Jul 27, 2012
24
0
41
Status
Resident [Any Field]
I was curious as to why phenylephrine isn't used more as a pressor. Especially in a community ED when you're very busy, don't have the time to put in a central line just give some phenyl through a peripheral. It also doesn't affect HR which is good too. I mean why not?
 

RPedigo

Moderator Emeritus
10+ Year Member
Aug 5, 2006
1,270
91
271
Los Angeles, California
Status
Attending Physician
As a pressor for what? Wouldn't be beneficial in a lot of states where your endogenous alpha activity is already maxed out (e.g., hemorrhagic shock), and norepinephrine has proven superior to other pressors in septic and cardiogenic shock. Also, saying that it doesn't affect the heart rate is not entirely true. It has a pure alpha agonist effect, of course, but when that causes an increase in blood pressure by an increase in SVR that triggers your baroreceptors and causes vagal outflow and often causes reflex bradycardia.

There's been some talk (see the most recent EM:RAP episode) about push-dose pressors for post-intubation hypotension, but there's a lot of back-and-forth on whether or not that's beneficial.

As far as its use in warm shock (e.g., septic shock) it probably would be okay because norepinephrine (the vasopressor of choice) is obviously mostly alpha adrenergic. There's a couple studies (http://ccforum.com/content/12/6/R143) showing that it's not bad. That said, in septic and cardiogenic shock, why not use the most evidence-based vasopressor (norepinephrine)? If they're truly in septic shock (not just severe sepsis) and need vasopressors, they should have a line.

I think push-dose pressors probably have a role as a bridge, but I don't think there's evidence to show that it should be a stand-alone pressor for any kind of shock.
 

Tiger26

Senior Member
10+ Year Member
15+ Year Member
Mar 14, 2004
1,445
105
381
Visit site
Status
Attending Physician
The reason is because you increase afterload without affecting cardiac output, so the heart is pumping against greater pressure. The flip side is that you may increase coronary perfusion. I use it in targeted situations without evidence of cardiogenic shock while I'm awaiting a more robust pressor. I'll also use it for transient shock states like sedations where you're waiting for the sedation drug to clear the system.
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,849
1,277
381
Visit site
Status
Attending Physician
I was curious as to why phenylephrine isn't used more as a pressor. Especially in a community ED when you're very busy, don't have the time to put in a central line just give some phenyl through a peripheral. It also doesn't affect HR which is good too. I mean why not?
In addition to the things mentioned above, phenylephrine is on backorder at my hospital and my nurses have very little experience with it.
 

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
Watch the mass gen/Brigham critical care board review with overview of septic shock, focusing mainly on EGDT. You'll notice that before a vasopressor is started, the central line and ideally the art line, are placed during the 30ml/kg volume resuscitation phase. The EGDT target for adequate volume resuscitation is the CVP. Unless your quite savvy with US, which is time consuming, you need a line to measure CVP. Both the CVC and the art line are level 1a recommendations in septic shock, and in general, in all forms of shock. There is no roll for non-invasive hemodynamic monitoring in shock pts. If your pt hits the ED doors with a map in the 50s, they should be getting a CVC that can monitor CVP and potentially PA pressures and CO depending on what type of shock it ends up being, while you are volume resuscitating them. Once the 3L or so of crystalloid are in you now can start your ideal vasopressor, which 9 times out of 10 is norepinephrine, through its appropriate CVC. The art line can wait till they get upstairs to me but if we're talking best practice, I expect you guys to have given appropriate volume resuscitation and started the pressors if needed. Both of those require a subclav/IJ.
 

Rendar5

15+ Year Member
Nov 12, 2003
6,995
623
381
Florida
Status
Attending Physician
Yes, that's the re-cap of the sepsis 2012 guideline summary with the modified River's EGDT set-up. Not sure that it answers the OP's question.
 

Hamhock

10+ Year Member
7+ Year Member
May 6, 2009
1,174
397
281
Status
Attending Physician
There is no roll for non-invasive hemodynamic monitoring in shock pts.
:eek::eek::confused:

What? I'll let the CVP stuff go for now (as you are likely just regurgitating guidelines), but to make such a statement about non-invasive monitoring in shock is just craziness.

Serial measurements of cardiac output (via ECHO, a non-invasive hemodynamic monitoring technique) are countless times more useful than your CVP.

HH
 

EMIM2011

7+ Year Member
Feb 14, 2011
176
32
161
Status
Unless your quite savvy with US, which is time consuming, you need a line to measure CVP.
Takes probably 1 minute, which includes plugging the US machine in, cleaning the probe, and printing the images....

and potentially PA pressures and CO depending on what type of shock it ends up being, while you are volume resuscitating them.
No evidence that monitoring these parameters affects outcome...
 

