Welcome to the e-resources for my talk & subsequent panel discussion at the Northern New England Critical Care Conference 2017.
Slides from the talk are located here here. Sorry they are black/white, it was the only way to reduce the file size enough to include it here. Full-color pictures of important figures are in the blogs below. More information about these topics is below, arranged in parallel to the structure of the talk:
- Early pressors
- Peripheral pressors
- Ignore CVP and mixed venous oxygen saturation
- More to volume overload than pulmonary edema
- Small IVC & hyperkinetic heart doesn't mean volume will help
- Lactate isn't an indicator of perfusion or anaerobiasis
- Consider epinephrine as a 2nd line pressor
- Maybe vitamin C can help
After the talk we had a panel discussion including Drs. William Charish (Surgery/CC) and Lyle Gerety (Anesthesia/CC). It was a great discussion, with a few salient points as below:
- Peripheral pressors
- Charish: Evidence consists of case reports, we may be over-reacting to the possible harm.
- Gerety: In the operating room we use peripheral phenylephrine like water.
- Me: For crashing patient, any peripheral catecholamine vasopressor is OK until stabilized (often with central line placement). For patient remaining on peripheral pressors for longer periods of time (e.g. 6-48hr) I only use phenylephrine or epinephrine.
- Gerety: In addition to risk of extravasation, need to also consider risk of central line insertion.
- Resuscitation targets
- Surprising amount of agreement about this, I thought, although there doesn't seem to be any magical resuscitation target. Ultimately I think we're all similarly befuddled.
- Important targets include urine output, MAP, skin perfusion, mental status, increasing/decreasing pressor requirement (back to the basics).
- Lactate isn't a great resuscitation target but we will continue to trend this because it's required by CMS.
- Rising lactate meaningless if patient is on epinephrine infusion (may be a harbinger of improvement rather than deterioration).
- Rising lactate in patient not on epinephrine is sign of badness, not a blind trigger for fluid administration. Evaluate patient globally: are we using wrong antibiotic? Missing surgical source control? Wrong diagnosis altogether?
Even more stuff:
- Alphabetized content (sepsis listed under the infectious disease category)
- iSepsis (resource by Paul Marik on sepsis)