Sepsis - ESRD

[mikky]

Advertisement - Members don't see this ad

Hi... Are there any specific guidelines in managing sepsis in patients with ESRD.. Do we have to follow Dr.Rivers guidelines in the management of sepsis? My main concern is how much fluid to transfuse in a patient with ESRD with out fluid overloading the patient...

 

[jdh71]

Hi... Are there any specific guidelines in managing sepsis in patients with ESRD.. Do we have to follow Dr.Rivers guidelines in the management of sepsis? My main concern is how much fluid to transfuse in a patient with ESRD with out fluid overloading the patient...

If they need the fluid, ****ing give it. Intubate for hypoxia and get the CRRT started. Renal might nit-pick you a little, they are as bad as the cardiologists - they can only see their one little organ. Sicker than **** people need aggressive management, and when it's just you on at night . . . tell them they are welcome to take primary 😉

EDIT: And remember you can always do dialysis on pressors

 

[ResidentMD]

If they need the fluid, ****ing give it. Intubate for hypoxia and get the CRRT started. Renal might nit-pick you a little, they are as bad as the cardiologists - they can only see their one little organ. Sicker than **** people need aggressive management, and when it's just you on at night . . . tell them they are welcome to take primary 😉

EDIT: And remember you can always do dialysis on pressors

I will start my internship soon, but how about using a central line in this case to at least get some idea of the volume status?

 

[jdh71]

I will start my internship soon, but how about using a central line in this case to at least get some idea of the volume status?

Sepsis will require a line, so you will be able to look at CVPs. But patients who are hypotensive in spite of this will still require fluids, fluids, fluids. Of course you will also be starting a pressor agent in this setting as well.

 

[sluggo]

In Rivers' follow-up article he had a little data suggesting that aggressive fluid challenge of ESRD patients actually makes it less likely that they will require intubation!

 

[mikky]

thanks for the inputs guys

 

[indiamacbean]

CVP monitoring needs to go ahead and die. If you talk to critical care doctors that really know the evidence and what they are doing, they will tell you that CVP should not be used to drive clinical decision making. We need to stop drinking the Kool Aid and move towards wide spread acceptance of more accurate measures.

 

[Firebird]

CVP monitoring needs to go ahead and die. If you talk to critical care doctors that really know the evidence and what they are doing, they will tell you that CVP should not be used to drive clinical decision making. We need to stop drinking the Kool Aid and move towards wide spread acceptance of more accurate measures.

Agree although cvp monitoring is entrenched in the early goal directed therapy bundles. They definitely have a place in the monitoring of septic pts. They are decent in following response to therapy. If you have a pt that you know is hypovolemic then you can at least let the cvp monitor guide you where you are at with resuscitation. If you are unsure about volume status, then cvp monitoring is unreliable as a diagnostic tool. Better of with a vigileo monitor with a flo trac.

 

[Speculatrix]

Agree although cvp monitoring is entrenched in the early goal directed therapy bundles. They definitely have a place in the monitoring of septic pts. They are decent in following response to therapy. If you have a pt that you know is hypovolemic then you can at least let the cvp monitor guide you where you are at with resuscitation. If you are unsure about volume status, then cvp monitoring is unreliable as a diagnostic tool. Better of with a vigileo monitor with a flo trac.

How does this magic vigileo/flotrac work? Why don't we just measure MVO2 and lactate/pH to monitor response to therapy in sepsis? Instead of using a CVP monitor, go all the way with a swann ganz / PA catheter to better guide regarding volume status?

 

[Firebird]

How does this magic vigileo/flotrac work? Why don't we just measure MVO2 and lactate/pH to monitor response to therapy in sepsis? Instead of using a CVP monitor, go all the way with a swann ganz / PA catheter to better guide regarding volume status?

To check mvo2 and lactate hourly would be very expensive. A swann is highly invasive with real risks and does not confer all that much benefit. In ards it has proven not to improve outcomes and may confer harm. You have to have a central line, so just hook it up to a cvp monitor if you have enough lumens and watch as the cvp goes from 2 to 12.

I can't explain the physics of the vigileo monitor, but it does provide some hemodynamic monitoring similar to a swann but instead of placing the transducer in the pulmonary artery, it is attached to the art line thAt you've probably already placed. If the stroke volume variation is great er than 13% then if i remember correctly, that is an indication that there is hypovolemia. I have only used it once. In reality management of sepsis is not all that hard and you don't need a bunch of fancy equipment to figure out that if the pt isstill hypotensive that you should give fluid. If the pt has chf then the vigileo would be more helpful.

