Grant:

Good questions. Sepsis is a very complicated disease, and our understanding continues to evolve. I think these patients are best treated at a tertiary care center with full time intensivists who have the resources to care for these very sick patients.

In terms of fluids during transit. I would always establish a “good” peripheral line. I would then evaluate the patients’ vital signs. If the vitals are “normal” don’t give fluids. If the patient is hypotensive (MAP 105) i would give a 500 cc bolus of NaCl. . However, MOST IMPORTANT is to monitor the response of the fluid bolus on the MAP, HR and resp rate. If no improvement and/or increase in respiratory rate STOP fluids. If the patient appeared to benefit from the first 500cc bolus I would cautiously give a second bolus (of 500cc). Never EVER give a rapid 30cc/kg bolus of fluid; this is a dangerous strategy. When you transfer the patient at the receiving hospital it would be important to convey this information to the receiving team.

Hope this helps.

Paul Marik.

Cyrus: Good questions,. No simple answers. I summarize my thoughts below: q1.In a resource limited setting one has to rely on ones clinical skills and the tools available. While the change in MAP or heart rate is an inadequate measure of the change in SV, close observation of the patient after a 500cc bolus is a key in determining if this was the right intervention and what to do next. A key factor is understanding the patients pathology and what you are trying to achieve. There is no technology that answers all ones clinical questions. We rely on bedside ECHO, as well as NICOM and PiCCO (when appropriate). However, as clinical medicine moves out of the dark ages, i believe that if a hospital has an ICU is should have the equipment necessary to safely manage these patients. q2 and q3. I agree, B lines have been shown to correlate well with EVLWI. See also my revised post on vena-caval ultrasonography – Dynamic Changes in Carotid Doppler flow is a simple method to assess fluid responsiveness. q4. The concept of the “third space” has been abandoned… it is a space that does not exist.., except in the imagination of the… Read more »

Studies such as those by Herran-Monge et al[1] are frequently published in the literature with the sole purpose of trying to justify the resources and effort involved in instituting the Surviving Sepsis Campaign (SSC) Guidelines. There is no credible high level scientific data that the institution of the SSC Guidelines has specifically and directly reduced the mortality of patients with severe sepsis or septic shock. The study by Herran-Monge et al in particular has a number of fatal flaws which should have precluded publication. The two populations differ significantly in disease severity and it makes it extremely difficult to make direct comparisons. The authors report that intra-abdominal infection was the commonest source of infection. This finding differs from almost all published sepsis studies, where pneumonia is by far the most common source of infection (approx. 50%). This is particularly relevant as the timing and methods of source control become the most important factor influencing outcome in patients with intra-abdominal infection, and it is likely that this has changed over the 9 year study period. It is extremely important to emphasize that numerous changes have occurred in the management of ICU patients generally and sepsis patients in particular over the last… Read more »

Corinna: I would not use the GUT as a route of fluid resuscitation in the ICU. This is a generally auseful approach in patients with diarrhea. However, in ICU patients who have a water deficit (not volume deficit) it is appropriate to increase the amount of “free water” provided enterally.