We've incorporated LR into our early sepsis 3-hr order set, although have been unable to sway our pharmacy leadership to use a more balanced crystalloid solution due to cost differential. Previously were I worked (UFlorida) we used plasmalyte for the majority of our sick patients.
And to touch on an earlier topic, our current three 3 hr bundle orderset doesn't favor vasopressor support early on, as Dr. Rivers noted, maybe detrimental. The focus of our 3 hr protocol is fluid resuscitation, which is nurse driven based on lactate clearance, MAP and UOP/HR. We are trying to incorporate more sensitive markers of fluid responsiveness that can be tracked by our nurses for additional bolus above 30ml/kg, although this is proving to be difficult as CVP hasn't caught traction here among our physicians. Ali H Dabaja, DO Director, Clinical Programs and Quality Oakwood Hospital & Medical Center Department of Emergency Medicine (313) 977-0130 On Fri, May 1, 2015 at 7:55 AM, Kramer, George C. <[email protected]> wrote: > Mk > > Normal saline vs. Lactated Ringer’s is a controversial issue in trauma, > surgical and medical critical care. > > This is my read of the literature. > > NS and LR were long considered to be equivalent with proponents making a > case for LR, but other saying no different. There is a cost difference LR > may be $1 or less more a bag. > > *HOWEVER, *there is now an extensive and compelling literature that > balanced solutions (LR and Plamalyte) are superior to NS. NS is not normal, > the boyd does have equal concentrations of Na and Cl. NS can cause renal > dysfunction and a hypercholermic acidosis. The acidosis is hard to treat > and is not an acidosis like low perfusion acid doses, but has the same > impact on enzyme and other functions in the extracellular fluid space. 20% > of body wt > > — *(Milieu intérieur)* > > I have seen that medical intensivist still believe little difference and > often don’t know the literature. While surgical intensivists and > anesthesiologist most often do, or at least I hope. > > Most Sepsis research focused on colloid vs crystalloid and since most > common crystalloid was NS it was believe that was superior. I say Spend the > extra dollar. > > read this recent review, from a surgical intensivist, it covers the > topic well. > > BioMed Research International > Volume 2014 (2014), Article ID 984082, 9 pages > http://dx.doi.org/10.1155/2014/984082 > > Review Article > Fluid Resuscitation in Sepsis: Reexamining the Paradigm > Poorna Madhusudan <http://www.hindawi.com/83284139/>,1,2 Bharath Kumar > Tirupakuzhi Vijayaraghavan <http://www.hindawi.com/51918305/>,2,3 andMatthew > Edward Cove <http://www.hindawi.com/62643189/>1,2 > > 1Cardiothoracic Intensive Care Unit, NUHS, Singapore 119074 > 2National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074 > 3Intensive Care Unit, NUHS, Singapore 119074 > > Received 25 February 2014; Revised 8 July 2014; Accepted 20 July 2014; > Published 11 August 2014 > > Academic Editor: Baoli Cheng > > Copyright © 2014 Poorna Madhusudan et al. This is an open access article > distributed under the Creative Commons Attribution License > <http://creativecommons.org/licenses/by/3.0/>, which permits unrestricted > use, distribution, and reproduction in any medium, provided the original > work is properly cited. > Abstract > > Sepsis results in widespread inflammatory responses altering homeostasis. > Associated circulatory abnormalities (peripheral vasodilation, > intravascular volume depletion, increased cellular metabolism, and > myocardial depression) lead to an imbalance between oxygen delivery and > demand, triggering end organ injury and failure. Fluid resuscitation is a > key part of treatment, but there is little agreement on choice, amount, and > end points for fluid resuscitation. Over the past few years, the safety of > some fluid preparations has been questioned. Our paper highlights current > concerns, reviews the science behind current practices, and aims to clarify > some of the controversies surrounding fluid resuscitation in sepsis. > > On Apr 29, 2015, at 10:28 AM, Mary Kay Bader <[email protected]> > wrote: > > We used it during the normal saline shortage crisis last year. I heard > an interesting presentation at ISICEM in Brussels where they compared NS to > LR re sodium content and advocated for its use when you are concerned about > sodium. Nothing official on which fluid was better > Mk > > Sent from my iPhone > > On Apr 29, 2015, at 7:45 AM, mabel bellanca <[email protected]> wrote: > > Hi