# Fluid in septic LRTI



## Melclin (Jun 22, 2012)

This is an issue that I've discussed with a lot of people at work and its hard to get a clear answer. I may have even asked the question here as well. 

I'll give you a quick scenario to illustrate my my point. 

55YOM, hx well controlled hypertension, "small MI" 3yrs previously with no subsequent issues on echo. Presents to GP with 2/7 productive cough, 1/7 rigors, night sweats, worsening SOB. Called to GP office to take pt hospital. SpO2 86 on RA, RR 32, T 39.8, BP 165/95, HR 111, ++cold extremities. Diminished breath sounds on lower L lung field. He got oxygen, bloods drawn, 2g of ceftriaxone and off to hospital we trot.  

Now comes the question of fluid. We're warned to be conservative with fluid admin in septic pts with a resp focus for fear of iatrogenic pulmonary oedema.

My question is how legitimate is this fear? If the pt above had a UTI, I'd be reaching straight for the fluid. But I worry about the pt with a resp focus. 

Are you adjusting the rate or dose of fluid in septic pts with respiratory focus? How and why? If not, why not.


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## Smash (Jun 22, 2012)

Melclin said:


> This is an issue that I've discussed with a lot of people at work and its hard to get a clear answer. I may have even asked the question here as well.
> 
> I'll give you a quick scenario to illustrate my my point.
> 
> ...



I've asked the same question myself and had no satisfactory answer.  There seems to be a confusion between pulmonary oedema and ARDS in whoever it was that has disseminated the information you are referring to.  Whilst fluid management in this patient may be modified down the track depending on his clinical course, and there may be changes in lung permeability, in the short term you should be sticking to the edicts of Early Goal Directed Therapy (EGDT) and giving fluids.  Fluid overload, whilst not desirable, can be managed, and it isn't something you are going to be dealing with in the short term anyway, especially not with the one or two litres you may get into them during transport.

I have no idea what they mean by "conservative".  "Careful" may have been a more appropriate wording.  I think it is just another poorly though out, poorly put together protocol.


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## mycrofft (Jun 22, 2012)

Maybe splitting beans here, but why would _this _pt get fluids IV except to carry meds?

Generically, I'm with you. A fevered pt, especially if old or was unable to self-care for a period of time, may need fluids of some sort in the presence of s/s of dehydration. How about a cautious IV fluid introduction with monitoring of lung sounds emphasized, and for pts only with signs/symptoms of need for fluid resuscitation ?


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## Melclin (Jun 22, 2012)

Smash said:


> I've asked the same question myself and had no satisfactory answer.  There seems to be a confusion between pulmonary oedema and ARDS in whoever it was that has disseminated the information you are referring to.  Whilst fluid management in this patient may be modified down the track depending on his clinical course, and there may be changes in lung permeability, in the short term you should be sticking to the edicts of Early Goal Directed Therapy (EGDT) and giving fluids.  Fluid overload, whilst not desirable, can be managed, and it isn't something you are going to be dealing with in the short term anyway, especially not with the one or two litres you may get into them during transport.
> 
> I have no idea what they mean by "conservative".  "Careful" may have been a more appropriate wording.  I think it is just another poorly though out, poorly put together protocol.



I'll have to sit down with my CSO again although I'm reasonably certain I'll be banned from his office if I go back in there any time soon. 

Good to know I'm not the only one finding that one to be a head scratcher. I've never encountered anyone who said that these pts shouldn't get fluid, but what being careful or cautious means in this situation, I'm still not sure. 

I also don't understand why it is that the MICA section of that guideline doesn't seem to include any worries about clear chests etc. Is it perhaps something to do with sepsis induced myocardial dysfunction and the ability to start adrenaline infusions?




mycrofft said:


> Maybe splitting beans here, but why would _this _pt get fluids IV except to carry meds?
> 
> Generically, I'm with you. A fevered pt, especially if old or was unable to self-care for a period of time, may need fluids of some sort in the presence of s/s of dehydration. How about a cautious IV fluid introduction with monitoring of lung sounds emphasized, and for pts only with signs/symptoms of need for fluid resuscitation ?



