PulmCrit (EMCrit)

Metabolic resuscitation for sepsis is currently quite controversial.  Marik et al. published a before-after study in 2017 describing the combination of hydrocortisone, ascorbate, and thiamine for septic shock. That study incited a media storm of surprising intensity.  Currently, several multi-center RCTs are underway to answer this question more definitively.  In the interim, some additional before/after trials may emerge.  These studies likely won’t answer the question, but they may provide us with some clues about whether metabolic resuscitation is on the right track.

Imagine that you admit a patient with septic shock.  You resuscitate the patient as best you can with inopressors, fluids, and antibiotics. An adequate blood pressure is achieved.  A reasonable amount of fluid is administered.  Despite all these measures, the urine output remains minimal.  What should you do next?

A common approach to TdP is shown above.  The initial episode is controlled with magnesium and perhaps defibrillation.  The patient is sent to ICU for close observation.  Usually the patient will be fine, but sometimes TdP does recur.  Recurrence triggers second-tier therapies, often including overdrive pacing.

The use of bicarbonate is a source of eternal disagreement.  Bicarbonate has a shameful history of being abused in situations where it’s unhelpful (e.g. cardiac arrest).  This has impugned its reputation, giving it an aura of ignorance and failure.  Consequently, bicarbonate is underutilized in some situations where it might actually help.

No high-quality evidence exists on fibrinogen monitoring in PE.  Most practitioners don’t check fibrinogen levels for patients getting TPA for PE.  This is a bit paradoxical, because fibrinogen is usually monitored in patients receiving catheter-directed thrombolysis – a procedure involving lower doses of TPA with a markedly lower risk of intracranial hemorrhage.