 

[jdh71]

In reality management of sepsis is not all that hard and you don't need a bunch of fancy equipment to figure out that if the pt isstill hypotensive that you should give fluid.

👍

 

[Speculatrix]

To check mvo2 and lactate hourly would be very expensive. A swann is highly invasive with real risks and does not confer all that much benefit. In ards it has proven not to improve outcomes and may confer harm. You have to have a central line, so just hook it up to a cvp monitor if you have enough lumens and watch as the cvp goes from 2 to 12.

I can't explain the physics of the vigileo monitor, but it does provide some hemodynamic monitoring similar to a swann but instead of placing the transducer in the pulmonary artery, it is attached to the art line thAt you've probably already placed. If the stroke volume variation is great er than 13% then if i remember correctly, that is an indication that there is hypovolemia. I have only used it once. In reality management of sepsis is not all that hard and you don't need a bunch of fancy equipment to figure out that if the pt isstill hypotensive that you should give fluid. If the pt has chf then the vigileo would be more helpful.

Thanks, this is quite helpful. Obviously I would push push as much fluids as possible in a septic patient. This seems pretty easy unless it is complicated by CHF, renal failure, or liver failure. Can you rely on the resultant third-spacing as a sign that you have given too much fluids? (i.e. push till you hear crackles?) Or is that way past the point of no return? In the absence of vigileo/other fancy monitors, I would be interested in hearing strategies or guidelines to balance give enough fluids in sepsis with avoiding fluid overload, especially in vulnerable patients.

 

[Firebird]

Thanks, this is quite helpful. Obviously I would push push as much fluids as possible in a septic patient. This seems pretty easy unless it is complicated by CHF, renal failure, or liver failure. Can you rely on the resultant third-spacing as a sign that you have given too much fluids? (i.e. push till you hear crackles?) Or is that way past the point of no return? In the absence of vigileo/other fancy monitors, I would be interested in hearing strategies or guidelines to balance give enough fluids in sepsis with avoiding fluid overload, especially in vulnerable patients.

Your goal is a mean arterial pressure of around 65. Until you get there, you give ivf and pressors. In any hypotensive process, if the pt is intubated, you can put them in pulmonary edema and be less concerned than you would otherwise. You don't want to drown anyone, but if they're not perfusing, then they're not perfusing. Gotta fix that.

 

[jdh71]

Thanks, this is quite helpful. Obviously I would push push as much fluids as possible in a septic patient. This seems pretty easy unless it is complicated by CHF, renal failure, or liver failure. Can you rely on the resultant third-spacing as a sign that you have given too much fluids? (i.e. push till you hear crackles?) Or is that way past the point of no return? In the absence of vigileo/other fancy monitors, I would be interested in hearing strategies or guidelines to balance give enough fluids in sepsis with avoiding fluid overload, especially in vulnerable patients.

Like firebird said, the surviving sepsis camapign has given us the "magic" number of 65, dump it in until you get there. Obviously, you'll be using pressor agents as well in this setting. These patients almost always get intubated, so as long as they are oxygenating you've not drowned them. There is, unfortunately, not a real hard and strict "science" to this . . . one other thing to watch, especially if concerned about thirdspacing, is if UOP drops off in the setting of a MAP >65, get a bladder pressure. I've seen more than a few guys requiring laporotomies for high abdominal compartment pressures from all the fluids given.

 

[ResidentMD]

Your goal is a mean arterial pressure of around 65. Until you get there, you give ivf and pressors. In any hypotensive process, if the pt is intubated, you can put them in pulmonary edema and be less concerned than you would otherwise. You don't want to drown anyone, but if they're not perfusing, then they're not perfusing. Gotta fix that.

I agree

. I dont mean to offend you, but I am kind of attacking the science. This all just seems so wishy-washy doesnt it? A person really doesnt kmow what he/she is doing....just give fluids..get up the MAP...okay, if you hear crackles/the patient's oxygenation starts desaturating, maybe you should stop...there has got to be a better way to deal with this.

Again, its not an attack against you. I'm just venting against what seems like a very imprecise science, and I hope there are some good trials (and even good fundamental research) in the near future that would tell us how to be more exact (without using ridiculous monitoring techniques).