Cold extremities and a tachy tell me he's doing some clamping of his own and may have some sepsis related perfusion problems. He also looked a bit dry and with that resp rate, he'd be prone to dehydration anyway right? Is there something about this pt that says 'no fluids'. He's pretty clearly septic in my mind.


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## Veneficus (Jun 22, 2012)

Melclin said:


> Good to know I'm not the only one finding that one to be a head scratcher. I've never encountered anyone who said that these pts shouldn't get fluid, but what being careful or cautious means in this situation, I'm still not sure.




Have you tried to estimate the amount of fluid required using a fluid replacement formula?


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## socalmedic (Jun 22, 2012)

mycrofft said:


> Maybe splitting beans here, but why would _this _pt get fluids IV except to carry meds?
> 
> Generically, I'm with you. A fevered pt, especially if old or was unable to self-care for a period of time, may need fluids of some sort in the presence of s/s of dehydration. How about a cautious IV fluid introduction with monitoring of lung sounds emphasized, and for pts only with signs/symptoms of need for fluid resuscitation ?



one of the most important therapies this patient could have gotten is early aggressive fluids. the staples of sepsis treatment is early fluids, early antibiotics, and glycemic control. while giving fluids to any patient with a respiratory/cardiac complaint should be done cautiously, they should not be withheld due to these pathologies.


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## Veneficus (Jun 22, 2012)

socalmedic said:


> one of the most important therapies this patient could have gotten is early aggressive fluids.



I do not agree with this. I maintain that fluid therapy must have some level of precision to it.


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## Melclin (Jun 22, 2012)

Veneficus said:


> Have you tried to estimate the amount of fluid required using a fluid replacement formula?




No. I've heard of the 4,2,1 rule for NPO pts but never anything for this kind of patient. 

What should I be googling?


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## socalmedic (Jun 22, 2012)

Veneficus said:


> I do not agree with this. I maintain that fluid therapy must have some level of *precision* to it.



care to expand on this thought, what kind of precision should we be looking at?


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## Veneficus (Jun 22, 2012)

socalmedic said:


> care to expand on this thought, what kind of precision should we be looking at?



From my research into shock states, overhydration causes pathology. Simply the other end of the scale of dehydration. 

If you think of the human organism as a chemical reaction in a watery medium, how would adding large amount of water affect the homeostatic relationships and balances. 

Capilary ischemia.
Brain edema.
Hematocrit reduction.
Decreased cardiac output.
Increased intraabdominal pressure.
Osmotic shifts. 

The list goes on. 

It seems like there is this idea that adding large amounts of fluids is only going to be beneficial. 

That is just not the case. 

Over hydration doesn't work in hypovolemic shock. It doesn't work in cardiogenic shock. When the mechanisms are the same and only the order of decompensation is different, what would cause anyone to logically think the idea would work?

As for how much fluid, I think the only way to answer this is:

Enough.

It will depend on estimated total body water, total loss, and estimated vascular volume requirements.

Fixed guidlines like 3:1 or 3L prior to a pressor while easy to understand and implement, are more directed at provider convenience than patient need.

Tight glycemic control is beneficial but tight volume control is not?

It doesn't even sound logical. 

Several recently cited sources on this very website demonstrate that volume expanders are prefered, usually stipulating a chrystaloid. 

Many seem to buy into the idea that early administration means via EMS or the ED. But EMS and the ED usually focus on the ease of treatment rather than the efforts of moderating treatment. 

The easiest way of describing it I guess is: Using a cannon to kill a mosquito.

The error is not in the treatment, but the manner and system it is applied in.


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## Veneficus (Jun 22, 2012)

Melclin said:


> No. I've heard of the 4,2,1 rule for NPO pts but never anything for this kind of patient.
> 
> What should I be googling?



I will look up the exact formula(s) when i get home.


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## Smash (Jun 22, 2012)

I think Vene is right, it is of course no good just to hose people down, there are definite issues associated with over-resuscitation.  However my personal feelig is that those issues are possibly less of an issue for those of us in the out of hospital arena.  
I'm not saying that we shouldn't be conscious of them and consider the ongoing course of the patients illness and treatment, but I think we are apt to do a greater disservice by under resuscitating than over resuscitating.  For many of us it is unlikely that we will come close to replacing total volume deficit in a septic patient in the time we have them in the ambulance.  Obviously it's more of a concern for those with extended time with the patient.

