At smaccChicago, I had the honor to host an incredible panel of Sepsis Experts. I think most everyone who heard it was left with more questions than answers. I have already posted a preemptive response to the panel here:
EMCrit Podcast Episode 154
In a few days, I will post a wee with some additional thoughts. I want to hear what you think–post your comments below.
The Blurb from the SMACC Folks
An all-star panel discuss the burning issues in sepsis right now. Hosted by Chris Nickson and I, the conversation on the controversial aspects of sepsis was lubricated with on-stage alcohol (my idea!)
Mervyn Singer (research guru, sepsis expert and self-proclaimed Sex-God) and Paul Marik (iconoclast and dogma-basher) reveal just how hard it is to describe what sepsis is. Flavia Machado (intensivist and researcher) brings common sense and the perspective from South America, representing middle-income countries. Kath Maitland (author of FEAST, African-based paediatrician and clinical trialist) talks about sepsis management issues in Africa, where sepsis strikes its biggest global impact. Heavyweight researcher and clinician John Myburgh, argues that the word “sepsis” should be removed from our language and turns the paradigm on its head, arguing for a more pragmatic approach to sepsis management. Simon Finfer (crit care clinician, clinical trialist, voice of reason) describes the history, the good, the bad and the ugly about the Surviving Sepsis Guidelines, and some of the controversy surrounding them.
There’s a fascinating, very high level discussion on antibiotics which is not as clear cut as you might imagine. You couldn’t discuss fluids without talking about fluids and this panel features several world experts on this topic. Kath Maitland’s insights from FEAST, combined with the opinions of the rest of the panel will hopefully leave you an informed agnostic.
We’d highly recommend watching this discussion with your colleagues at work and use it to spark more discussion on this incredibly important topic that still kills so many of our patients.
Additional Resources
- Mortality after Fluid Bolus in Children with Shock Due to Sepsis or Severe Infection: A Systematic Review and Meta-Analysis
- Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial
- John Myburgh on Fluids
- Surviving Sepsis Guidelines
- Simon Finfer on Sepsis in 2014
- NEJM article on Sepsis by Angus et al
Additional New Information
More on EMCrit
- EMCrit 318 – SSC Guidelines 2021 – The Good, The Bad, & The Ugly and What You Need to Know in Sepsis Resuscitation
- EMCrit 241 – Sepsis Update 2019
Additional Resources
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- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
I may be between two overnights, but I’m sitting down with a cup of tea and a notepad for this one. Probably a beer or two this weekend when I sit down to watch it again…
Very nice. Stark contrast between this discussion and the paternal/maternal sepsis lectures at the traditional conferences. I am so sorry I missed this. Look forward to attending next year. It is soo cool to see these men and women who are intelligent enough to see past the basic dogma. Yet. they still seem to rrside in the box (albeit in the corners). Most still seem to make the mistake of speaking of sepsis and it’s treatment as a unified thing. An alternativd view of sepsis is that it is a cognitive bucket comprised of phenotypes with different responses to different… Read more »
How strange then that ARISE, PROCESS and PROMISE weren’t able to show that tailored expert care was superior to a protocol when treating a heterogenous bucket…..
Not strange at all. House officers at academic centers (“experts”) generally treat sepsis as a unified thing with or without a protocol. Spinning ARISE, PROcess and PROMISS as showing anything other than that expensive and invasive protocols provide no outcome benefit is not science. These trials were not designed to determine if simple guessed thresholds and one size fits all (if x then y) protocols can replace sepsis experts. I have to say one more thing. First we heard that the controls were improved by long use of protocols and that this explained the failure of the trials. Now it… Read more »
Hey Dr. Scott,
This vodcasty thing was a fun experience to watch. And, fascinating to see the expert opinion. And also fun to see the standards chewed up and spit out.
Now for a request: Can you, in typical EmCrit fashion, do a follow up (wee maybe?) to this cast, translating it for us non-experts in the field? Just to get us back on track with sepsis, as now I am scared to give fluids, antibiotics, and I don’t dare mention SIRS criteria…
Thanks for all you do. You’re awesome as always
Adam
Oops. You already did a podcast, 154. I guess you are like a magic telepathic man from the future! Or something like that.
Anyway, great stuff.
Thanks again.
I enjoyed the presentation, though I tired of the discussion of the, “I’m an expert and don’t need this guideline crap.” The vast majority of sepsis patients are not seen by intensivists. In addition, early sepsis, when intervention is most important, is even less likely to be seen by an Intensivist. There was a passing comment about ATLS implying trauma patients should only be taken care of by experts. (The context of the comment was not on the video, so I apologize if my implication is wrong.). Guess what: most trauma patients will first be seen by non-experts. That is… Read more »
How is it that house officers in a 1st world academic hospital can be treating severe sepsis for several hours without senior input or intervention? And if that is the baseline care in the real world, it seems a protocol is the best you can hope for.
Yes, but listen to the podcast again. It should be obvious that first we have to figure out what sepsis is ….or more specifically, we must figure out what the phenotypes which comprise the cognitive bucket we call sepsis are. Then we can define the protocols to test. In rhe meantime it is our goal to displace the 1980s sepsis anchor. Popper says we should feel sorry for the “normal scientist” (normal in the Kuhn sense) as he(or she) has been taught in a dogmatic way and is the victim of indoctrination. The “sepsis” anchor is so deep and so… Read more »
Going beyond the molecular biology of sepsis/SIRS, a major part of the problem is that we only possess crude tools to evaluate important circulatory parameters such as global perfusion, local tissue perfusion, capillary leak, intravascular volume status and fluid responsiveness. This is itself an obstacle to developing any rational approach to its management with the current therapies at our disposal.
Exactly. So… here is the takeaway for all of the young who have watched this remarkably forthcoming and intellectually honest sepsis podcast. 1. We don’t even know what “sepsis” is. 2. The old experts clinicians and scientists need spend much direct time with sepsis patients and with comprehensive patient data sets of septic shock to relearn. This is required because sepsis is not the simple, threshold defined condition of “out of control inflammation”, they thought it was when they were young in the 1980s. Their 20th century ideas, while responsible for a great positive impact on public health (in terms… Read more »
Lawrence, I think the following points should be made 1) Sepsis pathophysiology is intricate and complex with variable manifestations and there is still much to understand about the molecular biology 2) Consequently, it unlikely any single magic bullet e.g. Protein C, will be effective. 3) Whilst a tailored molecular approach would seem ideal, we are limited by the current sophistication and run-time of laboratory methods. Additional challenges are multiple interdependencies in the inflammatory cascade that we may not appreciate. 4) SIRS, Sepsis definitions were originally conceived not as clinical decision tools but an attempt to characterise and define the scope… Read more »
Scott, I just want to say thank you and thank you. Thank you for the time and the effort and the resources that you put into this. I get that you enjoy this, but it is really an incredible amount of work that you do. The podcasts are amazing, the vodcasts that I have seen have been incredible. It has helped my practice to be better and it is helping our service to those that we work with to be better.