Provider variation

[sluggs]

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I have been doing crit care locums for a year now, and often see the horror stories I'd only read about before:
-aimless fluid resuscitation (not looking at any indicators/dynamic indices)
-cranking pressors on under-resuscitated patients
-using dobutamine with no goal or indication other than "blood pressure"
-stress dose steroids on patients on no pressors, or low dose levophed
-versed drips as primary sedation
-paralytics for a week
-no de-escalation of antibiotics
-hypotonic fluids on neuro patients with brain edema
-no de-resuscitation
-docs who don't believe in early proning, low tidal volumes, or running ARDS patients dry
-deferring extubation for days for no reason
The amount of this stuff that I am seeing boggles my mind. No one wants to be told how to practice by mandate, but has any one else here seen enough poor practice that you wish for dictatorially imposed "best practices"?

 

[Fox800]

-cranking pressors on under-resuscitated patients

CVP is out, and ultrasounding the IVC is out, what are you using as your primary indicators that someone is properly resuscitated these days? BP/HR (hard to tell on pressors sometimes)? Normalizing lactate? Peripheral pulses/skin/cap refill? UOP?

 

[CCM-MD]

CVP is out, and ultrasounding the IVC is out, what are you using as your primary indicators that someone is properly resuscitated these days? BP/HR (hard to tell on pressors sometimes)? Normalizing lactate? Peripheral pulses/skin/cap refill? UOP?

This remains the biggest question: is the tank full or not? There isn't a single test that can answer this but a combination of the following depending on the situation helps: NICOM, serial lactic acid levels, ScvO2, CVP, urine output, pCO2 gap. I still do IVC ultrasounding - its useful to me in identifying the extremes. The CVP trend can be helpful but the actual number is less useful.

 

[NontradICUdoc]

Does anyone use SVV with the more newer non invasive systems? I know people that are not trustworthy of it since it is calculated with a proprietary algorithm. Thoughts?

 

[sluggs]

In a patient who is intubated, not in fib, and not breathing spontaneously, you can use SVV from art line/vigileo. Otherwise devices include: NICOM or PICCO. As best I know, these are the only "pre-bolus" predictors of fluid responsiveness. If you don't have these, write down a BP, do a passive leg raise or give a 500 cc bolus over 10 minutes (pressure bag) and if your pulse pressure (not pulse pressure variation, but PULSE PRESSURE) improves by 10%, the patient did responds to that bolus and you can try again. Also, if you have a device that gives you continuous cardiac output, you can use "improvement in CO with a bolus" as your standard.

 

[engineeredout]

I have been doing crit care locums for a year now, and often see the horror stories I'd only read about before:
-aimless fluid resuscitation (not looking at any indicators/dynamic indices)
-cranking pressors on under-resuscitated patients
-using dobutamine with no goal or indication other than "blood pressure"
-stress dose steroids on patients on no pressors, or low dose levophed
-versed drips as primary sedation
-paralytics for a week
-no de-escalation of antibiotics
-hypotonic fluids on neuro patients with brain edema
-no de-resuscitation
-docs who don't believe in early proning, low tidal volumes, or running ARDS patients dry
-deferring extubation for days for no reason
The amount of this stuff that I am seeing boggles my mind. No one wants to be told how to practice by mandate, but has any one else here seen enough poor practice that you wish for dictatorially imposed "best practices"?

These sound like practices which may be used by providers not trained as intensivists. True?

 

[sluggs]

These sound like practices which may be used by providers not trained as intensivists. True?

Not true. Board certified in Pulm/CCM. Give me fits

 

[Nephro critical care]

Volume status indicators are a constant revolving door. 1st it was CVP then IVC/SVV now it looks like straight leg raising is the new fad. Swans may be back in business soon. I don't think it's one particular indicator. The best gauge is History/exam/UOP/CXR/ in-outs /CVP trend and then a physician judgement based on all of these and the response to a bolus. Physician judgement that what we get the big bucks for.

 

[SurfingDoctor]

Shock index trend

 

[sluggs]

It is important to understand why fluids are given in critically ill shock patients... the reason is to optimize cardiac output. As you are continuing a resuscitation, all of the history/exam/Ins/Outs are poor guides to whether your patient is or will respond to fluids.
This is the source of confusion! You need filling pressures or surrogates for filling pressures or dynamic response assessments.