TheBlueBlazer

10+ Year Member
7+ Year Member
Mar 17, 2008
214
91
171
Charm City
Status
Fellow [Any Field]
Unless your quite savvy with US, which is time consuming, you need a line to measure CVP.
I don't consider myself especially skilled with sono, but within like 2 months of starting residency I was facile enough to be able to assess volume status via IVC measurement in 20 seconds or less
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,849
1,277
381
Visit site
Status
Attending Physician
Don't use neo in spinal shock, could kill the patient. Always use dopamin or dobutamine.
Adding a drug to boost cardiac output when the issue is loss of SVR helps how? Levo would still be first choice.
 

iridesingltrack

10+ Year Member
5+ Year Member
Dec 28, 2007
139
0
0
Status
Fellow [Any Field]
Interesting question. The simple answer to why not always use Neo pushes is that it doesn't always address the underlying problem and it would require that I stand at the bedside and keep checking, pushing, checking, pushing etc. With that said, I do frequently use Neo pushes as a bridge until I can get something else established or if I think the hypotension will be short lived, as with post induction for intubation.

Ultimately, you want to tailor your treatment to the problem. If cardiogenic shock, give them something to improve cardiac performance. If loss of SVR, give them some vascular tone. If a little of both, give them both. If volume, well, don't use a pressor give them volume.

BTW, that is a curiously definitive post about neo killing "spinal shock" patients...do, tell us more. Also, I assume you are using the term spinal shock colloquially to describe patients with neurogenic shock after a spinal cord injury, is this accurate?

iride
 

glorfindel

Have you walked your dog?
10+ Year Member
Jun 16, 2004
315
2
241
Seattle, WA
Status
Attending Physician
Watch the mass gen/Brigham critical care board review with overview of septic shock, focusing mainly on EGDT. You'll notice that before a vasopressor is started, the central line and ideally the art line, are placed during the 30ml/kg volume resuscitation phase. The EGDT target for adequate volume resuscitation is the CVP. Unless your quite savvy with US, which is time consuming, you need a line to measure CVP. Both the CVC and the art line are level 1a recommendations in septic shock, and in general, in all forms of shock. There is no roll for non-invasive hemodynamic monitoring in shock pts. If your pt hits the ED doors with a map in the 50s, they should be getting a CVC that can monitor CVP and potentially PA pressures and CO depending on what type of shock it ends up being, while you are volume resuscitating them. Once the 3L or so of crystalloid are in you now can start your ideal vasopressor, which 9 times out of 10 is norepinephrine, through its appropriate CVC. The art line can wait till they get upstairs to me but if we're talking best practice, I expect you guys to have given appropriate volume resuscitation and started the pressors if needed. Both of those require a subclav/IJ.
An unfortunately poor post.

Several issues have been pointed out already.

I'll take issue with this: "If your pt hits the ED doors with a map in the 50s, they should be getting a CVC that can monitor CVP and potentially PA pressures and CO depending on what type of shock it ends up being...."

CVCs are not a benign intervention. The decision to place one depends on the entire clinical scenario and often on the response to peripherally-administered fluids. Putting in a CVC does not automatically follow from a MAP in the 50s.
 

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
Takes probably 1 minute, which includes plugging the US machine in, cleaning the probe, and printing the images....


No evidence that monitoring these parameters affects outcome...
Remember, most hospitals are not academic centers and do not have boarded EM docs trained in US. My Ed docs can't even use an US to place an IJ, let alone assess CVP.
 

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
:eek::eek::confused:

What? I'll let the CVP stuff go for now (as you are likely just regurgitating guidelines), but to make such a statement about non-invasive monitoring in shock is just craziness.

Serial measurements of cardiac output (via ECHO, a non-invasive hemodynamic monitoring technique) are countless times more useful than your CVP.

HH
I'm aware of data currently pointing towards CVP having major faults, but surv sepsis was just updated in 2012... And CVP monitoring with volume targets is still the recommendation.

Why do serial ECHO to measure CO when I can throw in a CCO swan through my cordis and have CO continually monitored without having me to re-echo them continuously? It takes time to properly echo a pt, even if in experienced hands that time. Is <5 min...it only took me 5 sec to read the number off the monitor. Busy ICU time management is important.

And there was a good paper, I believe in SCCM, not too long ago comparing invasive BP monitoring to cuff BP monitoring in MICU pts. Invasive was superior.

Nearly all pts in shock are goofing to be on multiple drips, pressors, insulin drips, ionoptropes, PRBC transfusions, vent sedation drips....most of them need a line purely for the amount of venous access they require. Add in the superiority for most invasive hemodynamic monitoring compared with non invasive, and very few pts pass through the MICU without central venous access. Let alone a shock pt as the OP was referring too.
 
Last edited:

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
An unfortunately poor post.

Several issues have been pointed out already.

I'll take issue with this: "If your pt hits the ED doors with a map in the 50s, they should be getting a CVC that can monitor CVP and potentially PA pressures and CO depending on what type of shock it ends up being...."

