Sepsis Multicast Episode 6.0: Sepsis Smackdown with Chad Case, MD

We brought in Chad Case, MD: our System ICU Director and Chief of Critical Care at our hospital system to talk controversies in sepsis management. Is EGDT dead? If so, what do we teach non-intensivists that staff 70% of ICUs nation-wide? Does dobutamine belong in the trash along with CVP, ScvO2, passive leg raise, PA caths & POCUS? Is there anything we CAN do nowadays??
Intro summary:
  • Sepsis is #1 reason for mortality in our healthcare system and many others
  • Prior to increased emphasis on sepsis nationally, sepsis mortality rates were hovering around 50%
  • Recent trials and in our own healthcare system have shown that we can drive sepsis mortality < 20%
3 hour bundle; no one disagrees right? 
  • Early Broad Spectrum Abx (< 1 hour)
  • Blood cultures
  • Lactate measurement
  • 30 cc/kg IVF
Case opinion:
Discussion around 30 cc/kg in all patients and some of the mixed results about timeliness of antibiotics in recent trials
Further Reading:
6 hour bundle/Sepsis Headlines and questions:
Case opinion:
  • Early adopters have been moving towards a usual care approach after PROCESS/PROMISE/ARISE
  • Some clinicians are choosing not to do EGDT but aren't doing something else (PLR, bedside re-examination, POCUS)
  • If not going to do EGDT need to be passionate about returning to the bedside for re-examination
Should we be using new Sepsis 3.0 Definitions?
Case opinion:
  • SSC Guidelines now align with Sep 3 definitions giving us better alignment with several parent companies
    • Severe sepsis not referenced anywhere in their documents
  • CMS has not adopted new Sepsis 3.0 definitions creating issues with insurance companies
  • Recommends knowing new definitions but still acceptable to use old definitions in charting for CMS
What do we teach our trainees? Should we teach them EGDT? How do we teach them Sepsis without EGDT?
Case opinion:
  • need to teach them EGDT because some providers are still doing it
  • teach them the history of sepsis
  • teach them the new trials: PROCESS/PROMISE/ARISE
  • teach them the controversies and what we have questions about all the trials
  • don't be indecisive
Case opinion:
  • Is Usual care in your environment similar to that of the big trials?
    • Early detection 
    • Early abx and volume resuscitation
    • Relatively normal SCVo2's and lactate abnormalities
  • If you are practicing in an environment closer to Rivers (higher lactates and lower scvo2's) then there could be a benefit to running EGDT
What would you run if not EGDT?
Case opinion:
  • How do you assess the volume status of the patient? 
  • no trial data to suggest superiority of any method of volume status
  • right answer is an individualized one for your patient
  • the wrong answer is to not re-evaluate your patient
Scvo2 and Dobutamine?
Case opinion:
Low Scvo2 and Hgb of 8?
  • Tranfuse to Hgb of 7
Would you add dobutamine?
  • adding dobutamine is up to the discretion of the provider
  • would not continue dobutamine if no clinical evidence it's working 
  • Add POCUS ability to your assessment
What is standard of care? What type of care are sepsis patients getting around the country?
  • Ideally each patient would get a global assessment by a knowledgeable provider whose is integrating multiple points of assessment to drive decision making for the patient 
  • Unrealistic to expect a sepsis expert to be available to assess every sepsis patient across the country
  • 70% of hospitals do not have intensivists in the US
  • if a hospital or system doesn't feel they can get the ideal scenario then they should consider defaulting to EGDT
What to do beyond the 6 hour mark? 
Case opinion:
  • sepsis experts traditionally recommended continuing with your resuscitative strategy beyond 6 hours until your shock state has normalized
  • After the new trials we are recommending having the clinical to reassess the patient and determine what to do next with their volume strategy 
Empiric fluids for hypotension?/Volume Strategy
Case opinion:
  • As POCUS is more relevant that is helping prevent scenarios of giving fluids to patients with PE's or cardiogenic shock 
  • However, we still see septic patients who are under resuscitated 
  • Be careful not to focus on the outliers and miss the largest population of patients
Give fluids in HF or ESRD?
Case opinion:
  • Don't mindlessly give them fluid but these patients get septic too and are included in the major sepsis trials
  • Come to the bedside and assess the volume status of the patient
Early Pressors?
Case opinion:
  • starting fluids and pressors sometimes simultaneously in the patient with profound shock 
  • severely low MAP is an emergent situation
  • safe to start pressors peripherally, have time to try pressors and volume resuscitation prior to CVL placement
  • Adhere to the methods used in those publications
What is the official ask from our sepsis committee? 
  • When an EMR alert fires meaning that the patient may have severe sepsis or septic shock we ask that a member of the sepsis team come assess the patient
  • If deemed to be septic place the sepsis order set on the patient to ensure they get timely administration of the 3 hour bundle 
  • thoughtful reassessment to further guide your volume resuscitation strategies

CME link coming! Please check back later this week!

Jeremy AmayoComment