Sepsis after cysto

[deleted875186]

Recently had a case where a healthy 40 something year old had a cysto and stent placed for obstructing stone and pyelonephritis. Hypotension in PACU, got about 3L between ED and OR, peeing a bunch, antibiotics in. MAPs now in high 50 to low 60s, systolic as low as 80. Patient looks fine, asking when she can go to work, mild Leukocytosis. I called hospitalist and told them she needs an ICU bed for overnight (no PACU coverage to board overnight).

what would you do?
1. Peripheral norepi overnight
2. Peripheral phenylephrine overnight
3. Central line, norepi overnight

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[DoctwoB]

Urologist here. Don’t F with septic stones. They’ll tank in a heartbeat. Line and unit. Think of the kidney as an abscess, because without drainage it basically is. usually they get transiently septic after the stent from manipulation and then turn the corner like after draining an abscess. But sometimes they’ll get bacteremic and drop like a rock. So be ready and watch closely.

Edit: also foley if she doesn’t have one. Maximum drainage.

 

[Airway]

1.
Assume 'reasonable' dose, good veins, a ICU I trust, with a peripheral vasopressor protocol and IVs I trust.

Otherwise cvc and #3

I'd give steroids too.

 

[abolt18]

I feel like this is just what I've come to expect from infected kidneys with stones. Had them start the swirl in the OR more than once. Personally I'd just place a good, VERY reliable long peripheral IV under ultrasound, maybe even exchange it over a wire for a single lumen peds IJ (effectively a midline now), and start some norepi. CVC if unable to gain very confident peripheral.

 

[MirrorTodd]

Text I sent my attending CA2 year. Can you guess what this is in reference to? He kinda laughed at how nonchalant I tried to sound.

 

[nimbus]

Aline/CVL/norepi/unit.

 

[coffeebythelake]

Recently had a case where a healthy 40 something year old had a cysto and stent placed for obstructing stone and pyelonephritis. Hypotension in PACU, got about 3L between ED and OR, peeing a bunch, antibiotics in. MAPs now in high 50 to low 60s, systolic as low as 80. Patient looks fine, asking when she can go to work, mild Leukocytosis. I called hospitalist and told them she needs an ICU bed for overnight (no PACU coverage to board overnight).

what would you do?
1. Peripheral norepi overnight
2. Peripheral phenylephrine overnight
3. Central line, norepi overnight

Agree with close monitoring overnight in ICU environment

I know that people love levo for sepsis, but why not use phenylephrine? Can titrate up or switch to levo later if needed. Why bring out the big guns right away?

Nothing you've said make me think this is anything other than vasodilatory shock which will improve with fluids, antibiotics and some good alpha1 agonist activity

 

[abolt18]

Agree with close monitoring overnight in ICU environment

I know that people love levo for sepsis, but why not use phenylephrine? Can titrate up or switch to levo later if needed. Why bring out the big guns right away?

Nothing you've said make me think this is anything other than vasodilatory shock which will improve with fluids, antibiotics and some good alpha1 agonist activity

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I believe that the simple answer is phenylephrine is PROBABLY okay, but meta-analyses have shown superior outcomes with early administration of NE in septic shock. If too tachy, phenylephrine may be better.

Also, vasodilatory shock in the setting of known source of infection = septic shock. Septic shock -> some fluids, some broad spectrum ABX, and some norepinephrine. Operative source control if appropriate.

Though, I admittedly don't have a ton of experience managing septic shock other than temporarily in the OR because most of my ICU experience as a resident has been in neuro ICU and CTICU.

 

[coffeebythelake]

PulmCCM | Substack

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I believe that the simple answer is phenylephrine is PROBABLY okay, but meta-analyses have shown superior outcomes with early administration of NE in septic shock. If too tachy, phenylephrine may be better.

Also, vasodilatory shock in the setting of known source of infection = septic shock. Septic shock -> some fluids, some broad spectrum ABX, and some norepinephrine. Operative source control if appropriate.

Though, I admittedly don't have a ton of experience managing septic shock other than temporarily in the OR because most of my ICU experience as a resident has been in neuro ICU and CTICU.

I say vasodilatory shock to distinguish it from myocardial dysfunction and reduced EF which can occur with septic shock

40 year old unlikely to have significant cardiac comorbidities and should be able to reasonably tolerate a pure alpha agonist without significantly dropping their cardiac output. And if they are going to sit in the unit with close monitoring of hemodynamics, why not titrate and escalate as needed?

