Cite this post as:
Scott Weingart, MD FCCM. Podcast 056 – Dr. Rivers on Severe Sepsis – Part III. EMCrit Blog. Published on September 13, 2011. Accessed on March 23rd 2023. Available at [https://emcrit.org/emcrit/rivers-sepsis-iii/ ].
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
Original Release: September 13, 2011
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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One thing I love about Dr. Rivers is his relatively rational approach to therapy. Intervene early, when appropriate and wait when appropriate. There’s a lot to learn from this.
How many other disease states are out there in which an earlier intervention is as powerful?
Status epilepticus? Yes
Mike Jasumback, MD
absolutely Mike. Hypoglycemia and any exsanguination as well.
Thanks guys for a truly inspiring and informative podcast. Dr Rivers , you are a living legend. Scott, you are the international man of ED critical care.
in regard to digoxin use in the tachycardic patient with sepsis, totally agree. I use it a lot and rarely have issues when you are using it for acute rate control. Usually with rapid AF but Rivers is right you can use it for any supra ventricular tachycardia includin sinus tachy. And if they have some heart failure element to their sepsis it’s a useful inotrope as well.
Minh, you are too kind! I’m glad to hear you like dig for these folks. I’ll have to give it a try. How long after giving it do you see any tangible change in the heart rate?
Scott, generally you see a response within 60min after a 0.5mg IV load
I give another 0.5mg dose depending upon the response at 1hr.
You reduce the dose in renal dysfunction of course, generally halve the dose.
Great advice. Suggested on rounds the other day for a tachy septic patient and it worked like a charm.
Also, I have used Scott’s method; opiates. I transfered a septic patient from the ED the other day only on a Propofol infusion. Up went the Fentanyl and the patient settled.
PS…Minh Le Cong: Did you post on Flight Web? You profile picture looks familar?
yep A1 sedation (analgesia first)!
good stuff, my friend
yep I did post on Flight web for a while. Then I found EMCrit
Great set of podcsts by Dr Rivers. One question with respect to digoxin use. I was always taught that dig has a vagotonic effect and would have little benefit in high sympathetic states (hence does not prevent exercised induced fibrillation). Would its effect as an inotrope indirectly reduce heart rate?
Alex, I have always thought the exact same thing. I guess even a bit of vagal tone may be helpful.
PRICELESS PRESENTATION BY DR RIVERS, THANKS MATE.
SPECIALITY REGISTRAR IN ACUTE MEDICINE
HEART OF ENGLAND, BIRMINGHAM, UK.
My pleasure, my friend
need your input. do you think early goal directed therapy w/ central line insertion should still be initiated even if a lactate of above 4 resolves or decreases after fluid resuscitation?
In NYC we use serial lactates as per the Jones trial rather than central line/classic egdt. See https://emcrit.org/sepsis