All, > Has anyone hear that lactated ringers solution should be used for fluid > resuscitation instead of normal saline? > > On Monday, April 27, 2015, Gail Taylor <[email protected]> wrote: > >> We are currently not using nurse driven protocols except in the ED and >> with our MRTs. These include lab orders but no fluid or antibiotics. >> >> >> >> On another subject, has anyone started to address the CMS requirements? >> >> >> >> Thanks, >> Gail >> >> >> >> Gail Taylor, RN, MPH, CCRN >> >> Corporate Administrator >> >> Patient Care Integration >> >> Methodist Le Bonheur Healthcare >> >> 1211 Union Avenue Suite 638 >> >> Memphis, TN 38104 >> >> Office: 901-516-0701 or >> >> 901-516-0749 >> >> Cell: 901-258-3349 >> >> Fax: 901-516-0794 >> >> [email protected] >> >> >> >> "Be treated well." >> >> >> >> >> >> >> >> >> >> *Privileged and Confidentiality Disclaimer* >> >> This correspondence and any attachments, is intended for the purposes of >> quality of care review and improvement. The source process and >> correspondence are confidential and protected pursuant to any and all >> applicable federal and/or state laws; including the 2005 Federal Patient >> Safety & Quality Improvement Act, and Medical Quality Improvement Act of >> 1986, 43 U.S.C. 1101, et seq., the Tennessee Patient Safety and Quality >> Improvement Act of 2011, T.C.A. 68-11-272 and/or any other law, statute, or >> doctrine applicable to protect the confidentiality and/or privileged nature >> of the process. Inclusion of disclaimer is not intended to restrict or >> otherwise limit the applicability of the privileges referenced above to >> documents or processes where the privilege would otherwise be applicable. >> If received in error please notify the sender and delete the content. Any >> hard copy should be discarded in an appropriate shredder. >> >> >> >> >> >> >> >> >> >> >> >> *From:* Sepsisgroups [mailto:[email protected]] >> *On Behalf Of *[email protected] >> *Sent:* Monday, April 20, 2015 2:08 PM >> *To:* [email protected] >> *Subject:* Sepsisgroups Digest, Vol 153, Issue 1 >> >> >> >> Send Sepsisgroups mailing list submissions to >> [email protected] >> >> To subscribe or unsubscribe via the World Wide Web, visit >> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org >> >> or, via email, send a message with subject or body 'help' to >> [email protected] >> >> You can reach the person managing the list at >> [email protected] >> >> When replying, please edit your Subject line so it is more specific >> than "Re: Contents of Sepsisgroups digest..." >> >> >> Today's Topics: >> >> 1. Re: Nurse Driven Sepsis Protocols (Stephens, Kari) >> >> >> ---------------------------------------------------------------------- >> >> Message: 1 >> Date: Sun, 19 Apr 2015 13:45:56 +0000 >> From: "Stephens, Kari" <[email protected]> >> To: "[email protected]" <[email protected]> >> Cc: "[email protected]" >> <[email protected]> >> Subject: Re: [Sepsis Groups] Nurse Driven Sepsis Protocols >> Message-ID: <[email protected]> >> Content-Type: text/plain; charset="us-ascii" >> >> I would be interested in nurse driven protocols also. >> >> Sent from my iPhone >> >> On Apr 17, 2015, at 10:25 AM, " >> [email protected]<mailto:[email protected]>" < >> [email protected]<mailto:[email protected]>> wrote: >> >> Good Morning, >> >> Our pharmacy department and myself are putting together a presentation on >> nurse driven protocols and we are needing further resources. We are looking >> for facilities who have implemented this and have evidence to support that >> this worked at your facility. Any PowerPoints, research articles or >> handouts are greatly appreciated! We love anything with stats and data. >> Even a contact person would be greatly appreciated. >> >> Thank you, >> >> Katerina Rhynes - RN, BSN >> Sepsis Coordinator >> Wesley Medical Center >> Quality Department >> 550 N. Hillside >> Wichita, KS 67214 >> Phone: 316.962.7007 >> Fax: 316.962.7467 >> Email: [email protected]<mailto:[email protected]> >> >> _______________________________________________ >> Sepsisgroups mailing list >> >> [email protected]<mailto:[email protected] >> > >> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org >> >> ________________________________ >> >> Confidentiality Notice: This email message, including any attachments, is >> for the sole use of the intended recipient(s) and may contain confidential >> and privileged information. Any unauthorized review, use, disclosure or >> distribution is prohibited. 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