I agree with Dr Allen's comments below. The mandated 30ml/kg IVF bolus may be harmful; if 20ml/kg or 10ml/kg is sufficient to improve perfusion; particularly in patients with acute lung injury, or those with underlying heart or kidney disease.
This reflex dosing takes away from the "attentive evaluation". It is this "attentive evaluation" which requires incentive. Many will need to practice down to these bundles and put their patient at risk to meet the CMS Core requirements. 1. 3 hours to volume resuscitate 2. 6 hours to assess volume status (which is only required if on vasopressors) 3. 6 hours to add vasopressors in the setting of fluid unresponsiveness 4. Normal Saline (pH 5.5, Cl 154) versus balanced salt solutions like plasmalyte (pH 7.4, Cl 98) Here's the irony: * If one is responsive to the patient's needs and prescribes 20 ml/kg in the setting of hypotension, because reassessment reveals improved perfusion and reversal of hypotension, this attentiveness results in penalty. If one however in unobservant, automatic and simply prescribes 30ml/kg IVF over 3 hours, starts norepinephrine within 6 hours (patient may have required at hour 1 or 2), and evaluates the patient within 6 hours - they've checked all the boxes and have met criteria with respect to volume, vasopressor initiation and clinical assessment. * Don't forget a patient with SBP <90 mmHg whose response to a fluid bolus of 20-30ml/kg over 30min resulted in SBP >90 would not have met inclusion into the EGDT trial. Arise and Process also required fluid unresponsiveness before being enrolled. * It's the unresponsiveness to fluids that determined enrollment; as determined by an "Attentive Evaluation" after a fluid bolus. Sincerely, Stuart F Reynolds, MD FRCPE FCCP Director Critical Care Services Clinical Professor Critical Care Medicine MUSC AHEC [Spartanburg Regional Healthcare System Email Logo] <http://www.spartanburgregional.com/> 101 East Wood Street | Spartanburg, SC 29303 o: 864-560-6531 e: [email protected]<mailto:[email protected]> | w: SpartanburgRegional.com<http://www.spartanburgregional.com/> Sean, I attended your webinar on Sepsis Core measures last week and was left with a number of concerning questions: 1. If we are using the logic that "there is no evidence to show it doesn't hurt" to justify follow-up physical exam measures for evaluation of response to resuscitation, then why does the same logic not apply to the use of Normsol and other chloride-balanced crystalloids? I would argue that there is a growing body of evidence that normal saline may indeed "hurt" (JAMA. 2012;308(15):1566-1572.; Br J Surg 102 (1):24-36. Crit Care Med 2014; 42:1585-1591. 2. In defending the use of many of these unproven metrics of volume responsiveness and distal perfusion, you described many of these measures as a "proxy" measure of "attentive evaluation" and intensive care. I full agree, and practice this way. I believe these measures help represent a collective epi-phenomenon of intensive and regimented care. Using the same reasoning, why then is there no provision in any of this for providers to document their own rationale for diverging from some of these restrictive mandates when judged to be clinically justified. Is this not also a worthy "proxy" of intensive and attentive care? 3. When does the clock really start ticking? Our hospitals still don't have a solid and reliable answer to this question. Is it when the physician documents their suspicion of sepsis, 3 hours after a fever and hypotension? When blood cultures are first ordered one hour after the fever? Or when an MD orders Tylenol, a CBC, lactate, and blood cultures on someone he/she suspects may be either bleeding, in pain, or possibly infected post-Op? When do these types of patients really "declare" themselves septic. The efforts to try to "capture" every element of Goal-directed care in an "all-or-none" pass/fail algorithm dooms itself from the beginning. Why didn't CMS just start off with the 3 hour bundle, monitor how others do with the 6 hour bundle, and try to figure out where (and why) their algorithm is succeeding, or failing, to capture (and enforce) best practice? I've augured to my group that there is absolutely no excuse for not getting blood cultures, a lactate, and fluids on board within one hour of a high suspicion of sepsis. This is a low bar we should all be meeting, but probably aren't. Why not simply start there, and work our way forward? Gilman B. Allen, MD Associate Professor Department of Medicine Director of Adult Critical Care Services University of Vermont / Fletcher Allen Healthcare HSRF 220, 149 Beaumont Ave Burlington, VT 05405-0075 (802)656-9004 Fax: (802) 656-8926 [email protected]<mailto:[email protected]<mailto:[email protected]%3cmailto:[email protected]>
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