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Septic Shock Management


chbare

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I recently had a discussion with a friend who turned me onto to some new material out of our friends at emcrit (Thanks Ronel!).

The original podcast with Dr. Marik's conclusions can be found here:

http://emcrit.org/po...-fluids-sepsis/

The response to Dr. Marik's lecture can be found here:
http://emcrit.org/po...-severe-sepsis/

I would strongly suggest people go through both the initial lecture and response before replying, but I would love to get every bodies take on this interesting issue.

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I watched the lecture from Dr. Marik and the response from Dr. Weingart when they first came out; absolutely worth listening to, and if you have the time to read through the discussion that followed (and even if you don't; it's that worth it) do so.

What they are both advocating really isn't that different; massive volume infusions in septic patients are bad, causing pulmonary edema in sepsis is bad, and patient's should be fluid resuscitated only as much as each individual requires. If you've been following any of the FOAMED websites this has been the line of thinking for quite some time, and from talking with a couple of local ER docs it's how many have been practicing locally.

http://resus.me/no-benefit-from-early-goal-directed-therapy/

The results of the ProCESS trial are now out (I think there's 2 more similar studies that are still finishing up) and the results aren't neccasarily that surprising; EGDT really doesn't make a difference in patient outcomes. (granted I haven't looked at the who study, so why mortality wasn't different, I don't know if there were differences in ICU time, intubation rates, etc)

Like the recent study on in-hospital hypothermia post cardiac arrest, I think what people are starting to realize is that if you have a semi-standardized approach and then actually PAY CLOSE ATTENTION to the patient, the outcomes are better.

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This is also being discussed on SDN in the EM forums. I think one of the best comments has to be the following (it's a little long):

This result does not surprise me. Doctors have always desperately wanted to feel their super cool gadgets actually make any difference. So the fact that they found no benefit from cool invasive catheters is no surprise to me, anyways. It makes me laugh, actually. Mark my words though, nobody will use them any less. Lol. They'll just come up with other biases to justify using them. It reminds me of the part in House of God where they stop all of there treatments, orders and medications on their floor and the patients suddenly all get better and go home. Lol.

EGDT itself was always a big "duh" event for me. The whole concept was equivalent to saying, "You know, it would really help if you did your job." You mean if someone is septic we're supposed to diagnose it? Yes. (Duh). You mean if we've diagnosed someone with sepsis (meaning "very sick") we're supposed to treat them right away, not in 6 hours or next week? Yes. (Duh). You mean we're supposed to pay close attention to abnormal oxygenation, hematocrit, and perfusion (signs of being "sick") and oxygenate if needed, transfuse if needed and give fluids if needed, sooner rather than later? Yes (duh)

But to think that forming some supposedly simple and dummy-proof protocol and pathway and adding a bunch of gadgets and geeky technical tools and lines are going to improve outcomes for the patients of clinicians who were treating these patients with urgency anyways, and recognized they were sick to begin with, always seemed doomed to fail. On the other hand, is a checkbox protocol policy and a mandate to put in a bunch of invasive lines and focus on central venous numbers make a difference for doctors who couldn't recognize sick patients in the first place, at a hospital that won't staff up ratios to allow nurses to give antibiotics quickly when needed, where people are just slammed through as fast as possible to make room for the next easy-collect quick in-and-out level 3 preferred "customer"?

I think not.

If you do your job, diagnose sick patients, treat your sick patients quickly as you should have been all along, I don't think you need some fancy protocol involving lines and fancy equations.

My point: if you know how to recognize and treat sick patients and you're at a place that carries out your orders promptly, you don't need these protocols that tell you what you should already know and be doing. If you don't recognize sick patients, let them crash while focusing on fast track, you're chronically shorted on nurses to pad the hospital profit margin, maybe you do need these protocols with cute names and can put in a bunch of invasive lines to run up the hospital bill by an order of magnitude. However, such people and places that need such such a "protocol" are exactly those who will not or are not capable of following such a protocol to begin with.

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On the other hand, is a checkbox protocol policy and a mandate to put in a bunch of invasive lines and focus on central venous numbers make a difference for doctors who couldn't recognize sick patients in the first place, at a hospital that won't staff up ratios to allow nurses to give antibiotics quickly when needed, where people are just slammed through as fast as possible to make room for the next easy-collect quick in-and-out level 3 preferred "customer"?

This scared the heck out of me doc. We had a pneumonia protocol in our hospital that when the doctor diagnosed a pneumonia or a sepsis we had a set of 3 or 4 antibiotics that we had to start within 4 hours of the diagnosis because JCAHO or whoever mandated that we did this. Didn't matter but dammit we had to start the antibiotics or our department would get dinged at the next nursing roundtables because we didn't start that golden nectar in time. It didn't matter that we were slammed with patients that were much sicker and we only had one nurse and two paramedics working to cover 12 patients in the ED and if an ambulance call came in, both medics left the ED and the nursing supervisor came down to help us or we got a nurse from the floor. Hows that for short staffed.

So to arbitrarily tell hospitals that if you don't meet these pulled out of the sky and cloud numbers or you might lose your JCAHO accreditation is just ludicrous. Let the health professionals practice medicine and leave it to the professionals, and stop mandating things that clog up the system that is already close to overload and collapse. Our numbers were always good but if they kept adding things there is a tipping point.

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Don't even get me started. Most of these JHACO rules are not based on any evidence either. There was no evidence to the support the 4 hour requirement, which has now been increased to 6 hours. It's the same way with EKGs. We are required to get an EKG on cardiac chest pains in less than 15 minutes. This has led to so many unnecessary EKGs. Yup, that 12 year old who has been coughing for 5 days and now his chest hurts? EKG.

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Don't even get me started. Most of these JHACO rules are not based on any evidence either. There was no evidence to the support the 4 hour requirement, which has now been increased to 6 hours. It's the same way with EKGs. We are required to get an EKG on cardiac chest pains in less than 15 minutes. This has led to so many unnecessary EKGs. Yup, that 12 year old who has been coughing for 5 days and now his chest hurts? EKG.

AMEN!! So many needless blood cultures, etc... We have became a "follow the alogrithm/tree" practice...

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Unfortunately, medicine is not nearly as evidence based as we often like to profess. There are many interesting situations. Think about "coma cocktails," tissue plasminogen activator for ischaemic stroke and others that are based on evidence that is perhaps not as robust as we would like.

Fortunately, we can have dialogue and discuss some of these issues. With that, I still believe general guidelines are still generally good and can act as a starting point or a place to run back home to mom when we are completely lost. They also help to put everybody on the same page in critical situations. However, sometimes our care may not be in perfect alignment with guidelines and guidelines can also change.

It's so important to look at the evidence as we are doing here. It's also possible for two very qualified people to come of with different conclusions and that discourse is interesting, relevant and hopefully, productive to discuss.

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I am all in favor of evidenced based medicine (EBM), the problem I have is in the true research of what is legit and what is not. There are several articles citing where bogus pay-offs to endorse EBM. Of course large fines have been set but ... the millions of dollars and opening of potential law suits because physicians follow set guidelines only to later find out they were falsified.

I have worked professionally in research and development, I have seen and understand the importance of rigid standards and ethics... and I also have seen the opposite to be published and some set as standards without questions.

Here is a link to an interesting article.

http://gaia-health.com/gaia-blog/2011-12-09/evidence-based-medicine-is-a-fraud-heres-why/

R/r 911

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