CVCs are not a benign intervention. The decision to place one depends on the entire clinical scenario and often on the response to peripherally-administered fluids. Putting in a CVC does not automatically follow from a MAP in the 50s.
Sepsis can be identified by most ED docs within a few minutes of seeing the patient and a set of vitals. " Mom hasnt felt well for a day or so coughing" temp is 102 HR is 110 shes tachypnic. Suspected source PNA + 3 SIRS. Bam sepsis. With point of care lactate and Chem7s severe sepsis can be diagnosed before you even have the first liter in. And the world consensus guidelines are to place a CVC during the volume resuscitation phase. I'm no expert, I just try and practice EBM and the NNT for EGDT in sepsis is 6....doesn't get much better than that accept maybe primary PCI in STEMI.

And I wasn't trying to stir the pot so sorry if I offended anyone, I just think the OPs notion of sending a pt up in shock with some neo running through a 20 in the hand would be considered poor form by most of the critical care community, though it happens quite frequently, though in In my observation it's with the far more caustic levophed running through that 20.

I guess I took offense to the "we're busy and don't have time to put in a CVC so instead of practicing standard of care well just throw in the weaker pressor through a peripheral and let you put In the line and switch to the more appropriate pressor". It's just passing the buck to me. And dont get me wrong im a procedure junky, but We're all busy.
 
Last edited:

EMIM2011

7+ Year Member
Feb 14, 2011
176
32
161
Status
I understand that sentiment, and it is probably common practice in the world of small community and rural EDs....but I do not think that it's acceptable.....but let's be honest, if you see 3 ankle sprains and 3 chest pains in the time it takes to line up a patient........you can't make that money with the lines. Period. Sad, but true. I feel like this is a much more common motivation than the "my responsibility for the potentially sick guy in the waiting room" mantra.

But there is one solution to still adequately resuscitate a patient without the central line, if not enough time in the ED:
1. non-invasive assessment of fluid status - ultrasound
AND
2. put in a humeral IO - great for pressors, large volume resuscitation etc.
3. ICU puts in CVC upstairs

That is still a much better approach than the "pressors thru the 20 in the hand", or the patient who arrives in the unit with a BP in the 60s.
 

deuist

Stealthfully Sarcastic
Lifetime Donor
10+ Year Member
15+ Year Member
Jun 14, 2004
4,468
357
381
37
Florida
www.ryanaycock.com
Status
Attending Physician
Watch the mass gen/Brigham critical care board review with overview of septic shock, focusing mainly on EGDT. You'll notice that before a vasopressor is started, the central line and ideally the art line, are placed during the 30ml/kg volume resuscitation phase. The EGDT target for adequate volume resuscitation is the CVP. Unless your quite savvy with US, which is time consuming, you need a line to measure CVP. Both the CVC and the art line are level 1a recommendations in septic shock, and in general, in all forms of shock. There is no roll for non-invasive hemodynamic monitoring in shock pts. If your pt hits the ED doors with a map in the 50s, they should be getting a CVC that can monitor CVP and potentially PA pressures and CO depending on what type of shock it ends up being, while you are volume resuscitating them. Once the 3L or so of crystalloid are in you now can start your ideal vasopressor, which 9 times out of 10 is norepinephrine, through its appropriate CVC. The art line can wait till they get upstairs to me but if we're talking best practice, I expect you guys to have given appropriate volume resuscitation and started the pressors if needed. Both of those require a subclav/IJ.
Man oh man you are really off on this one. First, do some reading on the "evidence" of CVP. I wasn't aware of any such 1A recommendations for arterial lines and central lines in all forms of shock. Perhaps you can point me to the research. And while we're at it, can you also enlighten me on the need for PA pressures?
 

deuist

Stealthfully Sarcastic
Lifetime Donor
10+ Year Member
15+ Year Member
Jun 14, 2004
4,468
357
381
37
Florida
www.ryanaycock.com
Status
Attending Physician
I'm aware of data currently pointing towards CVP having major faults, but surv sepsis was just updated in 2012... And CVP monitoring with volume targets is still the recommendation.
Yeah, and it's got disclosures that cover 3 pages; so what does that tell you? It's most recent recs even stated that Xigris should be utilized. Just because some group claims to print the Surviving Sepsis Guidelines doesn't mean it's whole truth and nothing but the truth.
 

TheBlueBlazer

10+ Year Member
7+ Year Member
Mar 17, 2008
214
91
171
Charm City
Status
Fellow [Any Field]
I'm no expert, I just try and practice EBM and the NNT for EGDT in sepsis is 6....doesn't get much better than that accept maybe primary PCI in STEMI.
The patients in the Rivers article are hardly your typical ED pt that counts as "septic" by fitting the relatively easy-to-qualify SIRS criteria. They were sick as snot, and while I think there's a definite role for CVC in really sick patients, the risk-benefit ratio just does not pan out in every patient.

