So I got to moderate a panel on Fluids in Sepsis with such luminaries as Manny Rivers, Dave Gaieski, Phillipe Rola, and Terry Clemmer. The panel was incredibly interesting, but in some ways exemplified treatment pathways that I don't quite agree with. If you'd like to listen for yourself, the link is here:
Fluids in Sepsis Panel
Since I felt some of the key messages were slightly askew, I wanted to debrief with my friend Phillipe Rola. Phillipe is a self-described Internist-Intensivist, mad sonographer, ducatista and Brazilian Jujitsu aficionado. He blogs at the site: Thinking Critical Care.
Topics we Discussed
- Fantastic Post on Fluid Tolerance/Responsiveness
- Cerebral and Somatic NIRS
- Hepatic Vein Doppler
- Portal Vein Flow
Now on to the Podcast…
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Scott Weingart
An ED Intensivist from NY. No conflicts of interest (coi).
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Scott, While I agree with the physiologic plausibility of the Auz/NZ approach to low-dose norepinephrine early to increase venous tone and decrease the size of the venous capacitance system, my gripe with this approach is more of a logistical one. Many patients who would potentially benefit from this approach are the ones who sit on the fence between needing ward and ICU level care: they have borderline low BPs, slightly elevated lactate, otherwise normal organ perfusion, etc. While I agree wholly that it would be wrong to give 5-6+ liters to a patient to avoid ICU admission, these are often patients who turn around after 2-3. We don’t have any high-quality data demonstrating that the early vasoactive approach leads to improvement in any patient-centered outcomes, though we may be able to extrapolate some data demonstrating higher mortality with ore positive fluid balance. This approach, however, may result in increased downstream resource utilization (e.g., an ICU bed and perhaps CVC, at least at many US centers). There are many potential systems-fixes to this problem (ED-ICUs, peripheral vasoactives on general wards, etc.), but change is slow at many institutions. In the interim, how do you justify this approach from a systems perspective… Read more »
I was wondering your thoughts on whether or not fluid management has changed for acute pancreatitis. If you have that gallstone pancreatitis patient without signs of cholangitis but with elevated BG/LDH/Transaminase but normal vitals, do they still deserve all the fluid we are giving in the first 24hr or might there be some other way to target IVF in these patients.
Josh Farkas wrote a fantastic post outlining the evidence (none) behind the strong (religious) recommendations for aggressive fluid resuscitation.
In my opinion there is no formula. You assess your patient, mainly by ultrasound-enhanced physical examination, and decide whether your patient needs none, a little or a lot. And you reassess again a few hours later.
Especially in pts with intra-abdominal pathology, you have to be wary about precipitating an abdominal compartment syndrome by aggressive but well-meaning resuscitation.
Cheers
PR
[…] Weingart and Phillipe Rola discuss fluids in sepsis (again). Is using vasoactive drugs earlier better? […]
Scott and Phillipe,
Thanks for a great cast. My question is what is your opinion on the utility of the Cheetah NICOM for determining fluid responsiveness. I have never used it and my ICU colleagues feel we should have it in the ED. Your opinions?
Gratefully,
AW
I’ve no experience with it but, as Scott says, the trend would be useful and I’d love to play with one. Trends are the key as far as I’m concerned.
had an emcrit episode on it with Paul Marik. if you need a CO monitor it is pretty good, at least for trends. I don’t bother with fluid responsiveness anymore.