I'm interested to know what formulae as well Vene.  It's tricky of course working out the parameters you mention whilst not having some of the monitoring capability to look at ScVO2 (if that is even any use) and CVP (probably less use).  Maybe we could be using pre-hospital lactate measurement to look at lactate clearance as a measure of effectiveness of our resuscitation *cough cough* h34r:


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## the_negro_puppy (Jun 22, 2012)

I guess you need to consider the risk vs benefit. If you are 15 minutes from hospital with a septic LRTI patient with the possibility of pulmonary oedema then I would probably hold off if in doubt. The question is whether the patient getting fluids 15 mins earlier is going to make a significant difference. Also significant pneumonia etc can actually be categorised as non cardiogenic APO, so I assume were are talking about cardiogenic/fluid overload causes.


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## Veneficus (Jun 22, 2012)

Smash said:


> I think Vene is right, it is of course no good just to hose people down, there are definite issues associated with over-resuscitation.  However my personal feelig is that those issues are possibly less of an issue for those of us in the out of hospital arena.
> I'm not saying that we shouldn't be conscious of them and consider the ongoing course of the patients illness and treatment, but I think we are apt to do a greater disservice by under resuscitating than over resuscitating.  For many of us it is unlikely that we will come close to replacing total volume deficit in a septic patient in the time we have them in the ambulance.  Obviously it's more of a concern for those with extended time with the patient.
> 
> I'm interested to know what formulae as well Vene.  It's tricky of course working out the parameters you mention whilst not having some of the monitoring capability to look at ScVO2 (if that is even any use) and CVP (probably less use).  Maybe we could be using pre-hospital lactate measurement to look at lactate clearance as a measure of effectiveness of our resuscitation *cough cough* h34r:



Quick and dirty because I didn't get to look up the actual formula yet.

If you take estimated total body water in KG. Subtract out estimated insensible loss, estimated urine output in ml/kg/hour from onset of symptoms, (this should slightly over estimate loss if urine output actually decreased) estimated loss in ambient room temperature justlike you would for a heat emergency, and add any fluid intake based on evidence or history, you should come up with a total fluid replacement estimate.(which over estimates actually, so it errs on the side of giving too much rather than too little) To make it more speedy I saw an actual chart for it in one of my books but will probably not get around to finding it before my trip back to KAF.

No, it will not be exact. But probabl more accurate than hanging a liter or 2. 

I can sympathize with the idea of not spending that much time with a patient, but I think it becomes a continuity of care issue. 

If you start 2 IV in the field (especially a 16 or 14g) hook up a liter to each anddrive 10 minutes down the road, you are already 2 liters in. When you get to the ED, they may likely replace at least 1 of the bags, so you are at 3L, minimum by the time they get to a unit. (Which desn't have the benefit of your earlier on scene estimations) So then they initiate care based most likely on What was given in the ED. 

This now eventually works itself out over days, but initial over resuscitation can have lasting effects and complications down the road. 

It is very short sighted to think of interventions as ok just because EMS or the ED doesn't see any negative consequences.

'out of sight out of mind" is not really a good performance measure.

Start some vanc or some anseph on the road to initiate early ab therapy? Sure, knock yourself out.

But over fluid resuscitate because you have no other option, think it is always benign, or some is good, more is better, is not something I can support.

EMS often complains that the hospital does not consider it as part of the continuum of care. 

I think more accurate treatment regiments that consider long term patient condition and complications is the step that EMS needsto take on its own to start being part of the patient's solution, rather than a wild treatment attempt before actual measured treatments are initiated.