I also don't think neo through a peripheral is the way to go usually, just that central lines in every pt is not the standard of care - which anyway is defined what people locally do rather than what some group publishes.
 

Rendar5

15+ Year Member
Nov 12, 2003
6,995
623
381
Florida
Status
Attending Physician
Septic Shock with a lactate > 4 unresponsive to fluid therapy = place a line now

Severe Sepsis with a lactate in the 2's? or a 1-time episode of hypotension resolved with a 30cc/kg bolus? CVC may or may not be required in the ED, and many times can be delayed to a less-rushed line in the ICU if one is even needed.

If someone comes in with a MAP in teh 50's, I will often put in a line, but sometimes do have 10 other people to simultaneously treat, so I may delay the decision on a line until i see what a fluid bolus does. That said, MAP in the 50's may be due to a variety of reasons.
 

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
Yeah, and it's got disclosures that cover 3 pages; so what does that tell you? It's most recent recs even stated that Xigris should be utilized. Just because some group claims to print the Surviving Sepsis Guidelines doesn't mean it's whole truth and nothing but the truth.
It should personally. The FDAs review of it was pisspoor and all the bad publicity made everoyne so afraid of it that Lilly discontinued the product line. But if you read through all the trials from PROWESS onwards, the REAL sickies, APACHE II's >25, had statistically significant mortality benefit outweighing bleeding risk. Its all the people who were <25 that got it that had poor outcomes. Its role was clearly shown in the trials to be for severe Septic shock. Too many people that didnt need the drug got it and it killed the outcomes, resulting in the population that does benefit from the drug no longer being able to get it.
 

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
Septic Shock with a lactate > 4 unresponsive to fluid therapy = place a line now

Severe Sepsis with a lactate in the 2's? or a 1-time episode of hypotension resolved with a 30cc/kg bolus? CVC may or may not be required in the ED, and many times can be delayed to a less-rushed line in the ICU if one is even needed.

If someone comes in with a MAP in teh 50's, I will often put in a line, but sometimes do have 10 other people to simultaneously treat, so I may delay the decision on a line until i see what a fluid bolus does. That said, MAP in the 50's may be due to a variety of reasons.
I suppose I can live with this reasoning. I just have yet to see any patient, including those with pH <7, Lactate >10, Levo on max dose,none of them, have ever come up with a line in. The few exceptions have been ones that came in as arrests and they had femorals. sometimes. My ED just routinely downplays sepsis with the 'They just have a touch of PNA and the pressures are a little low so I gave fluid vanc/zosyn and 1L of saline and all looks well". It never looks well.
 

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
Man oh man you are really off on this one. First, do some reading on the "evidence" of CVP. I wasn't aware of any such 1A recommendations for arterial lines and central lines in all forms of shock. Perhaps you can point me to the research. And while we're at it, can you also enlighten me on the need for PA pressures?
http://www.sccm.org/Documents/SSC-Guidelines.pdf

Page 5. and sorry its a 1c not 1a I was incorrect there. Repeated measuresments of CVP and SvO2/ScvO2/MAP are recommended throught out the resussitation period (first 6). I suppose you could rely on your cuff for map, again there is recent literature in SCCM i wil dig up for you showing it as inferior in the ICE setting to invasie BP monitoring, and you cpuld ECHO/US for CVP every 30 minutes while you are bolusing to goal, and you can draw venous gases continuously while titrating ionotropes/giving blood.....or you can thow in an art line and a cvc in <8 minutes and have all those continuosuly... I guess whatever floats your boat. If you have time to go in an reimage for CVP every 30 minutes for 3 hours while you are giving them volume, I would imagine a line would have been faster, atleast for me it definitely would.

And I should clarify. Not in all forms of shock. Anyone getting a vasopressor for any type of shock should have the pressor titrated off an art line, they are actually relatively benign with normal coags and a proper allen test, again, this is based off data showing superiority in an ICU setting to invasive BP monitoring. And no pressor shouls run through a peripheral. So, if you extrapolate, any patient in shock, that is to sayy hypotension refractory to appropriate volume resussitation, thus now requireing a pressor, should have a CVC and an art. And i said the art can slide til they get upstairs.

For the hemorragic shocks I actually prefer to see a 9 or 12 french short cordis in the chest/neck to a TLC, Pouseilles law obv. But thats still a CVC.