 

[chessknt]

Norepi peripherally unless on a high dose (alternatively if iv looks really good you'll probably be fine), appropriate abx (usually ctx is fine unless multiple infections/abx in past) and +/- steroids depending on how sick. Gram negative sepsis usually has a huge flare of shock that calms down slowly so as long as you have source control just gotta ride it but I wouldn't leave anyone septic on pressors in pacu since the nursing skillset is different unless you have a floater who does icu work watching the patient.

This is assuming you've thrown a sepsis level (30 cc/kg) bolus and still see shock physiology aside from blood pressure. Are you having to manage this all night? Seems appropriate to xfer to whoever covers icu and has more experience with it.

 

[Radetzky]

Phenylephrine through a PIV, switch to Levo and cvl if getting to high doses. In the ICU of course. These guys usually just need 24 hours of low dose vasopressors to ride it out. CVL is totally unnecessary in most cases, except for the occasional ones that get really sick with it. But still a lot of traditionalists that insist every sepsis must get a central line and levo.

 

[CodeBlu]

ICU Admit
A-line, 3 lumen
Levophed.
Cultures x2 from fresh 3 lumen.
Pip-tazo.
Had someone tank in PACU once. I was on call, one of my colleagues brought with peripheral phenylephrine.... then, of course we're on stupid doses of phenylephrine and the lactate is 6. But, doesn't "look" that sick.

Moral of the story: lactate 6... be scared. Do all the things.

 

[deleted875186]

I ended up placing CVC for norepi

I argued for peripheral norepi; I geuss the hospital doesn’t let them do it. Seemed like overkill which is why I ask, but I suppose the patient could have gotten much sicker.

looked at the chart the next day, person was in 4-6 mcg/min norep for 12 hours and then off :/

 

[vector2]

I ended up placing CVC for norepi

I argued for peripheral norepi; I geuss the hospital doesn’t let them do it. Seemed like overkill which is why I ask, but I suppose the patient could have gotten much sicker.

looked at the chart the next day, person was in 4-6 mcg/min norep for 12 hours and then off :/

Allowing less than ~12-15 mcg/min NE through a reliable midline for a couple days should be brought up in your hospital’s crit care committee. It is safe and effective and spares the pt the risks and discomfort of a totally unnecessary cvc stick.

For the pt in question, if she is 40 something and healthy at baseline, warm, well-perfused, normal mentation, making urine, no other organ failures, lactate clearing- ICU admission, no Aline, no cvc, good peripheral/midline NE

 

[coffeebythelake]

Sepsis with MAP of low 60 without pressors is fine. See the 65 TRIAL. Also echoed by several others. Giving patient pressors in of itself is not without risk. Perhaps we are being too aggressive in our MAP goals for septic patients?

What is thr evidence for steroids in sepsis? Makes sense if patient has adrenal insufficiency. But as I understand it, it's widespread use in sepsis controversial and several recent studies show no real outcome improvement.

 

[coffeebythelake]

I ended up placing CVC for norepi

I argued for peripheral norepi; I geuss the hospital doesn’t let them do it. Seemed like overkill which is why I ask, but I suppose the patient could have gotten much sicker.

looked at the chart the next day, person was in 4-6 mcg/min norep for 12 hours and then off :/

What's your ICU staffing like? For a reasonable hemodybamic stable patient that needed closer monitoring I would have sent them up on neo and have them put in a CVC if patient started to decompensate and they needed it.

 

[chessknt]

Sepsis with MAP of low 60 without pressors is fine. See the 65 TRIAL. Also echoed by several others. Giving patient pressors in of itself is not without risk. Perhaps we are being too aggressive in our MAP goals for septic patients?

What is thr evidence for steroids in sepsis? Makes sense if patient has adrenal insufficiency. But as I understand it, it's widespread use in sepsis controversial and several recent studies show no real outcome improvement.

PulmCrit- APROCCHSS vs. ADRENAL: Are we asking the right question?

ADRENAL and APROCCHSS were both designed with mortality as a primary endpoint. They reached opposite conclusions: steroid had no effect on mortality in ADRENAL, whereas it improved mortality in APROCCHSS. Why?

emcrit.org

A good primer on the nuance of interventions in sepsis. Almost no downside and easy to get off quickly. Looking for mortality benefit in every intervention in critical care isnt helpful.

