Poor man's sepsis protocol

[beyond all hope]

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So, I'm at a staff meeting, when I make the cardinal mistake of opening my fat mouth.

"We don't have the manpower to implement a River's protocol, but Rivers showed us that we need to be more aggressive with sepsis managment. What about a poor man's sepsis protocol?"

My chair turned to me and said.

"Okay, why don't you make one."

Oops.

So I'm in this predicament. I frequently do a modified sepsis protocol on septic-looking patients (for me - SIRS criteria plus hypotension/lactate/signs of end-organ failure/look sick) using heavy fluid resuscitation based on lung exam/foley outputs, broad spectrum early Abx, and pressors if needed. Don't know the evidence for dobutamine, familiar with the evidence of transfusing for oxygen-carrying capacity but haven't refreshed my memory.

Question: is anyone using or is aware of a modified sepsis protocol? What do you do if your nurses can't handle a CVP? Do you actually use mixed O2 sats and transfuse?

And please lead me towards the evidence.

 

[southerndoc]

Wasn't the average volume of fluids given to septic patients in the Rivers study only 2-3 liters?

I've seen people give 5 liters of fluid to try to get the blood pressure up. When a central line is inserted, the CVP is high.

Be careful with the fluids. Yes, they are needed, but many people overdo it when judging it by clinical parameters other than CVP monitoring.

 

[Dr.Evil1]

I have heard that instead of using one of the fancy SVO2 probes you can just draw venous gasses off of a central line and get the same info. You could use this to determine the need for transfusion or dobutamine.

As far as the fluids go the EGDT group got 2-3 L MORE than the "standard treatment" group. I don't know how you are really going to be able to do that unless you have a CVP. I know it is a pain in the ass in order to get nurses to do it but I think it provides so much info, especially if your patient doesn't have completely normal systolic function to begin with.

 

[BADMD]

I have heard that instead of using one of the fancy SVO2 probes you can just draw venous gasses off of a central line and get the same info.

As far as the fluids go the EGDT group got 2-3 L MORE than the "standard treatment" group. I don't know how you are really going to be able to do that unless you have a CVP. I know it is a pain in the ass in order to get nurses to do it but I think it provides so much info, especially if your patient doesn't have completely normal systolic function to begin with.

You can draw a VBG, however you loose the continuous SvO2 monitoring, which is kind of nice. It isn't hard to set up the catheter and placing it is exactly like placing a CVC. I usually do the first calibration myself.

As for the EGDT paper, both groups received the same amount of IV fluids, however the time frame the fluids were delivered over was radically different. The EGDT group received the fluids upfront, where as the control group received them over several days.

Frankly, I have no idea why it is that hard to set up a CVP. It is just a tranducer and a pressure bag. I suspect that it is more nursing resistance than anything else. I have to agree with the value of knowing the CVP. That plus a EDM and you likely have a pretty good idea about a patient's CV status.

 

[bluejay68]

Just a thought: I've heard about Ultrasound of the IVC being a decent proxy for CVP; you have to deal with inter-operator variability, but with minimal training and a bedside Ultrasound machine (which you should already have), perhaps you could use IVC diameter (or respiratory viariation in said diameter) as a guide for fluid resuscitation.

 

[BADMD]

Just a thought: I've heard about Ultrasound of the IVC being a decent proxy for CVP; you have to deal with inter-operator variability, but with minimal training and a bedside Ultrasound machine (which you should already have), perhaps you could use IVC diameter (or respiratory viariation in said diameter) as a guide for fluid resuscitation.

Eh, not really. One of the attendings did this in my former ED. I don't think he ever published the data because, while there was a trend, there was too much variation and you couldn't really individualize it.

 

[docB]

Question: is anyone using or is aware of a modified sepsis protocol? What do you do if your nurses can't handle a CVP? Do you actually use mixed O2 sats and transfuse?

This is my suggestion:

#1 Identify septic patient. If your patient was transferred to you by a nursing home they are septic.

#2 Place central line. Avoid placing line at same site where old, forgotten central line from last inpatient admission is festering away unnoticed by nursing home staff.

#3 Give IVF until patient better or in pulmonary edema.

#4 Start pressors, lasix or both.

#5 Call patient’s primary doctor to ensure they do not admit at your facility.

#6 Page internist on call and listen to 5 minutes of griping because patient has 27 pages of med problems which they’ll get to learn all about.

#7 Antibiotics! Crap! Don’t forget the antibiotics. Cultures first for core measures then give him something. I don’t care what. Whatever gorillacillin was bought cheap by the pharmacy. Just give a dose, it’ll get changed by the internist and then by the ID doc anyway.

#8 Discuss with family. Family doesn’t know any history, meds, surgeries or Jack s—t other than that Grandpa would want to be a full code.

#9 Admit patient to ICU in timely manner. Check on patient periodically over next 4 days as patient boards in your ED.

#10 Quit medicine. Buy goat ranch. Be happier standing ankle deep in goat manure than you ever were in the pit.

