Shock Journal Club

[Psai]

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You're an intern in the ED and the place is bumping, filled with your typical drunks, worried well and sick people.

A new patient is brought through the doors and assigned to you.

70 yo female, history of metastatic colon cancer with mets to brain, adrenals, bone, liver, dm2, htn biba to ED with decreased mental status, baseline a&ox3.

Has been receiving palliative chemotherapy and steroids in the outpatient setting, last one was a week ago.

T: 100.6 P 105 BP 86/56 RR 14 SpO2 97% on RA
Exam: patient somnolent and oriented to self only. dry mouth, no jvd, crackles heard at both lung bases, no edema
BMP: 136/4.3/102/25/5/0.4/91
CBC: 13 > 9/31 < 160
cortisol: 6 (drawn at 9 am)
UA: negative for leukocyte esterase, nitrites. no rbcs, no wbcs, no bacteria.
Blood cultures: pending
Chest xray: consolidation at both lung bases

You think the patient has septic shock from pneumonia.

How much fluid do you want to give?
Do you want to start pressors and if yes, which one and why?
What is the role of steroids in septic shock?

Will follow up with a few papers and discussion if people are interested

 

[dr zaius]

Urology consulted for difficult foley secondary to pannus. Foley placed easily with med student retraction of pannus. $250 collected and urology signs off. Resuscitation per primary team.

 

[PatsyStone]

Dermatology consulted for bilateral lower leg cellulitis. Derm resident tells ED staff that pt has cyanosis 2/2 to septic shock. Dermatology signs off. ED staff then starts vanc and zosyn for bilateral leg cellulitis

 

[dr zaius]

I love where this thread is going.

 

[neusu]

Better get rad onc in here STAT to give one last treatment before she tanks out.

 

[Crayola227]

I was told once that no septic patient should die without vanc in their system

and that no cancer patient should die without steroids on board

that is all I know that could be relevant

 

[GadRads]

Fluids: Bolus 1 L NS stat and possibly another liter, fluids at 30 ml/kg with frequent assessment of vitals. If no response to fluids at about 4L, start pressors. If poor response, will start hydrocortisone at a stress dose.

Abx: Vanc, Zosyn stat. Patient is also immunocompromised. So will consider fungal coverage with fluconazole. Will get ID on board.

I believe the CORTICUS trial did not show benefit with hydrocortisone in septic shock in patients with no response to CRH. There are probably other newer studies on this issue. But my arm-chair reasoning is to add stress dose steroids if fluids and pressors are not effective. What else is there to lose?

 

[masaraksh]

Did I hear bone mets? Page ortho and call in the Stryker rep

 

[cbrons]

You're an intern in the ED and the place is bumping, filled with your typical drunks, worried well and sick people.

A new patient is brought through the doors and assigned to you.

70 yo female, history of metastatic colon cancer with mets to brain, adrenals, bone, liver, dm2, htn biba to ED with decreased mental status, baseline a&ox3.

Has been receiving palliative chemotherapy and steroids in the outpatient setting, last one was a week ago.

T: 100.6 P 105 BP 86/56 RR 14 SpO2 97% on RA
Exam: patient somnolent and oriented to self only. dry mouth, no jvd, crackles heard at both lung bases, no edema
BMP: 136/4.3/102/25/5/0.4/91
CBC: 13 > 9/31 < 160
cortisol: 6 (drawn at 9 am)
UA: negative for leukocyte esterase, nitrites. no rbcs, no wbcs, no bacteria.
Blood cultures: pending
Chest xray: consolidation at both lung bases

You think the patient has septic shock from pneumonia.

How much fluid do you want to give?
Do you want to start pressors and if yes, which one and why?
What is the role of steroids in septic shock?

Will follow up with a few papers and discussion if people are interested

What are the goals of care? Probably do everything.

30cc/kg IVFs
Abx
4mg Dexamethasone

Do I think she has septic shock from pneumonia or could this be Addisonian crisis?

What is the role of steroids in septic shock?

Reduces duration of shock without affecting mortality. I had to look that one up cause I've heard several things.

 

[cbrons]

Fluids: Bolus 1 L NS stat and possibly another liter, maintenance fluids at at 30 ml/kg with frequent assessment of vitals. If no response to fluids at about 4L, start pressors. If poor response, will start hydrocortisone at a stress dose.

