MarylandCCProject - 16 August, 2014
"Evidence-based Care Pearls & PitfallsPreface: Beware of those who recommend treatments with limited data supporting it! (Ex: Activated protein C)
1. Low Tidal Volume Ventilation
6-8 cc/kg ideal body weight. One of the few interventions actually proven to improve mortality.
2. Glucose control
2. Glucose control
Tight glucose control is out, hypoglycemia is bad. Keep the FSG < 180.
3. Steroids
If you are still doing stim tests, just stop. Strongly consider stress dose steroids [hydrocortisone 50mg IV q6 hrs vs. continuous infusion (!) ] If you are starting a 2nd pressor (vaso or epi) just add the steroids.
Practical approach: If you are approaching norepi dose of 10 mcg/min, start to consider adding a second agent.
Start steroids EARLY, don’t wait for day 2 or 3. As soon as your patient shows signs of refractory shock and the tank is full – start the steroids. (Katsenos, 2014)
There appears to be a synergistic effect of vasopressin and corticosteroids (hmm… studies that are reminiscent of VSE?….) (Russell, 2009; Gordon, 2014)
4. Pressors
For septic patients (and most other types of hypotensive shock) start with norepinephrine.
What’s the max dose? There isn’t one!
Stop using phenylephrine: Unless the patient has had procedural sedation with propofol, put down the neosynephrine.
5. Perfusion
Adequacy of perfusion – ScVO2 or Lactate? What do you use?
If choosing lactate, normalization should be your goal! (10% is NOT enough!!!)
Remember, the potential for lab error can creep into resuscitation goals.
Pitfall: Checking an ScVO2 off a fem line.
One, put in a proper upper CVC if the patient isn’t crashing.
You can’t get an adequate ScVO2 from a fem line – it will always be low.
6. Fluids
Choose balanced solutions (Plasmalyte, Lactated Ringers) in the resuscitation of your critically ill patients.
Stop using starches."
3. Steroids
If you are still doing stim tests, just stop. Strongly consider stress dose steroids [hydrocortisone 50mg IV q6 hrs vs. continuous infusion (!) ] If you are starting a 2nd pressor (vaso or epi) just add the steroids.
Practical approach: If you are approaching norepi dose of 10 mcg/min, start to consider adding a second agent.
Start steroids EARLY, don’t wait for day 2 or 3. As soon as your patient shows signs of refractory shock and the tank is full – start the steroids. (Katsenos, 2014)
There appears to be a synergistic effect of vasopressin and corticosteroids (hmm… studies that are reminiscent of VSE?….) (Russell, 2009; Gordon, 2014)
4. Pressors
For septic patients (and most other types of hypotensive shock) start with norepinephrine.
What’s the max dose? There isn’t one!
Stop using phenylephrine: Unless the patient has had procedural sedation with propofol, put down the neosynephrine.
5. Perfusion
Adequacy of perfusion – ScVO2 or Lactate? What do you use?
If choosing lactate, normalization should be your goal! (10% is NOT enough!!!)
Remember, the potential for lab error can creep into resuscitation goals.
Pitfall: Checking an ScVO2 off a fem line.
One, put in a proper upper CVC if the patient isn’t crashing.
You can’t get an adequate ScVO2 from a fem line – it will always be low.
6. Fluids
Choose balanced solutions (Plasmalyte, Lactated Ringers) in the resuscitation of your critically ill patients.
Stop using starches."
http://marylandccproject.org/core-content/sepsis/