 

[deleted697535]

I ended up placing CVC for norepi

I argued for peripheral norepi; I geuss the hospital doesn’t let them do it. Seemed like overkill which is why I ask, but I suppose the patient could have gotten much sicker.

looked at the chart the next day, person was in 4-6 mcg/min norep for 12 hours and then off :/

Just go a 16g ej. No ones gonna know the difference.

 

[deleted875186]

What's your ICU staffing like? For a reasonable hemodybamic stable patient that needed closer monitoring I would have sent them up on neo and have them put in a CVC if patient started to decompensate and they needed it.

Doing a weekend shift in the OR in a small community hosptial. 5 ORs, 1 intensivist with a 10 bed unit.

hospitalist asked me to place a CVC for them.

 

[vector2]

Sepsis with MAP of low 60 without pressors is fine. See the 65 TRIAL. Also echoed by several others. Giving patient pressors in of itself is not without risk. Perhaps we are being too aggressive in our MAP goals for septic patients?

What is thr evidence for steroids in sepsis? Makes sense if patient has adrenal insufficiency. But as I understand it, it's widespread use in sepsis controversial and several recent studies show no real outcome improvement.

Steroids in (typically multi-pressor) septic shock are for faster resolution of shock and to get them out of the ICU faster- not for a mortality benefit.

More broadly, we have really started to plateau in regard to what we can do medically for sepsis. For christsakes, when people are getting hot and bothered with the possibility that vitamin c, hydrocort, and thiamine are the magic cure for septic shock, you know what I say has gotta be true. In fact, we are actually doing *less* now for sepsis than we were 15-20 yrs ago when Rivers was the shiny new thing.

 

[dhb]

In fact, we are actually doing *less* now for sepsis than we were 15-20 yrs ago when Rivers was the shiny new thing

Law 13?

 

[nimbus]

Just go a 16g ej. No ones gonna know the difference.

A 16g EJ is zero units.

 

[YadaYadaNext]

Look at the patient (yes, actually go in the room and examine/talk to them) and follow the urine output.... both of these will tell you more about the patient’s condition than any other number.

Not the board answer, but the real life answer.... If the patient looks good and is making adequate urine, then pressors through peripheral, Cuff pressures, and kick out of icu in a day or two when henodynamically stable.

Central line/art line, while typically safe, are not without complication. Don’t over treat.

 

[Radetzky]

Sepsispam and MAP65 showed different results. Notably though both are underpowered you find a mortality difference. I think it’s an individualised decision. If someone is perfusing well 60 is probably fine. But notably there is good observational data that the more and further time is spent away from baseline MAP the worse mortality.

Steroids shorten vasopressors but don’t change mortality? What is the scientific rationale for that. Again, underpowered to detect mortality if you look at everyone with sepsis rather than just those with severe shock.

Someone who just needs 24 hours to ride out a septic shower is going to get better regardless of steroids or not or MAP 60 vs 65.

 

[coffeebythelake]

Sepsispam and MAP65 showed different results. Notably though both are underpowered you find a mortality difference. I think it’s an individualised decision. If someone is perfusing well 60 is probably fine. But notably there is good observational data that the more and further time is spent away from baseline MAP the worse mortality.

Steroids shorten vasopressors but don’t change mortality? What is the scientific rationale for that. Again, underpowered to detect mortality if you look at everyone with sepsis rather than just those with severe shock.

Someone who just needs 24 hours to ride out a septic shower is going to get better regardless of steroids or not or MAP 60 vs 65.

I think the 65 trial and others like it suggest a greater need for individualized goals, based on ssx of end organ dysfunction. Perfusion is key. Pressors can improve macrocirculatory pressures but may harm flow in microcirculation..

 

[deleted697535]

A 16g EJ is zero units.

Lol.

It would want to be an extremely slow day to make a CVC in pacu a beneficial thing to do. Let me get back to my cabg+valve or fractured neck of femur and make some real $

 

[Velefunt]

Urologist here. Don’t F with septic stones. They’ll tank in a heartbeat. Line and unit. Think of the kidney as an abscess, because without drainage it basically is. usually they get transiently septic after the stent from manipulation and then turn the corner like after draining an abscess. But sometimes they’ll get bacteremic and drop like a rock. So be ready and watch closely.

Edit: also foley if she doesn’t have one. Maximum drainage.

I really like this abscess analogy.

 

[deleted875186]

Not to make a thing out of this, but I feel like the “vasopressors always need a CVC” is the hardest dogma to get past.