Abx: Vanc, Zosyn stat. Patient is also immunocompromised. So will consider fungal coverage with fluconazole. Will get ID on board.

I believe the CORTICUS trial did not show benefit with hydrocortisone in septic shock in patients with no response to CRH. There are probably other newer studies on this issue. But my arm-chair reasoning is to add stress dose steroids if fluids and pressors are not effective. What else is there to lose?

Found this:
https://emcrit.org/pulmcrit/steroids-in-septic-shock-four-misconceptions-and-one-truth/

 

[Tenk]

Talk to family. Comfort measures only. Next case.

 

[WildcatS11]

Fluids: Bolus 1 L NS stat and possibly another liter, maintenance fluids at at 30 ml/kg with frequent assessment of vitals. If no response to fluids at about 4L, start pressors. If poor response, will start hydrocortisone at a stress dose.

Abx: Vanc, Zosyn stat. Patient is also immunocompromised. So will consider fungal coverage with fluconazole. Will get ID on board.

I believe the CORTICUS trial did not show benefit with hydrocortisone in septic shock in patients with no response to CRH. There are probably other newer studies on this issue. But my arm-chair reasoning is to add stress dose steroids if fluids and pressors are not effective. What else is there to lose?

What do you mean by this? So in a 100 kg pt you will give mIVF of 3 L/hr? Or are you trying to get at the CMS measure of 30 cc/kg fluid bolus for sepsis? Remember mIVF and boluses are different.

 

[GadRads]

What do you mean by this? So in a 100 kg pt you will give mIVF of 3 L/hr? Or are you trying to get at the CMS measure of 30 cc/kg fluid bolus for sepsis? Remember mIVF and boluses are different.

brain fart. i meant goal for boluses.

 

[Psai]

So for fluids 30 mL/kg per cms guidelines ends up being about 2 L or so in the typical 70 kg patient but I would probably end up giving about 3-4 depending on what happens with the lactate, blood pressure and the rest of the clinical picture. There are things that they say help determine fluid responsiveness like straight leg test but I've never done it in real life. I do recognize that not all "hypotension" is shock and not all shock presents as hypotension.

Rivers trial:
http://www.nejm.org/doi/full/10.1056/NEJMoa010307#t=article

Very influential randomized trial, 263 patients in intention to treat in early goal directed therapy vs standard treatment. Basically they fluid bolused to cvp of 8-12, map > 65, pressors given, transfused to hgb of 10, scv > 70 with dobutamine support as necessary. Changed how we treat sepsis but the only things that really panned out were early recognition and intervention with fluid and abx. Having map goal > 65 also helps mortality.

Later trials: process, arise and promise were done in 2014-5 which showed that there was no difference in mortality between using a rigid protocol like that in the rivers trial vs "standard care".

Process:
http://www.nejm.org/doi/full/10.1056/NEJMoa1401602
Arise:
http://www.nejm.org/doi/full/10.1056/NEJMoa1404380
Promise:
http://www.nejm.org/doi/full/10.1056/NEJMoa1500896


Lot of controversy over this topic and even the definition of sepsis has changed from sirs + infection to " life-threatening organ dysfunction caused by a dysregulated host response to infection."

https://www.ncbi.nlm.nih.gov/pubmed/28130687
Here's a recent paper by Marik that shows some data on increasing mortality when patients are given more than 5 L on day 1 of sepsis treatment. He believes that the problem in sepsis is not hypovolemia but loss of vasomotor tone. By giving our patients fluid boluses we are drowning our patients as they third space these fluids and then mobilize it a few days later as they recover from sepsis.

 

[deleted763299]

Find out goals of care, if she has advanced directives, who will be making her decisions, all that stuff. If we're going full steam ahead...

Fluids: 30 mL/kg LR bolus initially, art line for hemodynamic monitoring, hopefully she's fluid responsive. If she likes the fluid, she can have even more!
Abx: Vanco 20 mg/kg load, Cefepime 2 g, Flagyl 500 mg (unless chart review shows that she's had organisms resistant to these in the past, or if local pseudomonas resistance to cefepime is high)
Pressors: Not yet, even though her MAP is 66, right on the border. If she doesn't respond to fluid resuscitation, I'd start Norepi with a MAP goal >65 (unless her HTN is poorly controlled outpatient, then perhaps a slightly higher goal).
Steroids: How much steroid is she getting outpatient? I'd probably continue her on an equivalent steroid to whatever she had been on outpatient initially, and reassess this after the initial sepsis management has been taken care of.