And PA pressures are quite useful in cardiogenic shock from AMI/massive PE. And I didnt say place a PA catheter, just said have a line in so that one could be placed if needed.
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,849
1,277
381
Visit site
Status
Attending Physician
http://www.sccm.org/Documents/SSC-Guidelines.pdf

Page 5. and sorry its a 1c not 1a I was incorrect there. Repeated measuresments of CVP and SvO2/ScvO2/MAP are recommended throught out the resussitation period (first 6). I suppose you could rely on your cuff for map, again there is recent literature in SCCM i wil dig up for you showing it as inferior in the ICE setting to invasie BP monitoring, and you cpuld ECHO/US for CVP every 30 minutes while you are bolusing to goal, and you can draw venous gases continuously while titrating ionotropes/giving blood.....or you can thow in an art line and a cvc in <8 minutes and have all those continuosuly... I guess whatever floats your boat. If you have time to go in an reimage for CVP every 30 minutes for 3 hours while you are giving them volume, I would imagine a line would have been faster, atleast for me it definitely would.

And I should clarify. Not in all forms of shock. Anyone getting a vasopressor for any type of shock should have the pressor titrated off an art line, they are actually relatively benign with normal coags and a proper allen test, again, this is based off data showing superiority in an ICU setting to invasive BP monitoring. And no pressor shouls run through a peripheral. So, if you extrapolate, any patient in shock, that is to sayy hypotension refractory to appropriate volume resussitation, thus now requireing a pressor, should have a CVC and an art. And i said the art can slide til they get upstairs.

For the hemorragic shocks I actually prefer to see a 9 or 12 french short cordis in the chest/neck to a TLC, Pouseilles law obv. But thats still a CVC.

And PA pressures are quite useful in cardiogenic shock from AMI/massive PE. And I didnt say place a PA catheter, just said have a line in so that one could be placed if needed.
You're using the definition for septic shock and inappropriately applying it to all forms of shock. The ACS criteria for hemorrhagic shock doesn't even require frank vital sign abnormalities for its least severe stage. And you seem to have a good understanding of your environment, but not so much for ours. I don't have POC lactate and it is typically 2+ hrs from time of arrival before I have it back. I think the Rivers' paper was useful in highlighting sepsis as a fixable disease. We've completely misapplied the central lessons learned though. Early detection and heavily resource intensive intervention help in sepsis and there are places that excel at providing that level of care. They're called ICUs. I can't provide the level of care that was given in the control arm of the study, let alone the intervention. What should of happened is that the ICU community should have taken the paper as a call to emergently rush the patient to the unit. Instead people are trying to replicate ICU care in the ED despite not having sufficient resources. The sepsis unit in the ED at Henry Ford had more physicians for 9 beds than my shop has for our 26 beds. It has a better nursing ratio then we have and the majority of our nurses can't reliably titrate pressors or insure that a liter of fluid is given through a 16g in anything under an hour. We need to change to more of a Code STEMI model where on recognition additional resources are mobilized (at least outside of resident rich academia). Also, I'm not sure you are in touch with community ICU care, since many of the patients in our MICU don't have a central line and many of them have Picc lines ordered so the intensivist doesn't have to place a CVL
 

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
I agree with you arcan. And I WANT that pt to come to me as soon as possible. I agree we should get that pt super fast as it is easier for me to provide care upstairs in terms of the level of intervention needed in edgt than you can downstairs...but that seems to not happen. Atleast at my community shop what happens is patient waits in waiting room 2+ hours, then the ed doc gives fluids and antibiotics. And by fluids I mean 500ml NS total....and 5 hours later they call and pt is in shock way behind in treatment with the 6 hour window almost up. If the ed doesn't have the resources then get the pt upstairs fast like the stemi's, great analogy. That just is not what I see happen.

And I am at a community hospital with a 35-40k visit ed and a 20 bed micu. Nearly every unit pt here has a line if it is warranted, which is most, because we put them in. I suppose that's different at a community shop that has no residents.
 

jdh71

epiphany at nine thousand six hundred feet
10+ Year Member
Dec 14, 2006
67,631
46,149
281
FEMA Camp, USA
Status
Attending Physician
Gotta love medicine and EMB - apply when and only when it supports a bias, usually an anecdotal bias . . . heh

It's the biggest complaint I have with the greater "critical care" community - ie. people that take care of very sick patients at some point, between the EPs, surgeons, gas guys, cardiologists, and medicine critical care guys (including pulm) - is this "gotcha" attitude and motherf***ing the guy trying to give some opinion on management, which always descends into this douchebag fest where everyone does their best to hit the other person over the head with some evidence that they like, but NONE of it is great . . . because it's pretty farking difficult to do anything randomized, double blinded, on the group of heterogeneous patients that need critical care. You go to meetings and just watch as these guys tear into each other, it's sick. And not helpful. There are more than one way to skin a cat here and I think it's time we stop trying to prove our own personal management as the best way, when it's actually really only one of many ways. There are certain things in critical care that NONE of us do and agree on because it's stupid, but finding a way, given whatever your resources are to do your best to help with coming up with a clinical rationale regarding fluid responsiveness for instance, isn't one of those topics that I've found to be satisfactorily settled in the literature. Hell, I don't think I've seen anyone mention pulse pressure variations yet . . . None of this really helps OP.

