Podcast 055 – Dr. Rivers on Severe Sepsis – Part II

Part II of Dr. Rivers’ talk on Severe Sepsis

Dr. Emanuel Rivers brought the concept of aggressive therapies for sepsis down to the Emergency Department with his seminal article on EGDT published in the NEJM in 2001. We were lucky enough to get an hour of his time to do a conference call with the NYC STOP Sepsis collaborative.

I broke the ~1 hour lecture into 3 parts.

If you haven’t already, check out Part I and Part III for more fun

In Part II, Dr. Rivers discusses:

  • CVP and Fluid Responsiveness
  • Should End-Stage Renal Failure patients get lots of fluids?
  • Should we be using albumin?
  • Should vasopressin be a first line pressor?
  • Steroids/Etomidate (See a paper by Dr. Marik on steroids in sepsis)

Here is a pdf of Dr. Rivers’ Slides

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Comments

  1. sai aleti says:

    Hi Scott thanks for posting/hosting Dr.Rivers thoroughly enjoyed the presentation and ur commentary, just tell us where this show notes is, and please keep this blog going on with new articles and concepts
    thanks :)!
    Sai

  2. I’ve noticed some recent studies that suggest a large percentage of sepsis patients present via EMS and that the mortality among the EMS cohort is higher (unadjusted rates). I’ve seen the SIRS criteria and the Denver EMS criteria, but both require bloodwork of some kind (or a lactate level). While POC lactate is probably within reach for some systems, I don’t see it being the mainstream.

    Do you or Dr. Rivers have a recommended screening tool for prehospital providers?

  3. Justin Koffer says:

    Thanks for posting that and giving everybody the opportunity to learn with one of the big players in sepsis. Can´t wait for your episode on fluid challenge/responsiveness! So what if a patient with known global heart failure prior to sepsis goes septic, gets oliguric and has a CVP of say 16 mmHg: No fluid because I met the EGDT-goals or fluid challenge because maybe that guy usually has a CVP even higher due to his heart failure and could use more fluid?
    Thx,
    Justin

  4. Another wonderful post, many thanks for bringing this to us. So much has been written about EGDT over the last 10 years its fascinating to hear the thoughts of ther guy who started it all!
    Love the example of using high CVP and low Sv02 to dx heart failure and inotropes bringing the CVP down – it all makes sense!

    Thanks again!

  5. Hi scott ,i just started listening to your podcast and i must confess that they are excellent and well informed ,the recent piece by Dr Rivers was full on ,never had a lecture about sepsis like that before.May i suggest that you do something about interpretation of CT in ED especially abdomen and brain.Thanks

  6. Mike Jasumback says:

    Finally, a topic on which I feel competent to speak!!!
    I have been an EMS medical director for ~10yrs or so and speak on this topic at CCTMC on a pretty much yearly basis. I have had pretty extensive discussions with lots of docs on the aeromedical side as well. My .02:
    The vast majority of EMS transfers are probably not long enough to qualify for the institution of antibiotics in the field. Even in my semi-rural environment, these episodes are extroardinarily rare. EMS involvement in sepsis really, in my opinion, should be primarily in the role of recognition and early resuscitation. That’s primarily what I teach. How to recognize Sepsis and begin EGDT in the field.

    Mike Jasumback, MD FACEP
    Medical Director
    PHI Air Medical- California

  7. Mike Jasumback says:

    Another .02 is this. In those settings that might require field abx, realize that these are usually places that are remote. You are often asking more inexperienced providers (with respect to Sepsis at least) to implement a therapy that they might use once a career.
    Gotta be carefull when asking folks to implement a therapy that they might only do once a year.

    Mike Jasumback, MD FACEP
    Medical Director
    PHI Air Medical- California

  8. Great discussion on steroids in severe sepsis

    On when to give steroids:
    Manny Rivers discusses adding steroids for vasopressor dependent refractory shock , or persistent hypotension despite norepinephrine for some time (6 hours)

    In the EM:RAP Critical Care Podcast (episode 2), Mike Winters, Robert Rodriguez, and Peter DeBleiux discuss a great “trigger” for steroids: when you’re considering adding a second pressor

    I don’t think there’s a clear evidence base for exactly when (eg 6 hours vs 2nd pressor) but when there’s a bunch of sick patients around the 2nd pressor as reminder, instead of (or in addition to) relying on keeping track of time

    • Great point. Before we replaced our Elmhurst protocol with the ALL NYC protocol for the sepsis initiative, we had the time you considered a 2nd pressor as a point to consider a bunch of stuff:
      Is this cardiac depression? consider adding inotrope instead of 2nd pressor
      Is it adrenal suppression? consider steroids
      Is it inadequate volume? Consider a bolus before the 2nd pressor
      Is this anemia? Consider knocking the Hb up
      Is the pt hypocalcemic? Get an Ical and augment calcium if low

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