Fluids and sepsis

[leviathan]

The concepts that always get mixed up are fluid responsiveness, fluid tolerance, and euvolemia. I don't know Rivers' rationale for choosing a CVP of 8, but I imagine they were attempting to resuscitate up to a point of fluid tolerance and/or euvolemia rather than the point they're no longer fluid responsive.

The CVP is completely useless for determining fluid responsiveness, but there's no evidence that we need to fluid load patients until they have plateaued on their Frank-Starling curve and are no longer fluid responsive. If any of us received a 1 litre bolus right now our cardiac output would increase; does that mean we needed the fluid? Maybe for me because I just finished a 24 hour call...

Sepsis is a state of distributive shock, not hypovolemic shock. Depending on the cause of sepsis, they may also be a bit negative in their fluid balance (vomiting, diarrhea, insensible losses from tachypnea, etc), but that's not the main driver of their shocked state. You can treat many cases of distributive shock by loading up with 10 litres of crystalloid, but that's not doing any favours to your patient when their vasodilatory state resolves and they're now 8-9 litres positive.

Bottom line, I think the days of drowning people until they need intubation is ludicrous. People should get a small fluid challenge and then go to pressors if they remain hypotensive, unless there's evidence that hypovolemia is playing a larger role.

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[Cytarabine]

What's your small fluid challenge? 2L up front wide open? If they're responsive then drop their pressures over the next hr as they presumably redistribute, pressors?

 

[MSmentor018]

Just add the volume used to reconstitute your antibiotics and you're there after 2L.*


*I'm not sure that would actually work.

it doesn't, guess-timated on wt. was 70cc short of the 30ml/kg goal. vanc/zosyn gave an additional 500+100 but they didn't care about that. was told it fell out of the CMS criteria

I love the academic discussion but bottom line: you can't fight the gov

 

[Psai]

it doesn't, guess-timated on wt. was 70cc short of the 30ml/kg goal. vanc/zosyn gave an additional 500+100 but they didn't care about that. was told it fell out of the CMS criteria

I love the academic discussion but bottom line: you can't fight the gov

This sounds really ****ing stupid

 

[HooliganSnail]

I'll just add that CVP is useless and should not be used to guide fluid resuscitation.

Any educational resource that mentions using it is out of date (cough cough EM basic).

And yet, CMS is using the utilization of CVP as a quality metric for septic patients......Uy Vey!

 

[MSmentor018]

This sounds really ****ing stupid

I hear ya man. over the top, you gotta be kidding, WTF stupid !! I don't know what falling out means at the admin level. does CMS not pay for the visit? or if it's just a slap on the wrist? but it enough pressure that there's a specific hospital sepsis RN (and even a rapid response RN) that monitors all this crap so it must be big $$