Why is phenyl not used more? Probably because most of us find it to be kind of weak as a pressor, though as far as I know, the last time it was randomized as initial pressor versus norepi, it didn't make much of a difference. It could probably be used rather effectively in patient who just need a whiff of pressor for some distributive shock, but normally the decision to add a pressor usually means the beginning of the woes for the patient and it quickly gets titrated to "max" (in quotes for a reason), so my bias is that any patient who needs a pressor for distributive shock should get something that I've found to work more predictably, such as norepinephine, and I shouldn't mess around with the neo.

Neo also causes horrible extravasation side effects and skin necrosis. I'm not about to tell emergency physicians (or anesthesiologists for that matter) that they should ot should not give boluses through a peripheral if they think that is needed. I don't practice that way, so I won't comment, BUT, I will say that my bias is if you're planning an continuous infusion, that patient NEEDS a central line, so please don't send those patients to the MICU without central access on neo running through a peripheral IV. (And I know you guys can place a line quick, you brag about it, until you're asked to do it, when suddenly there is not time? heh)
 

glorfindel

Have you walked your dog?
10+ Year Member
Jun 16, 2004
315
2
241
Seattle, WA
Status
Attending Physician
... I just think the OPs notion of sending a pt up in shock with some neo running through a 20 in the hand would be considered poor form by most of the critical care community...
I think we can all agree on that, at least.

(And I know you guys can place a line quick, you brag about it, until you're asked to do it, when suddenly there is not time? heh)
Funny how often people claim to excel at something, while not actually being that good at it. It's been a universal human flaw since at least the mid-1970s. :naughty:
 

RPedigo

Moderator Emeritus
10+ Year Member
Aug 5, 2006
1,270
91
271
Los Angeles, California
Status
Attending Physician
...If your pt hits the ED doors with a map in the 50s, they should be getting a CVC that can monitor CVP and potentially PA pressures and CO depending on what type of shock it ends up being, while you are volume resuscitating them...
Repeated measuresments [sic] of CVP and SvO2/ScvO2/MAP are recommended throught [sic] out the resussitation [sic] period (first 6).
With regard to sepsis... Their recommendation is: "We recommend the protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration &#8805; 4 mmol/L)" (Class 1c). So therefore if "someone hits the ED doors with a MAP in the 50s" that absolutely does not necessitate a central line (unless their lactate is >4, then it may be beneficial, but again "as they hit the ED doors" we do not have that information). If their end-organ dysfunction and hypotension resolve with fluid administration alone, that patient didn't need a line, because they fell squarely into the "severe sepsis" category, and not the septic shock category. I think this is what people are taking issue with, because you are going back and forth with who you think needs a line, but not all the ones you are talking about need a line. They need good peripheral IV access, prompt antibiotics, and fluids.

Nobody is going to argue that you do not need a central line if you are giving continuous vasopressors. However, as an aside, I would take my bedside ultrasound over a CVP number any day of the week.

Bostonredsox said:
So, if you extrapolate, any patient in shock, that is to sayy [sic] hypotension refractory to appropriate volume resussitation [sic], thus now requireing [sic] a pressor, should have a CVC and an art.
See, I think everyone agrees here, but that's not what you said in your previous posts.
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,849
1,277
381
Visit site
Status
Attending Physician
Regarding quick central lines, they don't exist in the ED. While from U/S transducer on skin to secured and dressed central line takes about maybe 3-4 minutes the f'ing around with securing all the parts of the full sterile barrier kit, manually typing the patient's info into the U/S machine, and locating flush take a minimum of 15 minutes and not being personally involved guarantees at least one mission critical failure in the preparation (current popular failure point is obtaining a mask)
 

UnderwaterDoc

Status Hispanicus
5+ Year Member
Jul 23, 2010
269
33
111
Lurking 100 ft underwater
Status
Attending Physician
http://www.sccm.org/Documents/SSC-Guidelines.pdf....or you can thow in an art line and a cvc in <8 minutes and have all those continuosuly... I guess whatever floats your boat. If you have time to go in an reimage for CVP every 30 minutes for 3 hours while you are giving them volume, I would imagine a line would have been faster, atleast for me it definitely would.
You've seen this yes?



From here http://journal.publications.chestnet.org/article.aspx?articleid=1085950

Conclusion of article - This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/&#916;CVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.
 

jdh71

epiphany at nine thousand six hundred feet
10+ Year Member
Dec 14, 2006
67,631
46,149
281
FEMA Camp, USA
Status
Attending Physician
Regarding quick central lines, they don't exist in the ED. While from U/S transducer on skin to secured and dressed central line takes about maybe 3-4 minutes the f'ing around with securing all the parts of the full sterile barrier kit, manually typing the patient's info into the U/S machine, and locating flush take a minimum of 15 minutes and not being personally involved guarantees at least one mission critical failure in the preparation (current popular failure point is obtaining a mask)
15 minutes still sounds pretty quick to me ;)

(but that's just because I don't want to take my own 15 minutes)

You know, and I suppose it all depends on how adversarial the relationship is with the ED and MICU (hope not very), I've often found having a quick conversation about the line to be pretty helpful to patient care because sometimes it's just better to have the ED put it in and sometimes, it's not a big deal to just have the patient sent up and the MICU guy does it. At the end of the day, some doctor needs to not be too busy to put in the line in a patient that needs it, right? :)
 

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
You've seen this yes?



