be interesting to see a much larger study done.


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## Nova1300 (Feb 1, 2017)

Just to give you guys some perspective on how absurd these CMS mandates have become:

A few weeks ago I admitted an obese patient with ischemic cardiomyopathy and an EF of 20%.  She was in respiratory failure from volume overload, on a background of severe COPD, and may have had pneumonia.  She was weeping fluid from her legs.  She was "hypotensive" (90/50) and "tachycardic" (110) with mild patchy airspace disease on her x-ray, more than likely from volume overload, but I gave her a possible pneumonia diagnosis as well and started Abx.  

The patient had distended jugular veins.  She had bilateral crackles. She just looked plethoric. You get the picture here.  And of course that was documented in my exam. 

She go intubated, she got placed on a low dose of inotropes.  She got some antibiotics and some diuretics.  And maintenance IV fluids.  

Today, I have an email in my inbox.  And the magical, number-scanning computer of mystery in the performance improvement department has flagged this "hypotensive" and "tachycardic" patient with "possible pneumonia" as falling out of CMS sepsis guidelines because I did not administer a 30 ml/kg fluid bolus to this 120 kg patient.  

I'll give you a moment to do some math there.... 

And now, unless I correct my charting to explain why I elected not to administer that volume of fluid to the heart failure patient, the case will be a "fallout" and must be discussed at the monthly meeting of the sepsis minds, which interestingly enough does not even involve a physician.  Lots and lots of white coats.  But no physicians.  

I get at least 3-4 of these per month.  I am to go explain my clinical decision-making to a well-paid, full-time registered nurse in "performance improvement," lest the hospital lose money because of bad medical practice enforced by CMS.  

Sadly, some of my colleges have resorted to just giving the fluids, no matter their clinical judgement, simply to avoid the hassle of explaining the Frank-Starling curve to a nurse in performance improvement every couple weeks.


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## Summit (Feb 1, 2017)

Nova1300 said:


> Just to give you guys some perspective on how absurd these CMS mandates have become:
> 
> A few weeks ago I admitted an obese patient with ischemic cardiomyopathy and an EF of 20%.  She was in respiratory failure from volume overload, on a background of severe COPD, and may have had pneumonia.  She was weeping fluid from her legs.  She was "hypotensive" (90/50) and "tachycardic" (110) with mild patchy airspace disease on her x-ray, more than likely from volume overload, but I gave her a possible pneumonia diagnosis as well and started Abx.
> 
> ...


It was so jaw dropping to me when I heard the CMS CM for Sepsis. I remember sitting in the room where some "educator" was explaining to the professional group was explaining these things like it was 2002 and the Surviving Sepsis campaign had just been announced. I remember looking at my fellow CCRN colleagues and shaking our heads as blanked protocols and mandation of questionable treatments in innaplicable circumstances were declared as if this was an idea of the Gods. One of my snarkier colleagues raised her hand and said something like "will CMS reimburse when their mandated removal of clinical judgement kill the patient?" Before the now-sour-faced presenter could respond, I asked "she just wants to know if CMS considers the results of these required therapeutic misadventures to be HACs? I want to know will there be a new ICD10 code for-" I got elbowed in the ribs.

I do hope your quality department doesn't need the Frank-Starling curve explained. I think I learned that A&P and again in Nursing Fundamentals and it was built on many other times. I do a little QI work and when I bring something to a provider like that, I take the time to understand the case so it usually goes: "good job, makes sense, but the system is stupid and here is how you can CYA." It goes over well except for the extra documentation requirement. A providerless star chamber treatment must be a frustrating waste of time.

I wrote some code to make an early warning program for our EHR. When I moved it from beta to production, the email I sent to the intensivists/hospitalists/ACNPs/charge RNs had 3 sentences:
1. This could give you early warning of sepsis indicators, drops in MODS, MEWS/PEWS
2. Click here to access
3. This is only to make you look twice: clinical judgement trumps all!


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## aquabear (Feb 3, 2017)

VentMonkey said:


> Quick thread derail...
> 
> You know if WilCo EMS moved to an all ALS intercept service, I'd call it just about as close to a unicorn as one could ask for. Even still, you all have what I consider a career-service for paramedics down enticingly well.
> 
> ...back to the sepsis talk.


Off topic, but Wilco already runs a single medic squad and will be staring a second one. The current squad is on a rotation with a busy station since the call volume is so low where they are located.

...back to the sepsis talk.


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