Fluid Resuscitation in Sepsis

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EpiEMS

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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.
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Curious what everybody thinks!
 
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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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.
 
@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!
 
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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o_O
 
Ensihoitaja said:
o_O
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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:).
 
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!
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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.
 
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".
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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.
 
Ensihoitaja said:
I do disagree with the gratuitous slam against urban medics.
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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.
 
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.
 
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
 
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.
 
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
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Right...even in healthy patients, only 25% of a liter of crystalloid remains intravascular.
 
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)
 
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.
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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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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.
 
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!
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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.
 
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.
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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.
 
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.
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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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