image by: Sepsis Alliance

HWN Suggests

A Paradigm shift: re-thinking sepsis, and maybe shock in general

My (very) humble opinion on this is a rather simple, almost philosophical one: why are we seemingly obsessed with treating a predominantly vasodilatory pathology with large amounts of volume? I’ve said this in previous posts and podcasts, but this, in my opinion, is largely cultural and dogmatic. “Levophed – Leave’em dead” is something I heard as a student and resident, and came to take for granted that I should give lots of fluid in hopes of avoiding pressors… But there’s no evidence at all to support this. The common behavior of waiting until someone has clearly failed volume resuscitation before starting pressors befuddles me (think how long it takes to get two liters of fluid in most…

read full article

Featured

  SIRS, Sepsis, and Septic Shock Criteria

When a patient presents with two or more SIRS criteria but with hemodynamic stability (i.e. blood pressure at baseline), a clinical assessment must be made to determine the possibility of an infectious etiology. Note: sepsis definitions are evolving and difficult to finalize without a gold standard. These criteria are what is reported and the literature is listed, but note that nuances exist for all sepsis definitions and can differ locally, regionally, nationally, and internationally, as well as in clinical vs administrative vs research settings.

 Sepsis: What Works, What Doesn't?

Central lines are no longer thought to be mandatory for all sepsis patients, Dr. Whittle said. “We now have solid data saying that high-quality peripheral lines are safe for administration of low-dose vasopressors for a limited time. Now, if your patient is going to need pressors longer than that, or if they're going to need more ports than you can get in a peripheral line because you're administering numerous meds, sometimes you will need a central line. Over the last few years, my practice has evolved to where I initiate pressors more quickly and allow less hypotension, preferably almost none, but I initiate far fewer central lines.”

 Six myths promoted by the new surviving sepsis guidelines

The unfortunate reality is that the Rivers trial was a flimsy study. It was a single-center study with dodgy methodology, including mysterious disappearance of 25 patients who were randomized but never analyzed. Dr. Rivers had major conflicts of interest, including patenting a catheter to monitor svcO2. The Rivers trial and the Surviving Sepsis Campaign popularized sepsis protocols, which saved lives. Massive accomplishment. However, that doesn't validate the individual components of early goal-directed therapy. Any protocol involving early identification and intensive care of septic patients probably would have worked. Over time, nearly every component of early goal-directed therapy was disproven

 Understanding lactate in sepsis & Using it to our advantage

Lactate elevation in sepsis seems to be due to endogenous epinephrine stimulating beta-2 receptors. Particularly in skeletal muscle cells, this stimulation up-regulates glycolysis, generating more pyruvate than can be used by the cell's mitochondria via the TCA cycle. Excess pyruvate is converted into lactate. This process is entirely aerobic, occurring despite adequate oxygen delivery. Lactate generation doesn't occur because the mitochondria are unable to function in the absence of oxygen. Instead, lactate generation occurs because the TCA cycle simply isn't able to keep up with a very rapid rate of glycolysis.

Previously Featured

The Sepsis Continuum

Going over SIRS and septic shock came across this old slide.

ProCESS Trial Highlights Global Trends in Sepsis Management

This landmark trial suggests that complex, invasive sepsis care brings no statistical mortality benefit while consuming healthcare resources. Here is a quick run-down of the study that is shifting the sepsis conversation. So what does this mean going forward? It means that the things we postulated for many years have panned out – it’s really all about early identification, early fluids, and early antimicrobials when it comes to saving lives. While prior data suggested this, it’s time for everyone to get on board. You don’t need a complex algorithm, invasive and painful procedures, or expensive equipment to provide good care. And now you have the data to prove it.

Sepsis and septic shock: current approaches to management

Sepsis, defined as life‐threatening organ dysfunction due to a dysregulated host response to infection, is recognised by the World Health Organization as a global health priority.

Treatment of Patients with Severe Sepsis and Septic Shock: Current Evidence-Based Practices

Management of sepsis and septic shock involves early interventions to achieve hemodynamic stability. Due to the heterogeneity and complexity of sepsis pathophysiology, there is no perfect therapy for sepsis that “fits for all.” However, implementation of best-practice guidelines based on evidence-based medicine has shown to improve mortality associated with sepsis and septic shock. Many elements of the guidelines remain controversial and more research is needed to address these important unanswered questions.