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## Melclin (Jun 23, 2012)

Veneficus said:


> If you take estimated total body water in KG. Subtract out estimated insensible loss, estimated urine output in ml/kg/hour from onset of symptoms, (this should slightly over estimate loss if urine output actually decreased) estimated loss in ambient room temperature justlike you would for a heat emergency, and add any fluid intake based on evidence or history, you should come up with a total fluid replacement estimate.(which over estimates actually, so it errs on the side of giving too much rather than too little) To make it more speedy I saw an actual chart for it in one of my books but will probably not get around to finding it before my trip back to KAF.



Thats seems like it would be difficult to with any accuracy.


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## Veneficus (Jun 23, 2012)

Melclin said:


> Thats seems like it would be difficult to with any accuracy.



I think it is a start, not perfect.


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## zmedic (Jun 24, 2012)

If they are septic, I give fluids based on a couple of things. BP, lactate, how collapsible their IVC is on ultrasound. If they stay hypotensive in spite of adequete fluids, I add pressors. 

What I've been hearing from attendings is "if they need fluids, give them fluids. If they get pulmonary edema we'll intubate them and deal with it."

That shouldn't really apply pre-hospitally. I can't think of too many situations where the patient should be getting more than 2 liters before getting to the hospital. But if you have a nursing home patient who feels warm, is tachycardic and hypotensive, give them fluids. I don't care if they are a dialysis patient or have CHF. (Again, I'm talking about a liter or two. You give someone 5 liters prehospitally you are on your own.)


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## NYMedic828 (Jun 24, 2012)

This is kind of random but does anyone have any good links for info on effects of over hydration and why fluids aren't always a good choice for hypovelimic and cardiogenic shock?

Unless the main reason is simply to avoid upsetting balances and heme levels but I'm sure it can't be that simple.


As far as the main topic, here in NYC transport times are 5-15 minutes at most to hospitals with every capability known the medicine (I think). 

For us to give 2-3liters by the time of ER arrival probably means we tried to play doctor for too long.


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## Melclin (Jun 24, 2012)

zmedic said:


> If they are septic, I give fluids based on a couple of things. BP, lactate, how collapsible their IVC is on ultrasound. If they stay hypotensive in spite of adequete fluids, I add pressors.
> 
> What I've been hearing from attendings is "if they need fluids, give them fluids. If they get pulmonary edema we'll intubate them and deal with it."
> 
> That shouldn't really apply pre-hospitally. I can't think of too many situations where the patient should be getting more than 2 liters before getting to the hospital. But if you have a nursing home patient who feels warm, is tachycardic and hypotensive, give them fluids. I don't care if they are a dialysis patient or have CHF. (Again, I'm talking about a liter or two. You give someone 5 liters prehospitally you are on your own.)



Very interesting, thank you for your input. I've read quite a bit about the IVC on U/S in regards to fluids...perhaps a use for prehospital US 

The idea that if their lungs get wet with our fluid, we can cross that bridge when we come to it has been voiced to me before. One of my senior clinical overseers was very much of the opinion that I should be aggressively fluid resuscitating these patients, regardless of the origin of the infection or any hx of CHF. Despite his enthusiasm for aggressive anything, it would very much depend for me on the proximity of MICA/hospital given that I cannot start inotrope infusions, intubate or apply NIV. It seems likely that the lack of these interventions in the scope of the basic paramedic here has a lot to do with the fear of fluid in these patients. This seems wise, however, the fear is not limited to just us. Plenty of MICA dudes and dudettes have been made conscious of this as well.

While we're at it, I may as well bring up the topic of drawing cultures and administering abx. 

In the case I mentioned we were a very long way from a real hospital. The GP wanted us to give ceftriaxone straight off the bat. I wasn't convinced that this bloke couldn't wait for some cultures, but I really didn't wanna wait several hours for destination hospital, so a few phone calls later we were able to organise a quick stop over at the more local band aid station, staying on stretcher, while cultures and other blood work were drawn, 2g of ceftriaxone administered before reloading, taking a total of 15 mins, before heading off to the ICU capable hossy a further hour down the track with a ramp time of 1 hour at the stage. Also not a hospital that is great with early abx or anything else with its septic pts. 