I often think about myself deciding between an LMA and an ETT for a case, I’m certainly not putting in ETTs for every case just because patients obese, GERD, etc etc, and the complications of placing an ETT in my hands is probably much smaller than the complications of placing a CVC.

 

[GassYous]

I just figure that if I'm thinking about it, it's probably a good idea to just do it. I've regretted not tubing or placing a line.

 

[Katheudontas parateroumen]

Central line for all vaso pressors is big time dogma. Doing anesthesia we know that giving pressors through peripheral IV (even a 20g in the hand) is possible at least for the short term bolused and dripped. But many papers are coming on this question if it’s safe. I’d say it is. My practice so far is if I suspect longer term >24hrs or high doses >5mcg/min NE kind of things then I’ll place a central line. As for arterial like for all titratble vaso pressors, I also think that if the dose of the vasopressor isn’t changing significantly and stable, then I don’t think an art line is necessary. Overall for us anesthesia folk, we do enough lines that it’s easy enough for us to just pop one in. But in general, it’s probably less necessary.

https://journals.lww.com/anesthesia-analgesia/Citation/2020/10000/Yes_You_Can_Cautiously_Infuse_Norepinephrine.11.aspx

Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study
Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study - PubMed

-Over 14,000 patients going for elective surgery had NE infusions via peripheral IV. Only 5 had extravasation, and none needed medical intervention.

 

[Ronin786]

I know the data supports short term peripheral pressor use, but all it takes is to go look at anybody who has been in the hospital for more than a few and see how puffy they are to make you think long and hard about it.

Yeah, if you're coming in through the ED and need quick vasopressors it makes total sense. But given the dogmatic crystalloid flooding, I don't trust many veins in my ICU.

 

[deleted171991]

I ended up placing CVC for norepi

I argued for peripheral norepi; I geuss the hospital doesn’t let them do it. Seemed like overkill which is why I ask, but I suppose the patient could have gotten much sicker.

looked at the chart the next day, person was in 4-6 mcg/min norep for 12 hours and then off :/

This is typical for urosepsis in relatively young and otherwise healthy people. As long as the patient is feeling well and making urine, he's fine. Once the source is controlled, it's usually over in less than a day.

Similar case in fellowship: I let him be on up to 200 mcg of peripheral phenylephrine, even fought the nurses. Patient off pressors in 8-12 hours, out of ICU the next day (I think it was a discharge to home). I have rarely felt better about a decision.

When in doubt, just use peripheral phenylephrine (if enough). There have been no documented cases of major bad outcomes with peripheral phenylephrine ever. One should do onto patients EXACTLY what one would like to be done onto oneself; no central line for me, if avoidable, thanks.

 

[Beeftenderloin]

Can someone please help me with parking the MAP in the low 60s across the board? I know the literature says there’s no change in mortality driving it higher, but there is potential benefit driving it higher to protect the kidneys. Pushing higher (75-80) leads to lower rates of AKI and RRT in patients with pre-existing HTN, renal dysfunction or significant atherosclerotic burden (which is essentially everyone in America over 60).

I feel like this just makes sense physiologically. Adequate renal perfusion pressure (RPP = MAP - CVP) is somewhere around 65-70. How can you possibly be adequately perfusing the kidneys with a map of 60? Even if you’re in profound vaso-dilatory shock and CVP is in 2-5 range, a MAP of 60 isn’t going to get you their and the beans are taking a hit.

If the 40 year old patient in this case is otherwise healthy and is septic from an infected stone, fine 60-65 is probably okay for a little bit. And I totally understand that people are responding to this case specifically. But that’s not most septic patients. What are people doing in this same case with a comorbid 65yo.

 

[deleted171991]

Can someone please help me with parking the MAP in the low 60s across the board? I know the literature says there’s no change in mortality driving it higher, but there is potential benefit driving it higher to protect the kidneys. Pushing higher (75-80) leads to lower rates of AKI and RRT in patients with pre-existing HTN, renal dysfunction or significant atherosclerotic burden (which is essentially everyone in America over 60).

I feel like this just makes sense physiologically. Adequate renal perfusion pressure (RPP = MAP - CVP) is somewhere around 65-70. How can you possibly be adequately perfusing the kidneys with a map of 60? Even if you’re in profound vaso-dilatory shock and CVP is in 2-5 range, a MAP of 60 isn’t going to get you their and the beans are taking a hit.