 

[waterski232002]

Frankly, I have no idea why it is that hard to set up a CVP. It is just a tranducer and a pressure bag. I suspect that it is more nursing resistance than anything else.

I agree 100%... People don't like change. But all you really need to do is drop a central line above the diaphragm, transduce a CVP, and then draw off a VBG for an SvO2. This can tell you so much info, and really makes monitoring the patient's cardiovascular status simple. Have the RN's draw lactate's and VBG's every few hours to make sure your rescusitation is moving in the right direction. At least RN's will be happy they don't have to stick the patient for all those VBG's and lactate's you'll be sending!

I also agree... you really can't do this very well based on clinical judgement alone.

 

[DeLaughterDO]

This is my suggestion:

#1 Identify septic patient. If your patient was transferred to you by a nursing home they are septic.

#2 Place central line. Avoid placing line at same site where old, forgotten central line from last inpatient admission is festering away unnoticed by nursing home staff.

#3 Give IVF until patient better or in pulmonary edema.

#4 Start pressors, lasix or both.

#5 Call patient’s primary doctor to ensure they do not admit at your facility.

#6 Page internist on call and listen to 5 minutes of griping because patient has 27 pages of med problems which they’ll get to learn all about.

#7 Antibiotics! Crap! Don’t forget the antibiotics. Cultures first for core measures then give him something. I don’t care what. Whatever gorillacillin was bought cheap by the pharmacy. Just give a dose, it’ll get changed by the internist and then by the ID doc anyway.

#8 Discuss with family. Family doesn’t know any history, meds, surgeries or Jack s—t other than that Grandpa would want to be a full code.

#9 Admit patient to ICU in timely manner. Check on patient periodically over next 4 days as patient boards in your ED.

#10 Quit medicine. Buy goat ranch. Be happier standing ankle deep in goat manure than you ever were in the pit.

👍

that's great... goat manure indeed!

 

[edinOH]

This is my suggestion:

#1 Identify septic patient. If your patient was transferred to you by a nursing home they are septic.

#2 Place central line. Avoid placing line at same site where old, forgotten central line from last inpatient admission is festering away unnoticed by nursing home staff.

#3 Give IVF until patient better or in pulmonary edema.

#4 Start pressors, lasix or both.

#5 Call patient’s primary doctor to ensure they do not admit at your facility.

#6 Page internist on call and listen to 5 minutes of griping because patient has 27 pages of med problems which they’ll get to learn all about.

#7 Antibiotics! Crap! Don’t forget the antibiotics. Cultures first for core measures then give him something. I don’t care what. Whatever gorillacillin was bought cheap by the pharmacy. Just give a dose, it’ll get changed by the internist and then by the ID doc anyway.

#8 Discuss with family. Family doesn’t know any history, meds, surgeries or Jack s—t other than that Grandpa would want to be a full code.

#9 Admit patient to ICU in timely manner. Check on patient periodically over next 4 days as patient boards in your ED.

#10 Quit medicine. Buy goat ranch. Be happier standing ankle deep in goat manure than you ever were in the pit.

I didn't realize we both work in the same ED. Do you want to trade my night shift next Friday for your day shift next Wednesday?

 

[Dr.Evil1]

This is my suggestion:

#1 Identify septic patient. If your patient was transferred to you by a nursing home they are septic.

#2 Place central line. Avoid placing line at same site where old, forgotten central line from last inpatient admission is festering away unnoticed by nursing home staff.

#3 Give IVF until patient better or in pulmonary edema.

#4 Start pressors, lasix or both.

#5 Call patient’s primary doctor to ensure they do not admit at your facility.

#6 Page internist on call and listen to 5 minutes of griping because patient has 27 pages of med problems which they’ll get to learn all about.

#7 Antibiotics! Crap! Don’t forget the antibiotics. Cultures first for core measures then give him something. I don’t care what. Whatever gorillacillin was bought cheap by the pharmacy. Just give a dose, it’ll get changed by the internist and then by the ID doc anyway.

#8 Discuss with family. Family doesn’t know any history, meds, surgeries or Jack s—t other than that Grandpa would want to be a full code.

#9 Admit patient to ICU in timely manner. Check on patient periodically over next 4 days as patient boards in your ED.

#10 Quit medicine. Buy goat ranch. Be happier standing ankle deep in goat manure than you ever were in the pit.

This should be widely distributed across the board. This is the funniest thing I have read in the last 3 months.

 

[icu RN]

Me being an ICU RN i'm quite insulted, all YOU need to do MD is put in a central line then after an xray to confirm placement all I have to do is hook up a pressure bag and transduce it while the pt is flat. WOW CVPs are hard to do. NOT!! maybe if you (MD) can't put the line in or don't write the order to confirm placement it might take a while. On my end it takes 2 minutes to do a CVP. Oh yeah also 2-3 liters of fluid in septic pt's is sad, try 7-8. draw cx's start abx's. monitor vs, i&o's, see where your at.