 

[PlutoBoy]

I have been doing crit care locums for a year now, and often see the horror stories I'd only read about before:
-aimless fluid resuscitation (not looking at any indicators/dynamic indices)
-cranking pressors on under-resuscitated patients
-using dobutamine with no goal or indication other than "blood pressure"
-stress dose steroids on patients on no pressors, or low dose levophed
-versed drips as primary sedation
-paralytics for a week
-no de-escalation of antibiotics
-hypotonic fluids on neuro patients with brain edema
-no de-resuscitation
-docs who don't believe in early proning, low tidal volumes, or running ARDS patients dry
-deferring extubation for days for no reason
The amount of this stuff that I am seeing boggles my mind. No one wants to be told how to practice by mandate, but has any one else here seen enough poor practice that you wish for dictatorially imposed "best practices"?

Well, I saw a patient ADMITTED to the ICU for Acute Respiratory Failure 2/2 COPD on prednisone 20 mg daily and levofloxacin 500 mg daily, no labs or ABG. One CXR. That's it. It is very hard to kill a patient apparently.

If you are sick enough to need critical care you probably need more than that?

 

[Nephro critical care]

If you admit someone and give just PO levaquin and prednisone you are going to have a difficult time justifying inpatient admission rather than Obs let alone ICU admission.

 

[SurfingDoctor]

Well, I saw a patient ADMITTED to the ICU for Acute Respiratory Failure 2/2 COPD on prednisone 20 mg daily and levofloxacin 500 mg daily, no labs or ABG. One CXR. That's it. It is very hard to kill a patient apparently.

If you are sick enough to need critical care you probably need more than that?

No oral Albuterol?! That's malpractice!

 

[mochief2000]

CVP is out, and ultrasounding the IVC is out, what are you using as your primary indicators that someone is properly resuscitated these days? BP/HR (hard to tell on pressors sometimes)? Normalizing lactate? Peripheral pulses/skin/cap refill? UOP?

When you say CVP is out what do you mean? i would say CVP is not out, but if you have a better way of resuscitation, you don't need it (as proven by ARISE, promise, process). I would extrapolate and say same for ultrasound. Everybody has their particular way of assessing volume status. I have colleagues that like Esophageal dopplers, the ultrasound people love their toys (assessing IVC/ hypercontractile heart, B lines) , the ER people love their lactate and some people like the good ole fluid challenge. I think while critical in still in flux, it still up in the air. I think key at this point is just having a way to reassess...

 

[Nephro critical care]

I like the old fashioned CVP it gives you a trend and most people with a CVP under 8 would do well with a little bit of fluid. Yes if > 8 it's not helpful. My personal feeling is that U/S doesn't help I see so many with a big juicy IVC and yet a hyperdynamic heart who will respond to a liter of crystalloid.
Realistically on day 1 most people aren't going to be hurt by a couple of extra liters of crystalloid. I would rather be couple of liters positive in the real septic shock/pancreatitis pt than be behind and deal with the AKI/RRT and bowel ischemia. Most people do just well with swollen legs and even if you end up with pulm edema just tube the patient it's not the end of the world. Dead gut is harder to deal with than a vent every single time.
I like a little bit of 5% albumin too once they got their 4th liter just to mix up the flavor. Sprinkle a unit of PRBC even between Hgb 7-9. None of this is strictly EBM but seems to work for most patients.
On day 5 when pt is 16 liters up I am gonna be more miserly with fluids.

 

[Siggy]

-no de-escalation of antibiotics

One thing that's stuck with me from the old ICU Rounds podcast by Dr. Guy (surgical ICU attending) was when he said he forces his residents to sacrifice an antibiotic and a piece of plastic (central line, foley, ETT, etc) every day to the ICU gods.

 

[sluggs]

I'm not saying this to be critical, but this is exactly the problem... CVP is not a good predictor of pre-load/fluid needs; "a couple extra liters of crystalloid" has been demonstrated to be harmful in a population of patients, and if your patient is 16 liters up on day 5, something went terribly wrong!

 

[Nephro critical care]

I'm not saying this to be critical, but this is exactly the problem... CVP is not a good predictor of pre-load/fluid needs; "a couple extra liters of crystalloid" has been demonstrated to be harmful in a population of patients, and if your patient is 16 liters up on day 5, something went terribly wrong!

CVP is not good as an absolute number but can be useful to trend. Maybe we have a different population. We get a good number of good old variceal bleeds and pancreatitis and the post-long abd surgery with big fluid shifts that anesthesia has invariably underresusicated in the OR. My last multi-trauma with lung resection/liver/spleen lac/72 units PRBC/54 units FFP/30 platelets/TRALI needing ECMO related to blood products was more than a few liters positive by the end of it.
Fluid spacing is inevitable in distributive shock patients, all the fluid I give is intended for the vascular compartment but little stays there initially.