If the 40 year old patient in this case is otherwise healthy and is septic from an infected stone, fine 60-65 is probably okay for a little bit. And I totally understand that people are responding to this case specifically. But that’s not most septic patients. What are people doing in this same case with a comorbid 65yo.

It's a matter of individualized risks vs benefits.

The MAP of 65 was invented mostly as a compromise so that all those *****s playing with pressors, without checking their effects on microcirculation and internal organs, don't put patients into bowel and finger necrosis etc. It has the best chances of good outcomes, as far as we know, at population level.

That number should be highly personalized, based on the patient's mental status, peripheral perfusion, urine output etc.

True story: I had a patient in the SICU who had a stroke and a hip fracture. After the fracture was fixed, he also developed some sepsis, so he was transferred to the MICU. While still in the SICU, I noticed that his mental status would dip whenever his MAP was lower than about 75. So, when signing him out, I told the MICU fellow to keep him at a MAP higher than 75 and why. What do you think the order they put into the EMR was? Keep MAP over 65. These are the people we have the protocols for, knee-jerk idiots, not true intensivists. If the protocol said 55, I bet they would have kept him at 55.

Any doctor who treats patients generically, based on recipes, deserves to be replaced by a midlevel. So kudos to you.

 

[nimbus]

This is typical for urosepsis in relatively young and otherwise healthy people. As long as the patient is feeling well and making urine, he's fine. Once the source is controlled, it's usually over in less than a day.

Similar case in fellowship: I let him be on up to 200 mcg of peripheral phenylephrine, even fought the nurses. Patient off pressors in 8-12 hours, out of ICU the next day (I think it was a discharge to home). I have rarely felt better about a decision.

When in doubt, just use peripheral phenylephrine (if enough). There have been no documented cases of major bad outcomes with peripheral phenylephrine ever. One should do onto patients EXACTLY what one would like to be done onto oneself; no central line for me, if avoidable, thanks.

Your unit must maintain their IV’s better than mine. I end up replacing over 50% of ours that come to the OR. I’ll take a central line any day.

 

[coffeebythelake]

Your unit must maintain their IV’s better than mine. I end up replacing over 50% of ours that come to the OR. I’ll take a central line any day.

I wonder if it is technique related? If you get flash right away and most of your catheter is in the vein (especially a long IV) it shouldn't infiltrate so easily. What I see a lot of is nurses who dig around for the IV so that only a little bit of it is actually in the vein. Add on top of that a mobile area of the body (lots of overlying adipose tissue, near a joint, etc)..

 

[YadaYadaNext]

Ultrasound guided, long axis, in plane technique with a long angiocath (1.75inch). Takes a bit to learn, but once you master the technique, it’s very hard to miss a vein.

 

[deleted171991]

Ultrasound guided, long axis, in plane technique with a long angiocath (1.75inch). Takes a bit to learn, but once you master the technique, it’s very hard to miss a vein.

Most peripheral pressor infiltrations happen with short catheters, where the infusate gets to the holes poked in the vein walls during placement.

Another mechanism is reversal of flow in the vein, due to proximal occlusion (e.g. flexing the elbow above the IV), again with holes in the walls.

 

[coffeebythelake]

Most peripheral pressor infiltrations happen with short catheters, where the infusate gets to the holes poked in the vein walls during placement.

I think it should be said. Never trust an IV that you didn't place yourself (or watch someone place). I'm sure we all have stories about IVs from the floor.

Old school nurses have the skills. The new breed seem quite weak with IVs.

 

[GassYous]

I think it should be said. Never trust an IV that you didn't place yourself (or watch someone place). I'm sure we all have stories about IVs from the floor.

Old school nurses have the skills. The new breed seem quite weak with IVs.

New ones are too busy doing their leadership essays for their doctorate of practicing healthcare assignments

 

[deleted697127]

Stents for infected stones in youth healthy patients are typically quick cases that recover from sedation quickly. Pacu nurses hear 3 minute case and like to clear them out of pacu as soon as possible. I have a very low threshold to send a lactate if HR is trending up or BPs are soft. It’s a bad look if they get up to the floor too quickly with systolics in pacu that were 110/60 HR 91 on emergence, 90/50 HR 98 on last documented PACU vitals, and end up with systolics 70s maps 50s with a lactate of 6 half an hour after reaching the floor. Delayed treatment of hypotension on the floor is likely worse for the patient than your choice of pressor. If nothing else sending the lactate gives you some reassurance perfusion is adequate and communicates your concern to the pacu and accepting nurse on the floor not to blow off soft vitals in a septic patient.

