tag:blogger.com,1999:blog-1474751880645498536.post3282580917603029404..comments2023-10-10T10:14:36.340-04:00Comments on Medical Evidence Blog: Sepsis Bungles: The Lessons of Early Goal Directed TherapyScott K. Aberegg, M.D., M.P.H.http://www.blogger.com/profile/17564774546019869201noreply@blogger.comBlogger6125tag:blogger.com,1999:blog-1474751880645498536.post-9946778671865632102014-05-24T17:50:38.847-04:002014-05-24T17:50:38.847-04:00metabolic theory of septic shock
http://www.wjgnet...metabolic theory of septic shock<br />http://www.wjgnet.com/2220-3141/full/v3/i2/45.htmandrewhttps://www.blogger.com/profile/05708396832821349752noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-37222143311132585722014-03-21T13:51:22.024-04:002014-03-21T13:51:22.024-04:00Thanks! I am with you on the LR!Thanks! I am with you on the LR!Anonymoushttps://www.blogger.com/profile/06791654657223028320noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-42049400169480102692014-03-21T11:29:39.361-04:002014-03-21T11:29:39.361-04:00Javad - I would say we resuscitate with holistic r...Javad - I would say we resuscitate with holistic rather than simplistic goals such as CVP. I think chasing lactate is a fool's errand. Should I really give more fluids if the lactate is persistently high? I'm not giving blood or dobutamine. Do we think that pressors are going to drive the lactate down? Lactate is an epiphenomenon and it will come down when I give antibiotics and basic hemodynamic support. Or it won't.<br /><br />The pressor question is addressed in the next article I'm going to review here about MAP targets in septic shock. I'm gonna bet that relaxing MAP targets or capping pressor doses does not change outcomes. My MAP target in urosepsis is 50 mm Hg.<br /><br />The resuscitation fluid question has been answered far beyond what is necessary and I think further trials in this domain are futile and a waste of resources. See: <br /><a href="http://medicalevidence.blogspot.com/2013/11/dead-in-water-colloids-versus.html" rel="nofollow">Dead in the Water </a><br />There is ANOTHER online first article March 18th NEJM of albumin in sepsis and it too was a FAIL.<br />I am impressed by emerging data that LR is superior to NS and that has been my experience and I've switched to LR as my preferred resuscitation fluid. Seems like chloride loads might be bad for people. <br /><br />And, yes, as always, identify the problem and treat the root cause. Gorillacillins and source control as appropriate are paramount. A lot of the rest, in my estimation is handwaving and chasing epiphenomena.Scott K. Aberegg, M.D., M.P.H.https://www.blogger.com/profile/17564774546019869201noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-12327832739527644772014-03-21T11:18:16.938-04:002014-03-21T11:18:16.938-04:00PulmCCM - Craig Lilly, the editorialist, says that...PulmCCM - Craig Lilly, the editorialist, says that "If one assumes that the treatments for septic shock, as well as the timing of the treatments, that would be administered in all emergency departments, regardless of size or available resources, would be equivalent to those used in the no-protocol (usual-care) group of the ProCESS trial (which included strategies for early recognition of sepsis), one could come to the dubious conclusion that protocols and decision prompts do not have a role in the treatment of septic shock. I prefer to think differently."<br /><br />I'm not sure he and I disagree as much as I originally thought, but he seems to be saying that we should retain selected parts of the Rivers protocol (what parts?) regardless of the findings, that's where I take exception. But as far as early identification and resuscitation especially early antibiotics, we're on the same page.<br /><br />One practical problem we have in my practice is missing sepsis altogether because of "premature closure" - another diagnosis is settled upon (DKA, drug overdose, stroke, CHF) and they're septic too but nobody gives antibiotics. Which is why I posted on Status Iatrogenicus <br /><a href="http://statusiatrogenicus.blogspot.com/2013/11/in-praise-of-lasix-utility-approach-to.html%22" rel="nofollow">In Praise of Lasix on Status Iatrogenicus </a><br />that I have a very low threshold for antibiotics in ICU admissions of all sorts.Scott K. Aberegg, M.D., M.P.H.https://www.blogger.com/profile/17564774546019869201noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-53289581027877992552014-03-21T10:07:00.981-04:002014-03-21T10:07:00.981-04:00Amen! I like your philosophical point. On a prac...Amen! I like your philosophical point. On a practical level though--now that we know that was nothing superhuman about the Rivers trial--where do we go from here? How do we save those on the margins? For instance, how do we measure resuscitation? Lactate? CVP? UOP? Ultrasound of the IVC? What about pressors--are they helpful? What is the best resuscitation fluid? NS, LR, Colloid? Is there good evidence for any of this beyond the basic point that the very sick need prompt attention and antibiotics?Anonymoushttps://www.blogger.com/profile/06791654657223028320noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-67171927913181122372014-03-21T08:49:13.119-04:002014-03-21T08:49:13.119-04:00Great post as usual Scott. I'm going to read t...Great post as usual Scott. I'm going to read that editorial. "Dubious conclusion"? Based on what argument? Not a statistical one, apparently.PulmCCMhttp://pulmccm.orgnoreply@blogger.com