From here http://journal.publications.chestnet.org/article.aspx?articleid=1085950

Conclusion of article - This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/&#916;CVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.
I am quite familiar with that article...from 2008. I am also very familiar with the Surv Sepsis guidelines updated in 2012. I am also familiar with the original and all of the subsequent followup articles from Rivers et al. I am also familiar with the 50+ repeated trials reproducing the mortality benefit from the original EDGT. You'll notice, in every single one of them, volume titration based on CVP is what is utilized and thus what is recommended. I would advise you look at the whole body of work, not one or two papers showing a single component of the system, CVP, may not work. There are few therapies in the Critical care world that have double blinded studies to support them, and have been shown to have the mortality benefit of EDGT. And EDGT uses CVP goals for volume titration. Even after these few articles have come out doubting CVP, the updated consensus is still to use CVP. The worlds guidelines for septic shock volume resusitation are sitll to use CVP monitoring for volume target. I really dont see how there is an argument here. Perhaps in cardiogenic, neurogenic and hemorrhagic shock, you can make arguements. I wont disagree with you there. But the data for septic shock is amongst the most studied in the critical care world and its current guidelines are to utilize CVP. Perhaps down the road that will change, but until it does, if you are not adhering to the guidelines and following the EDGT protocol, you are deviating from the standard of care.
 

Dr.McNinja

Nobel War Prize Winner
Moderator
10+ Year Member
Aug 2, 2006
9,915
6,350
381
Texas
Status
Attending Physician
erhaps down the road that will change, but until it does, if you are not adhering to the guidelines and following the EDGT protocol, you are deviating from the standard of care.
And we're done here.
Thank you for telling emergency physicians the ICU standard of care based on guidelines. I'm sure you follow each and every guideline to the letter, not deviating from it because you're a mindless robot and not a trained physician.
In the future, all medicine questions will be directed towards you.
 

xaelia

neenlet
15+ Year Member
Aug 17, 2002
2,126
281
381
PDX
emlitofnote.com
Status
Attending Physician
Bostonredsox said:
if you are not adhering to the guidelines and following the EDGT protocol, you are deviating from the standard of care.
There is plenty of room outside those guidelines to provide quality sepsis care. They are so fraught with biases and financial conflicts of interest that adhering to them as gospel is likely to be harmful to patients. I agree with your problems with the review of Xigris – but I'd also caution reading too much into subgroup effects as anything more than hypothesis generating.

There's no evidence that non-invasive BP measurement is systematically inferior. There's nothing therapeutic about an arterial line; I don't think they have any routine role in the ED.

There's no evidence that non-invasive evaluation of volume status is systematically inferior. I place central lines mainly for vasoactive drugs – but, I also measure CVO2s, lactates, CVPs and place them in context with bedside ultrasonography.

I don't have any specific critique of phenylephrine – other than the hemodynamic profile of norepinephrine or epinephrine seems to be more favorable regarding cardiac output – but I wouldn't run it through a peripheral more than transiently. And, then, once you have central access, use something with a little more validation.


neusu said:
Don't use neo in spinal shock, could kill the patient. Always use dopamin or dobutamine.
Uh, what?
 

e30ftw

peace
7+ Year Member
Feb 23, 2012
484
381
181
Status
Attending Physician
now that the topic has switched to sepsis..

let's be realistic... we have 2 hours to dispo a patient or else it looks bad.

so at my shop an obvious septic shock patient usually gets intubated, CVL, aline, +3 liters of NS +/- levophed if needed, vanc/zosyn/levaquin (or zithromax) along with bedside IVC/echo/ U/S and a big ole lab/imaging/ekg work up.

this all gets done generally within 1-2.5 hours of arrival. by this point pt ready to go upstairs to the unit. What more realistically should an ER doc be responsible for doing for these patients while simultaneously managing the department? frankly I don't really give a **** about scvo2 while they're in the ED because we start off with lung protective ventilation at 100% fio2 anyway and wean down as tol but the weaning will be done in the unit anyway. if they're hypotensive it really doesn't matter what the lactate comes back as because septic + hypotension = AGGRESSIVE FLUID RESUS and i'm going balls to the wall with fluids/cultures/abx/pressors all while trying to get medical records to see what their last EF was, what PMH they have, trying to expand the differential, etc, while managing 6-10 other patients who need orders/dispo, etc. sure if they have obvious CHF + sepsis it needs a little more finesse but overall I think if an ER doc tubes/lines and resuscitates the patient as above there realistically isn't anything more we can do in <3 hours.
 