---Article on pressor choice: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523170/
---Article on MAP goals: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1312173

 

[SurfingDoctor]

The unfortunate truth is that this patient's history make the mortality near 100% (not to mention the ethical concerns of subjecting someone with terminal cancer to a hospitalization that will more certainly be there last... but that's a different discussion). Probably not the best case to discuss the controversies of sepsis the guidelines (most of which is based on "weak evidence" according to the guidelines and will be unlikely to ever get better due to the heterogeneity of the clinical entity) when the reality is that in a patient like this, their outcome has been set long before they reach the hospital.

 

[Crayola227]

septic shock feels pretty crappy -

remember that sometimes palliation can include fluids, abx, and steroids,
and being aggressive about things that make people feel better
maybe not about MAP re: mortality and organ function, but if raising it improves her AMS...
it's hard to know if someone's indifferent to their AMS or will be very grateful/upset when you resolve it, sometimes you have to resolve it to know

dying of sepsis, awake, form any source sucks....
anything that affects breathing.....

having experienced hypotension, tachycardia, SOB from hemorrhage,
I can tell you what they told us in med school, and programmed Sim Man to say loudly, to be true,
that shock like this usually causes a "sense of impending doom"
It's not just a phrase, it feels like an invisible sky monster is trying to sit on your chest.
(vagus is often not a pleasant nerve to activate)

some people love steroids, some hate them...
like the experience of mania... it can be euphoric, or dysphoric
if I'm being palliative, if she likes them she can have as much makes her feel like Superwoman here in a good way

anyway, I agree this lady is a goner, I just think that means you think about things differently,
even though the tx overlap for "save your life from sepsis" vs "make sick cancer lady feel better" can be substantial

Now, what I don't now that I've always wondered, is what it's like to be on pressors, never got to ask any awake patients.
They seem happier campers tach-ing along holding vs when their pressures tank, then they seem pretty anxious, but I don't know for sure.
If hypotension is more "doom"-provoking than a jolt of adrenal juice, that would make sense.

That's my "palliative sepsis managment" question, subjective effects of different pressor choices, and how does that compare to not maintaining her pressure from a patient subjective standpoint?

TLDR:
with any patient I think it doesn't hurt to stand back and wonder if you're going to make them feel better
sepsis and shock usually feel crappy
I don't know if cancer lady with PNA will feel better with PNA tx, like abx
hypotension and the vagus nerve make people feel DOOM with a capital D
pressures up with less tachy, usually feels better
although I'm not clear how pressors affect a patient's subjective
steroids, mania, euphoric, dysphoric, keep the 4 words together in your mind, they can be a useful tidy brain package

 

[OrthoTraumaMD]

Bone mets without fracture? I won't fix it. Sign off and rad-onc for palliative radiation.
Seriously, it reminds of me of House of God...

 

[WheezyBaby]

Bone mets without fracture? I won't fix it. Sign off and rad-onc for palliative radiation.
Seriously, it reminds of me of House of God...

But this family said they wanted *everything* done. I really think you should reconsider limb salvage for that femur met

 

[Psai]

So just like everything else, pressor use is murky

You have norepi, epi, vasopressin, dopamine but we don't know which one is the best

Most people use norepi to start and add stepwise (for example, max out one pressor then start another one). Data?

nejm 2008 - vasopressin vs norepi in patients with septic shock showed with no significant difference between vasopressin and norepi in 28 day or 90 day mortality. no significant difference in overall rates of serious adverse effects.
http://www.nejm.org/doi/pdf/10.1056/NEJMoa067373

nejm 2010 - comparison of dopamine and norepi in septic shock - 1679 patients, no significant difference in rate of death but dopamine causes more arrhythmic events. subgroup analysis shows dopamine with increase rate of death in cardiogenic shock but not hypovolemic or septic shock
http://www.nejm.org/doi/pdf/10.1056/NEJMoa0907118

Jama 2016 - vanish trial - 409 patients, no difference in vasopressin vs norepi in effect on kidney failure in septic patients