 

[jdh71]

I agree

. I dont mean to offend you, but I am kind of attacking the science. This all just seems so wishy-washy doesnt it? A person really doesnt kmow what he/she is doing....just give fluids..get up the MAP...okay, if you hear crackles/the patient's oxygenation starts desaturating, maybe you should stop...there has got to be a better way to deal with this.

Again, its not an attack against you. I'm just venting against what seems like a very imprecise science, and I hope there are some good trials (and even good fundamental research) in the near future that would tell us how to be more exact (without using ridiculous monitoring techniques).

If you can get those randomized trials through an IRB I will fly to wherever you are and BUY you dinner!! 😀

If you can get a patient's family to agree to the trial, despite knowing their loved one could possibly be "placebo", I will refer to you as a god among men to anyone who asks.

 

[ResidentMD]

If you can get those randomized trials through an IRB I will fly to wherever you are and BUY you dinner!! 😀

If you can get a patient's family to agree to the trial, despite knowing their loved one could possibly be "placebo", I will refer to you as a god among men to anyone who asks.

Well, dont do it against a placebo, do it against the current standard of treatment (which in this case appears to be doing whatever it takes to get a MAP of 65). The trial published in JAMA earlier this year at least came close in study design, but it used SvO2 and serum lactate levels. But frankly, I think more fundamental research is needed (possibly using animal studies) before another RCT, to get a better understanding and develop this into a more precise science...I dont know, just my two cents, but am open to suggestions/arguments.

 

[Firebird]

Septic Patients are like freight trains. If they are headed in a direction really fast there is almost nothing you can do to turn them around towards another direction. If they're moving slowly, you don't need to sit down with a calculator to determine the exact force and momentum with which they are traveling so that you can apply exactly the same force in the opposite direction. Any person would know to just apply the breaks and push in the opposite direction until the train turns around. Again, this is how septic pts are. You push them in the right direction. If they're not at death's door then you'll probably fix them. If they are a cancer pt on chemotherapy who is neutropenic, hypothermic and hypotensive, then you might not be able to save that person despite a wide evidence base and all the mixed venous o2 sats and lactates you can order. We have killed the art of medicine by insisting everything be evidence based to the degree that you're reading a cookbook...only to say 10 years later there is now a study that contradicts the dogma we've ascribed to for the last ten years.

I'm not bashing evidence and science. But you will drive yourself crazy trying to practice medicine that says you must manage a pt by doing x y z at times q r s. I think sometimes our lack of confidence manifests as this drive to KNOW that what were doing is appropriate as evidenced by randomized trials. The fact is that when we KNEW that we were appropriately controlling a pts glucose by keeping it between 80-120, we were actually wrong according to the most recent trial (nice sugar). In another 2-3 years well find a new target. So the take home is don't let your pts glucose get to 600 or 60. Follow the most recent and robust recommendation but don't freak out if there's no clear guideline or if you can't seem to easily meet that guideline.

 

[jdh71]

Septic Patients are like freight trains. If they are headed in a direction really fast there is almost nothing you can do to turn them around towards antihero direction. If they're moving slowly, you don't need to sit down with a calculator to determine the exact force and momentum with which they are traveling so that you can apply exactly the same force in the opposite direction. Any person would know to just apply the breaks and push in the opposite direction until the train turns around. Again, this is how septic pts are. You push them in the right direction. If they're not at death's door then you'll probably fix them. If they are a cancer pt on chemotherapy who is neutropenic, hypothermic and hypotensive, then you might not be able to save that person despite a wide evidence base and all the mixed venous o2 sats and lactates you can order. We have killed the art of medicine by insisting everything be evidence based to the degree that you're reading a cookbook...only to say 10 years later there is now a study that contradicts the dogma we've ascribed to for the last ten years.

I'm not bashing evidence and science. But you will drive yourself crazy trying to practice medicine that says you must manage a pt by doing x y z at times q r s. I think sometimes our lack of confidence manifests as this drive to KNOW that what were doing is appropriate as evidenced by randomized trials. The fact is that when we KNEW that we were appropriately controlling a pts glucose by keeping it between 80-120, we were actually wrong according to the most recent trial (nice sugar). In another 2-3 years well find a new target. So the take home is don't let your pts glucose get to 600 or 60. Follow the most recent and robust recommendation but don't freak out if there's no clear guideline or if you can't seem to easily meet that guideline.

👍