 

[tkim]

Me being an ICU RN i'm quite insulted, all YOU need to do MD is put in a central line then after an xray to confirm placement all I have to do is hook up a pressure bag and transduce it while the pt is flat. WOW CVPs are hard to do. NOT!! maybe if you (MD) can't put the line in or don't write the order to confirm placement it might take a while. On my end it takes 2 minutes to do a CVP. Oh yeah also 2-3 liters of fluid in septic pt's is sad, try 7-8. draw cx's start abx's. monitor vs, i&o's, see where your at.

Hi. This is the ED. The ICU is on the second floor. Thanks.

 

[MushieCookie]

Me being an ICU RN i'm quite insulted, all YOU need to do MD is put in a central line then after an xray to confirm placement all I have to do is hook up a pressure bag and transduce it while the pt is flat. WOW CVPs are hard to do. NOT!! maybe if you (MD) can't put the line in or don't write the order to confirm placement it might take a while. On my end it takes 2 minutes to do a CVP. Oh yeah also 2-3 liters of fluid in septic pt's is sad, try 7-8. draw cx's start abx's. monitor vs, i&o's, see where your at.

digging up TWO posts that are over a YEAR old...

👍 🙄

 

[EM2BE]

I just love how everything is blamed on the MD. I am always excluded since I (will) have those other initials.

 

[lucky_deadman]

Me being an ICU RN i'm quite insulted, all YOU need to do MD is put in a central line then after an xray to confirm placement all I have to do is hook up a pressure bag and transduce it while the pt is flat. WOW CVPs are hard to do. NOT!! maybe if you (MD) can't put the line in or don't write the order to confirm placement it might take a while. On my end it takes 2 minutes to do a CVP. Oh yeah also 2-3 liters of fluid in septic pt's is sad, try 7-8. draw cx's start abx's. monitor vs, i&o's, see where your at.

This is all fine and well with you and your grand total of 2 patients (with one usually having already been there for some time and at least marginally stable - read as not actively dying/requiring life saving measures at that very moment).

What was discussed is that trying to get ED nurses to do CVPs is a completely different situation. One they do it pretty infrequently. Next, it seems that there are a lot of newer/inexperienced nurses in EDs these days.

Then you have the ED nurse who has the patient needing the CVP, while trying to triage the 2 new ambulance patients, while trying to deliver meds to another patient, while trying to discharge still another patient. Then you have the issue of where the supplies (if they exist in the ED) are.

Read this not as excusing them for not doing CVPs in the ED, but just stating that the ED is a whole different animal for trying to get CVPs than is the ICU.

 

[theCamel]

Me being an ICU RN i'm quite insulted, all YOU need to do MD is put in a central line then after an xray to confirm placement all I have to do is hook up a pressure bag and transduce it while the pt is flat. WOW CVPs are hard to do. NOT!! maybe if you (MD) can't put the line in or don't write the order to confirm placement it might take a while. On my end it takes 2 minutes to do a CVP. Oh yeah also 2-3 liters of fluid in septic pt's is sad, try 7-8. draw cx's start abx's. monitor vs, i&o's, see where your at.

i hope you are a gimmick account

 

[roja]

1- PM me if you want. I have already build a protocol that is easily modified for your situation, that we used in our hospital before we got our cvp monitors.

1- Recognition that patient is septic.
2-labs, including lactate, lft's, random cortisol, etc
3. IVF (most need 6-8 liters total.) you need to hav some measure of fluid status prior to starting pressors. starting pressors in a patient with no volume is useless.
-ways to monitor without cvp: Urine output, IVC measurement by U/S, clinical exam, guess (if you have put in 2-3 liters you are probably replacing volume)
4. Don't hold back IVF because you are afraid of intubation. Many advocate very early intubation, or intubation based on exam. (if you have given 1 liter and you start to hear crackles, you probably should seriously consider intubation)
5. start pressors. (no evidence between levophed vs dopamine interms of outcomes, although the new trend is levophed first -based on the theory that these patients are catecholamine depleted and thus need a direct agonist. Use doputamine with caution).
6. SvCO2s (not continous are just as good as the fancy continous ones. you just have to remember to pull them).
7. consider transfusing if the volume status is good and the svo2 stays in the tank.
8. If after fluids, abx, pressors and transfusion scvo2 are still bad, consider dobutamine.




Other factors to consider from an admin prospective:
-look at the cost analysis. (rivers has a good one)
-get your sepsis data from your hospital (admissions to ICU, etc)
-get buy in from your chair, etc that CVP monitors will ultimately save you money.
-work with your ICU staff. They often have pull in a hospital because they bring in $.
-Educate your nurses. Not just on HOW to do a cvp, but why. Explain that it is no different than a trauma resusc. Show them how they can help save lives with EGDT.
-CQI your cases.
-Educate on critical care billing ($$ and will help get admin buy in from your department).

Feel free to PM me if you want a copy of the protocol (its a hand held card that is easy to read. I also have good slide data you can present to support your cause.