Updates and Controversies in the Early Management of Sepsis and Septic Shock

This issue of Emergency Medicine Practice reviews the recent changes in sepsis criteria, prognosticators, and quality metrics and offers recommendations on the recognition and treatment of sepsis, severe sepsis, and septic shock in the emergency department.

Trial by Fire: Critics Demand That a Huge Sepsis Study Be Stopped

A large government trial comparing treatments for a life-threatening condition called sepsis is putting participants at risk of organ failure and even death, critics charge, and should be immediately shut down.

ACEP task force on septic shock should replace the Surviving Sepsis Campaign

The critical care community has long been plagued by a series of antiquated, overbearing guidelines created by the Surviving Sepsis Campaign (SSC). The campaign was originally sponsored by Eli Lilly and Edwards Life Sciences, as a commercial marketing campaign. The backbone of the original guidelines was a single center trial by Rivers, which has failed to be replicated. Nonetheless, despite new evidence, the guidelines have been highly resistant to change, often causing them to lag several years behind modern sepsis care.

Doctor Turns Up Possible Treatment For Deadly Sepsis

Marik tried this treatment with the next two sepsis patients he encountered, and was similarly surprised. So he started treating his sepsis patients regularly with the vitamin and steroid infusion.

Doctors have resisted guidelines to treat sepsis. New study suggests those guidelines save lives

Even in the face of increased pressure from regulators, many doctors have failed to fully embrace early screening and treatment protocols for sepsis, an infection-related complication that afflicts tens of thousands of Americans every year and that can be life-threatening. Skeptics have argued that there haven’t been any comprehensive studies to support the notion that the protocols can actually save lives. On Sunday, however, the New England Journal of Medicine published a large study that could make doctors reconsider — and help hospitals address head-on one of the most common dangers their patients face.

Fluids in Sepsis, A New Paradigm

Dr. Paul Marik is a renowned intensivist and a confirmed critical care skeptic. He has broken down many myths such as the use of CVP for volume assessment.

Initial Management of Sepsis

It is acceptable to give vasopressors (e.g. noradrenaline infusion) via a proximal peripheral venous line (e.g. large bore cannula in antecubital fossa) in the short-term (e.g. first 6 hours) with close observation for extravasation (Loubani and Green, 2015; Cardenas-Garcia et al, 2015))

Metabolic sepsis resuscitation: the evidence behind Vitamin C

Sepsis resuscitation generally focuses on hemodynamics. Rivers of ink have been spilled writing about oxygen delivery and fluid responsiveness. This is clearly important, but it's possible that our focus on easily observable phenomena has led us to ignore something of equal importance: metabolic resuscitation. We can deliver all the oxygen we want to the tissues, but if the mitochondria are failing it won't work.

Passive leg raise offers promise in predicting fluid responsiveness

When trying to ascertain a patient's fluid responsiveness, our current choices are gestalt (i.e., high uncertainty) and an invasive pulmonary artery catheter of doubtful benefit and possible harm. Using passive leg raise as a test routinely could help, and it's hard to see how it could hurt.

ProCESS Trial Highlights Global Trends in Sepsis Management

This landmark trial suggests that complex, invasive sepsis care brings no statistical mortality benefit while consuming healthcare resources. Here is a quick run-down of the study that is shifting the sepsis conversation. So what does this mean going forward? It means that the things we postulated for many years have panned out – it’s really all about early identification, early fluids, and early antimicrobials when it comes to saving lives. While prior data suggested this, it’s time for everyone to get on board. You don’t need a complex algorithm, invasive and painful procedures, or expensive equipment to provide good care. And now you have the data to prove it.

Recent advances in understanding and managing sepsis

Sepsis is one of the oldest described illnesses. The term sepsis is derived from the ancient Greek term “σῆψις” (“make rotten”) and was used by Hippocrates around 400 BCE to describe the natural process through which meat decays and swamps release decomposing gases but also through which infected wounds become purulent 3. After this recognition, it took over 2,000 years to establish the hypothesis that it is not the pathogen itself but rather the host response that is responsible for the symptoms seen in sepsis.

The Controversies of Corticosteroids in Sepsis

Corticosteroids may not decrease mortality at physiologic doses, but they do possess important effects. Patients with septic shock given corticosteroids demonstrate decreased need for vasopressors, which has the potential benefit of improving peripheral vascular recovery and organ function.