No offense to anyone here, but this type of measurement is ubiquitous in medicine. We measure blood pressure, which tells us what directly again? We measure heart rate, which tells us tamponade or afib or digoxin overdose -- no direct correlation -- but plenty of indirect correlation. We measure train of 4 -- same. So no physiologic measurement tells us much about disease directly. We measure elevated RVSP and might have PE or pulmonary hypertension or something else.
We are stuck with imagination and differential thinking and that's what makes a good doc versus someone reading the meter. ScvO2 is a clue. 80% or more if the time it adds to the picture rather than subtracts info. It's more like resolution of a photograph. More pixels = more information. Maybe you like looking at blurry pictures or limiting your pixels. The ostrich keeps it's head in the ground. I don't know any more....ProCESS people seem happy to know less and make decisions anyway. Sean R. Townsend, M.D. Vice President of Quality & Safety California Pacific Medical Center 2330 Clay Street, #301<x-apple-data-detectors://0/0> San Francisco, CA 94115<x-apple-data-detectors://0/0> email [email protected]<mailto:[email protected]> office (415) 600-5770<tel:(415)%20600-5770> fax (415) 600-1541<tel:(415)%20600-1541> On Jul 21, 2014, at 9:33 AM, "Kramer, George C." <[email protected]<mailto:[email protected]>> wrote: what about urinary output? it is the gold standard for burn shock a type of shock with high permeability, loss of vascular volume, depressed cardiac contractility, SIRS, hmm, that sound similar to sepsis. g On Jul 18, 2014, at 11:13 AM, Richard Teplick <[email protected]<mailto:[email protected]>> wrote: One obvious problem with the initial study (Rivers) is that SvO2 is that cannot possibly uniquely reflect adequacy of organ perfusion; at best it reflects extraction. Because of the disparity in organ blood flow and autoregulatory reserve, low flow to, for example, the kidneys could never be detected in the presence of high muscle and skin flow (both of which generally occur in septic shock). Moreover, elite aerobic athletes can reduce their PvO2 to the teens producing SvO2s < 0.3. Yet they clearly have adequate muscle and skin flow although gut and renal flow may be reduced and may have low SvO2 but this cannot be determined from the SvO2 alone. Moreover, giving fluid to increase cardiac output may not alter blood flow to vital organs. My point is that we shouldn’t blindly accept study results that are physiologically unsound. I am most interested in other opinions. Dick From: Sepsisgroups [mailto:[email protected]<mailto:[email protected]>] On Behalf Of Ron Elkin Sent: Thursday, July 17, 2014 17:13 To: Sue Beswick Cc: [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] Impact of ProCESS study on your protocols Hi Sue, The study has certainly generated a buzz. For objective, serious students of this disease, however, the study should raise serious concerns about protocol, data, and conclusions. I'm sure these will be addressed in medical and other nursing forums in the months to come. A few comments or questions as examples: 1) "Usual care" has been irrevocably changed since publication of the EGDT study in 2001, as well as guidelines from SSC supported by many of our professional societies. Indeed sepsis management protocols existed in many of the ProCESS hospitals, so the control groups, protocol-based (PB) standard care and usual care, were treated by physicians well versed in EGDT protocols. 2) The mortality rates in each study group were unexpectedly and remarkably low, around 20%, and probably not representative of the mortality rates for similar patients in most US hospitals. As a result of the low mortality rate, some question whether the study was adequately powered to examine differences between study groups, and whether the study is generalizable to 5000 US hospitals. Moreover, why abandon measures that contributed to such impressive mortality reductions? Are we immune to regressive behavior if practice guidelines are relaxed or removed? 3) The protocol instruction for the first 6 hours was to avoid central line placement, CVP measurement, and ScvO2 in both control groups, PB standard care and usual care, unless peripheral access was inadequate. Yet, over 55% of patients in these groups received them for unstated reasons. One might reasonably speculate they were placed for hypotension and administration of vasopressors. Not stated, however, is how often these lines were utilized for CVP measurements that confirmed or guided resuscitation. In the transcript of a recent NQF conference call, available to the public, an author of the study stated CVP measurements were documented in about 1/3 of the control patients but were not used to guide therapy as evidenced by the lack of followup measurements. However, almost any experienced clinician will act similarly on some single measurements - a patient with a CVP of 3 on vasopressors will almost always receive volume. Also not reported are the number of control patients with lines who had ScvO2 measurements, except for the few who received continuous oximetry lines. It also remains possible that blood sample measurements of ScvO2 were utilized in control patients, but this is not addressed in the manuscript. We don't know how often CVP and ScvO2 measurements were made in control patients with central lines before randomization. We don't know how often clinicians acted on CVPs estimated by bedside neck exam, vertical column height of blood in the lines that were inserted, or IVC dimensions and change with respiration. We don't know how many lines, CVPs, and ScvO2s were added in the control groups after the protocol instructions expired at 6 hours. It is still possible and beneficial to rescue an inadequate resuscitation beyond 6 hours. In short, we don't know enough about management of the control groups. 4) Protocol non-adherence was reported in 11.9% but information in the appendix suggests higher. MAP goals were achieved in only 83%. Overall bundle compliance is not reported. In short, we don't know enough about the quality of management in the EGDT group. 5) Not reported are statistical comparisons between all study patients with lines versus without, control patients with lines versus without, and each of the 2 control group. So in summary, care in any of the study groups is not adequately described, and care in the control groups appears to be significantly contaminated by EGDT. I for one do not favor protocol changes on the basis of this study at this time, and I know for a fact that I have a lot of company. Thanks Ron Elkin MD California Pacific Medical Center San Francisco, CA On Thu, Jul 17, 2014 at 6:23 AM, Sue Beswick <[email protected]<mailto:[email protected]>> wrote: Is anyone adapting their protocols with the findings that came out this year with the ProCESS study? We are looking at making some changes. Sue Sue Beswick APRN, MS, CCNS, CCRN CNS Critical Care Greenville Health System 701 Grove Road l Greenville, SC 29605 Office: 864-455-4884<tel:864-455-4884> _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
