question on giving IVF to patients with high shock index

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tdod

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If you have a patient that has a high shock index I know you don't want to always through IVF at him, as this could worsen an obstructive or cardiogenic shock. On the other hand, if the patient is highly unstable you may not want to wait for that workup before resuscitating. In the latter case I imagine that you would give IVF empirically if there is strong clinical suspicion for distributive or hypovolemic causes of shock. In the former I imagine you still might give empiric fluids if the diagnosis is clinically obvious (i.e. anaphylaxis in a previously healthy young adult with h/o food allergies).

I haven't been able to verify this online, and I won't have access to an EM doc for another 3 weeks so I'm asking here. I made a flow chart of my thought process. The big difference is p I would greatly appreciate any feedback regarding if my thinking is accurate.

Thanks!


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You're overthinking it. If the patient is not hypoxic and does not look like a balloon, give fluids. Even patient's concerning for cardiogenic or mixed etiology might get a small volume trial if breathing comfortably.
 
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There is evidence even those with fluid overload such as in the setting of CHF also with sepsis have a better clinical outcome if they receive IVFs. [...] Compliance with the SEP-1 measure has shown reduction in mortality, however nationally consistent compliance is very poor.

Can you share the evidence you're referring to for these statements? I'm not saying you're wrong, I just haven't come across it and would be curious to see that study as it may influence my current practice. Regarding the second statement, I've seen two studies that would say SEP-1 compliance does not reduce mortality, and one that suggested it did but it was a single-center retrospective series. I would love to see any other good data on this.
 
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Here's one (retrospective/matched) evaluating the administration of 30cc/kg to ESRD, cirrhotics and HF patients with sepsis on the rate of mechanical ventilation and alive ICU free days...


A negative study. That for some reason will be used by 'sepsis coordinators' to advocate for the indiscriminate use of empiric large IVF boluses for undifferentiated patients.

Yes, I think giving a good sized fluid bolus to a shocked septic patient is reasonable and probably beneficial (even though I recognize, that it is not proven so). But, no, I don't think giving a 6 L IVF bolus to a morbidly obese patient patient w/ a h/o CHF and CKD presenting short of breath just because he has a lactate 2.1 is either reasonable or beneficial. I certainly don't think it's reasonable to criticize someone who decides it's not in the patient's best interest to receive such a bolus. I especially don't think it's reasonable to mandate the administration of such a bolus to said patient, simply because a subsequent lactate might be further elevated and the floor team cannot be expected to continue care for the patient (in effect broadening the target population from septic patients to possibly septic and then even further to might possibly become septic).
 
A negative study. That for some reason will be used by 'sepsis coordinators' to advocate for the indiscriminate use of empiric large IVF boluses for undifferentiated patients.

Yes, I think giving a good sized fluid bolus to a shocked septic patient is reasonable and probably beneficial (even though I recognize, that it is not proven so). But, no, I don't think giving a 6 L IVF bolus to a morbidly obese patient patient w/ a h/o CHF and CKD presenting short of breath just because he has a lactate 2.1 is either reasonable or beneficial. I certainly don't think it's reasonable to criticize someone who decides it's not in the patient's best interest to receive such a bolus. I especially don't think it's reasonable to mandate the administration of such a bolus to said patient, simply because a subsequent lactate might be further elevated and the floor team cannot be expected to continue care for the patient (in effect broadening the target population from septic patients to possibly septic and then even further to might possibly become septic).

I can't comment on the use of this study to further their agenda, but it should provide some reassurance to folks that administering the bolus doesn't automatically buy their patient some plastic.

I also don't defend the guidelines as they are currently written. Think that an individualized approach beats out a protocolized one in many situations.

Does your shop not allow the IBW variant for the biggos? BMI >30 go off of IBW.
 
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This isn’t what we are talking about and you are making this seem unnecessarily extreme. You don’t seem to know the SEP-1 guidelines. 30 cc/kg is almost never more than 3L. If a patient is obese you should be basing on IBW. If the lactate is <4 and they are normotensive then there is no requirement for IVFs per SEP-1.

Sorry about the transference--my hostility is based on prior experience at "high-performing" medical centers. You and I both know the guidelines, that's not the point. The 'sepsis coordinator' probably doesn't. All they know, and care about, are the compliance rates.
 
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If you have a patient that has a high shock index I know you don't want to always through IVF at him, as this could worsen an obstructive or cardiogenic shock. On the other hand, if the patient is highly unstable you may not want to wait for that workup before resuscitating. In the latter case I imagine that you would give IVF empirically if there is strong clinical suspicion for distributive or hypovolemic causes of shock. In the former I imagine you still might give empiric fluids if the diagnosis is clinically obvious (i.e. anaphylaxis in a previously healthy young adult with h/o food allergies).

I haven't been able to verify this online, and I won't have access to an EM doc for another 3 weeks so I'm asking here. I made a flow chart of my thought process. The big difference is p I would greatly appreciate any feedback regarding if my thinking is accurate.

Thanks!


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Take the guesswork out of the situation and just put a phased array probe on the patients chest. You don’t need to be a cardiologist to recognize LV good squeeze/bad squeeze, right side blown out (greater than 2/3 size of left side) or big pericardial effusion surrounding heart. Throw in a look at the IVC: small and collapsing and at the very least you know they’ll tolerate some fluid. Big with no respiratory variation, fluid maybe not the most clever move.
 
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