 

[lymphocyte]

Shock index trend

Really? That's pretty neat. I've never heard of it used outside of EM.

 

[SurfingDoctor]

Really? That's pretty neat. I've never heard of it used outside of EM.

HR trend is the most important vital sign in my opinion. Add in another datapoint of BP, I've never seen SI be wrong.

 

[deleted547339]

HR trend is the most important vital sign in my opinion. Add in another datapoint of BP, I've never seen SI be wrong.

You mean you don't think a perpetual RR of 16 is useful? Lol

 

[SurfingDoctor]

You mean you don't think a perpetual RR of 16 is useful? Lol

If someone is grey with rigor mortis.... no.

 

[sluggs]

I like the old fashioned CVP it gives you a trend and most people with a CVP under 8 would do well with a little bit of fluid. Yes if > 8 it's not helpful. My personal feeling is that U/S doesn't help I see so many with a big juicy IVC and yet a hyperdynamic heart who will respond to a liter of crystalloid.
Realistically on day 1 most people aren't going to be hurt by a couple of extra liters of crystalloid. I would rather be couple of liters positive in the real septic shock/pancreatitis pt than be behind and deal with the AKI/RRT and bowel ischemia. Most people do just well with swollen legs and even if you end up with pulm edema just tube the patient it's not the end of the world. Dead gut is harder to deal with than a vent every single time.
I like a little bit of 5% albumin too once they got their 4th liter just to mix up the flavor. Sprinkle a unit of PRBC even between Hgb 7-9. None of this is strictly EBM but seems to work for most patients.
On day 5 when pt is 16 liters up I am gonna be more miserly with fluids.

Do you have any data to support using CVP or CVP trend to guide early fluid resuscitation? There is, as you know, data against using the former.

 

[jdh71]

Are we really trying to have an argument about CVP in here?

I've never seen one of those.

 

[Nephro critical care]

Do you have any data to support using CVP or CVP trend to guide early fluid resuscitation? There is, as you know, data against using the former.

Can you recommend one single foolproof tool I can use in every patient ? No because there is none. It’s the whole clinical presentation. I use CVP trend in some patients as a part of the entire picture.

 

[leviathan]

Can you recommend one single foolproof tool I can use in every patient ? No because there is none. It’s the whole clinical presentation. I use CVP trend in some patients as a part of the entire picture.

There is never one single foolproof tool, but CVP with an ROC approaching 0.50 is essentially a useless piece of data that you shouldn't use. If anything, we know an elevated CVP>8 is probably associated with higher mortality in patients with sepsis, so you could use it as marker of fluid tolerance. But as others said, not really up to having yet another CVP debate. It's 2017.

 

[sluggs]

Can you recommend one single foolproof tool I can use in every patient ? No because there is none. It’s the whole clinical presentation. I use CVP trend in some patients as a part of the entire picture.

There is never one single foolproof tool, but CVP with an ROC approaching 0.50 is essentially a useless piece of data that you shouldn't use. If anything, we know an elevated CVP>8 is probably associated with higher mortality in patients with sepsis, so you could use it as marker of fluid tolerance. But as others said, not really up to having yet another CVP debate. It's 2017.

The area under the ROC for CVP as a predictor of fluid responsiveness is .56. Area under ROC for using Passive leg raise or "mini bolus" or NICCOM to guide fluid therapy is .83-.86. These latter methods are certainly not perfect, but are better indicators.

 

[engineeredout]

The area under the ROC for CVP as a predictor of fluid responsiveness is .56. Area under ROC for using Passive leg raise or "mini bolus" or NICCOM to guide fluid therapy is .83-.86. These latter methods are certainly not perfect, but are better indicators.

Aren't there other uses for CVP than fluid responsiveness, and other ways of interpreting it besides using the absolute values ala EGDT

 

[leviathan]

Aren't there other uses for CVP than fluid responsiveness, and other ways of interpreting it besides using the absolute values ala EDGT

I still think it has a role as an additional data point to add to the total picture for fluid tolerance, or when de-escalating therapy, or for people with RV failure as some examples.

 

[jdh71]

I still think it has a role as an additional data point to add to the total picture for fluid tolerance, or when de-escalating therapy, or for people with RV failure as some examples.

Even in RV failure though . . . The pressure over there is highly irrelevant to the cardiac output.

I guess if you didn't swan you could titrate CVP to other downstream markers potentially.

Though when the RV fails it's usually a forward feeding cycle of sheet and your numbers wherever you are getting them are all fairly "academic". You're just doing something. Anything. And making appeals to the higher power of your choosing.