 

[PainDrain]

Had a case very similar to the one posted by the OP. 48 yo F athlete w/no PMH who presented with an infected stone. Cysto was under 15 minutes and she had MAPs >65 the entire case but when we got to PACU I noticed her skin was mottled. She spikes a temp in PACU to 103, now tacky, and pressure starts to trend down. I told the resident to book her an ICU bed, bumped her fluids up and got better access. She ended up staying in the ICU for 3 days on NE.

 

[jwk]

Truly amazing how quickly urosepsis can crank up. One of my best friends went from first twinge of flank pain at home to a vent in under four hours. Several days on the vent and a week-long ICU stay. Zero sequelae, but scary as hell.

 

[vector2]

Speaking of urosepsis, just had a pt come to OR for obstructing stone yesterday. Unlike the OP, she was

77yo
5’5” , 275lb
Febrile to 102.9
6L N/C satting 94% with pulm edema and bilateral pleural effusions
On norepinephrine 0.15 mcg/kg/min with SBP ~100
Recent mid-LAD stent still on DAPT
Boarding in the ED since no ICU beds

 

[deleted875186]

Speaking of urosepsis, just had a pt come to OR for obstructing stone yesterday. Unlike the OP, she was

77yo
5’5” , 275lb
Febrile to 102.9
6L N/C satting 94% with pulm edema and bilateral pleural effusions
On norepinephrine 0.15 mcg/kg/min with SBP ~100
Recent mid-LAD stent still on DAPT
Boarding in the ED since no ICU beds

So bypass PACU and send home after the cysto

 

[epidural man]

Can someone please help me with parking the MAP in the low 60s across the board? I know the literature says there’s no change in mortality driving it higher, but there is potential benefit driving it higher to protect the kidneys. Pushing higher (75-80) leads to lower rates of AKI and RRT in patients with pre-existing HTN, renal dysfunction or significant atherosclerotic burden (which is essentially everyone in America over 60).

I feel like this just makes sense physiologically. Adequate renal perfusion pressure (RPP = MAP - CVP) is somewhere around 65-70. How can you possibly be adequately perfusing the kidneys with a map of 60? Even if you’re in profound vaso-dilatory shock and CVP is in 2-5 range, a MAP of 60 isn’t going to get you their and the beans are taking a hit.

If the 40 year old patient in this case is otherwise healthy and is septic from an infected stone, fine 60-65 is probably okay for a little bit. And I totally understand that people are responding to this case specifically. But that’s not most septic patients. What are people doing in this same case with a comorbid 65yo.

Healthy kidneys are probably the best auto regulating organs on the body. They get the job done.
If the patient is making urine, kidneys are perfuming.
I bet they could tolerate much lower pressures.

 

[epidural man]

Recently had a case where a healthy 40 something year old had a cysto and stent placed for obstructing stone and pyelonephritis. Hypotension in PACU, got about 3L between ED and OR, peeing a bunch, antibiotics in. MAPs now in high 50 to low 60s, systolic as low as 80. Patient looks fine, asking when she can go to work, mild Leukocytosis. I called hospitalist and told them she needs an ICU bed for overnight (no PACU coverage to board overnight).

what would you do?
1. Peripheral norepi overnight
2. Peripheral phenylephrine overnight
3. Central line, norepi overnight

I agree with ICU.

But if there is NO sign of low perfusion state of the end organs (making urine, talking while sitting up with no symptoms, HR below 100, lactate stable), what is the need to treat?

I’m not sure I would start anything. Maybe give some single doses of vasopressin.

 

[nimbus]

Healthy kidneys are probably the best auto regulating organs on the body. They get the job done.
If the patient is making urine, kidneys are perfuming.
I bet they could tolerate much lower pressures.

I have adult family members who walk around with MAP<60. Once we had to sign out AMA after a colonoscopy because SBP wouldn’t stay above 90.

 

[chocomorsel]

Healthy kidneys are probably the best auto regulating organs on the body. They get the job done.
If the patient is making urine, kidneys are perfuming.
I bet they could tolerate much lower pressures.

Except sometimes it takes days for those kidneys to show that they were underperfusing. Doesn’t always happen right away.
Keep the MAPs reasonable >65 and they should be fine.

 

[dhb]

perfuming

Performing or perfusing or both?

Or maybe it's the smell?