In my ignorance, feel quite proud of having been able to organise this but I do wonder whether or not I'm patting myself on the back for no reason. What do people think of this idea? Any comments on just how bad abx before culture actually are? Do the cultures suffer from sitting in the back of the back of the stretcher for 2 hours (I did ask about this. I was told no, but I'd like to hear a few more opinions)? Do people foresee any problems with this way of doing things? Its something I would be interested in exploring again in the future but I think I need a bit more guidance.


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## KellyBracket (Jun 24, 2012)

EMS needs to get more involved in the identification and treatment of sepsis. I think it's an area where a big difference can be made.

For instance, there's an abstract in JEMS that describes the use of a portable lactate analyzer to guide fluid therapy by EMS. (*See abstract #1*), with some suggestive, positive, results.

I reviewed some of the other recent results into prehospital sepsis treatment,  suggesting that EMS is already having an impact on patient outcomes. Check out * Prehospital sepsis - new research* for more analysis.


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## LondonMedic (Jun 24, 2012)

KellyBracket said:


> For instance, there's an abstract in JEMS that describes the use of a portable lactate analyzer to guide fluid therapy by EMS. (*See abstract #1*), with some suggestive, positive, results.


The study you link to didn't use lactate levels to guide fluid therapy ("Treatment was not dictated by this study and was administered according to EMS protocols."). It is a technically poor study that shows that IV fluid lowers serum lactate - something that won't come as a shock to most of us.


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## Veneficus (Jun 24, 2012)

LondonMedic said:


> The study you link to didn't use lactate levels to guide fluid therapy ("Treatment was not dictated by this study and was administered according to EMS protocols."). It is a technically poor study that shows that IV fluid lowers serum lactate - something that won't come as a shock to most of us.



Along the same lines, I atended a seminar on the use of bicarb to theraputically lower lactate in the ICU. 

The speaker made a really good case that it is pointless to do this because all it does is mask pathology, it doesn't really treat it.

Another point was since lctate is a by product coming out of permiable cells, while it alters lactate levels in the blood, it doesn't actually restore aerobic metabolism in cells that can do it.


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## KellyBracket (Jun 24, 2012)

LondonMedic said:


> The study you link to didn't use lactate levels to guide fluid therapy ("Treatment was not dictated by this study and was administered according to EMS protocols."). It is a technically poor study that shows that IV fluid lowers serum lactate - something that won't come as a *shock* to most of us.



Shock - I get it.

Yeah, "guide" was a poor choice of words, and a small abstract only published on the JEMS website isn't the highest quality evidence to wave around. Regardless, it's an example of EMS using lactate levels in the field, _associated_ with some benefit, despite the lack of a protocol. 

In the same vein, though, the two studies I reviewed at *Prehospital sepsis - new research* both show that EMS, even without specific training or protocols, is able to identify and improve processes of care for septic patients. Imagine how much better care could be if we devoted some education and training to it.


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## Melclin (Jun 26, 2012)

Anybody else like to offer some wisdom on formulas to guide fluid in these pts?



KellyBracket said:


> Shock - I get it.
> 
> Yeah, "guide" was a poor choice of words, and a small abstract only published on the JEMS website isn't the highest quality evidence to wave around. Regardless, it's an example of EMS using lactate levels in the field, _associated_ with some benefit, despite the lack of a protocol.
> 
> In the same vein, though, the two studies I reviewed at *Prehospital sepsis - new research* both show that EMS, even without specific training or protocols, is able to identify and improve processes of care for septic patients. Imagine how much better care could be if we devoted some education and training to it.



Mate you're killing me with these lit review/blog post/common language summaries.. I've been working on something similar for a few months but I'm too stupid to come up with anything I'd want in the public eye...then you come along and do something similar but much better. Nice work..you prick. Keep it up


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## Doczilla (Jun 27, 2012)

Veneficus said:


> Along the same lines, I atended a seminar on the use of bicarb to theraputically lower lactate in the ICU.
> 
> The speaker made a really good case that it is pointless to do this because all it does is mask pathology, it doesn't really treat it.
> 
> Another point was since lctate is a by product coming out of permiable cells, while it alters lactate levels in the blood, it doesn't actually restore aerobic metabolism in cells that can do it.



Yup. Bicarb might make you feel better if you want to just look at the numbers.


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