I agree with Dr. Clemmer and others. If one is going to make an error with fluid in severe sepsis/septic shock, it is best made on the wet side. The mortality risk of under-resuscitation greatly exceeds that of fluid overload. On the other hand, it is helpful to avoid fluid overload when possible.
Guideline care, in some respects, seems to have drifted from evidence-based to expert opinion in the hope of benefiting the majority of patients. Yet, there was no prescribed fluid bolus in the original EGDT trial. The patients received the fluid required to achieve resuscitation targets. In the EGDT group, the mean was 5L in 6 hours with quite a large standard deviation. The range was perhaps 1 to 11 L. The only bolus referenced in the EGDT study, 20ml/kg, was given only to hypotensive patients for the purpose of excluding them from the study if they responded to the fluid challenge. So one size does not fit all and not all patients, especially those with CHF or renal failure are the same. Nor will some tolerate a bolus of 30ml/kg. These are the minority of patients that are perhaps most challenging. While some fluid is almost universally required, the most fragile of these patients will greatly benefit from early close monitoring with a central line. Also, CHF requires qualification. A history of CHF is not necessarily current CHF that requires special consideration. A reduced ejection fraction is not necessarily CHF; the patient may have entirely compensated for it, but may still be sensitive to fluid loading and therefore benefit from close monitoring. Thanks just my $0.02 Ron Elkin, MD California Pacific Medical Center San Francisco On Tue, Oct 1, 2013 at 2:45 PM, Terry Clemmer <[email protected]>wrote: > Do not omit them. They need the fluid if they have hypotension or lactate > greater than 4.0. Evidence is now available that fewer will end up on > ventilators if they get adequate initial resuscitation, they will have less > renal failure and dialysis if they get adequate initial fluid > resuscitation. Remember, of 1000 ml of NS only 250 ml stays intravascular. > Most septic patients are vasodilated and frequently dehydrated and need > fluid. Not giving fluid is dangerous, it increases mortality and is only > treating physician fear, not the patient.**** > > ** ** > > Terry P. CLemmer, MD Director of Critical Care Medicine**** > > LDS Hospital**** > > Salt Lake City, Utah 84143**** > > ** ** > > Professor of Medicine**** > > University of Utah School of Medicne**** > > Salt Lake City, Utah 84143**** > > ** ** > > Phone: 801-408-3660**** > > Fax: 801-408-1668**** > > [email protected]**** > > ** ** > > *From:* [email protected] [mailto: > [email protected]] *On Behalf Of *Tracey Helmick > *Sent:* Tuesday, October 01, 2013 12:41 PM > *To:* [email protected] > *Cc:* [email protected]; [email protected] > *Subject:* [Sepsis Groups] fluid resuscitation in CHF or renal patients*** > * > > ** ** > > Our institution continues to monitor and assess our Sepsis patient data. > We are having difficulty meeting the new 30ml/kg recommendations for fluid > resuscitation. We are finding that some of our outliers are the patients > with CHF or renal failure. Is this a common barrier and if so, what are > other institutions doing to assure those patients are receiving adequate > fluid resuscitation without causing harm to the patient? Should we omit > those patients from our data collection?**** > > ** ** > > Respectfully, **** > > ** ** > > Tracey Helmick RN, CCRN**** > > Meadville Medical Center**** > > MMC Severe Sepsis Team Nurse Champion**** > > [email protected]**** > > ** ** > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > >
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