Fluid Resuscitation in Sepsis

[TXmed]

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.

 

[Tigger]

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.

 

[VentMonkey]

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.

 

[ERDoc]

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

 

[EpiEMS]

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!

 

[Handsome Robb]

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
Temp >100.4 or < 96.8

AND

EtCO2 <25mmHg

So suspected infection plus two SIRS criteria and EtCO2 <25 is a Sepsis alert.

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


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[E tank]

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.

 

[StCEMT]

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.

 

[ERDoc]

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

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

 

[reaper]

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

Showing very good results so far.

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[ERDoc]

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

Showing very good results so far.

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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.

 

[Summit]

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

 

[reaper]

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

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[ERDoc]

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

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

 

[reaper]

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]

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

See if that works?

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[ERDoc]

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.

 

[reaper]

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]

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.

 

[Nova1300]

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.