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
And we're done here.
Thank you for telling emergency physicians the ICU standard of care based on guidelines. I'm sure you follow each and every guideline to the letter, not deviating from it because you're a mindless robot and not a trained physician.
In the future, all medicine questions will be directed towards you.
alright stop your over reacting. I wasnt trying to be confrontational and I do not practice critical care like a mindless robot. But CVP monitoring is one of the 4 core goal measurements in EDGT and thus deviation from routinely using them because of a few papers questioning the true validity of CVP sounds asinine to me. Were not talking +/- stess dose steroid administration or whether not etomidate should be avoided in the RSI of the septics, were talking about one of Rivers main fundamental resussitaion goals. CVP/MAP/urine output/ScvO2. I personally think the body of evidence is on the whole very supportive of these targets.
 
Last edited:

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
now that the topic has switched to sepsis..

let's be realistic... we have 2 hours to dispo a patient or else it looks bad.

so at my shop an obvious septic shock patient usually gets intubated, CVL, aline, +3 liters of NS +/- levophed if needed, vanc/zosyn/levaquin (or zithromax) along with bedside IVC/echo/ U/S and a big ole lab/imaging/ekg work up.

this all gets done generally within 1-2.5 hours of arrival. by this point pt ready to go upstairs to the unit. What more realistically should an ER doc be responsible for doing for these patients while simultaneously managing the department? frankly I don't really give a **** about scvo2 while they're in the ED because we start off with lung protective ventilation at 100% fio2 anyway and wean down as tol but the weaning will be done in the unit anyway. if they're hypotensive it really doesn't matter what the lactate comes back as because septic + hypotension = AGGRESSIVE FLUID RESUS and i'm going balls to the wall with fluids/cultures/abx/pressors all while trying to get medical records to see what their last EF was, what PMH they have, trying to expand the differential, etc, while managing 6-10 other patients who need orders/dispo, etc. sure if they have obvious CHF + sepsis it needs a little more finesse but overall I think if an ER doc tubes/lines and resuscitates the patient as above there realistically isn't anything more we can do in <3 hours.
Thats FANTASTIC. "applauding you" But if youll read my earlier posts, I am not even looking for all of that. That is very labor intensive and as Arcan57 said, he like most ED docs, does not have the resources/time to provide all of this care. All I asked for was a line, 30ml/kg of fluid, an appropriate pressor through the line, appropriate broad spectrum antibiotics with cultures done and a call for admission in around 2-2.5 hour instead of 5+. I get none of those things at my shop. I get a 20gau with dopamine in it, 1L of total NS, vanc/zosyn (quick check of records and their last admission had ESBL in urine) and all of this after being in ED for 5-7 hours.
 
Last edited:

Bostonredsox

7+ Year Member
Mar 15, 2011
1,235
115
181
southern comfort
Status
Attending Physician
There is plenty of room outside those guidelines to provide quality sepsis care. They are so fraught with biases and financial conflicts of interest that adhering to them as gospel is likely to be harmful to patients. I agree with your problems with the review of Xigris &#8211; but I'd also caution reading too much into subgroup effects as anything more than hypothesis generating.

There's no evidence that non-invasive BP measurement is systematically inferior. There's nothing therapeutic about an arterial line; I don't think they have any routine role in the ED.

There's no evidence that non-invasive evaluation of volume status is systematically inferior. I place central lines mainly for vasoactive drugs &#8211; but, I also measure CVO2s, lactates, CVPs and place them in context with bedside ultrasonography.

I don't have any specific critique of phenylephrine &#8211; other than the hemodynamic profile of norepinephrine or epinephrine seems to be more favorable regarding cardiac output &#8211; but I wouldn't run it through a peripheral more than transiently. And, then, once you have central access, use something with a little more validation.




Uh, what?
http://www.medscape.com/viewarticle/777389

No it is not the most compelling of articles but if you read through their results and interventions there is atleast a trend to the non-invasive armed patients having overestimation of SBP and had higher AKI and ICU mortality compared with invasive monitoring in the same SBP range. The numbers were much closer though not equal if you used MAP compared with SBP, which I feel most all of us probably do. But I have encountered several docs who still right there pressor titration orders based on the cuff SBP, which it seems is inferior to an invasive SBP reading.

And I agree with you, they do not need to be placed in Ed, which I said in an earlier post. I am perfectly fine placing the art upstairs.
 

e30ftw

peace
7+ Year Member
Feb 23, 2012
484
381
181
Status
Attending Physician
I should definitely clarify that my above scenario is at an academic hospital with resident coverage and therefore we have a lot more time to work on lines/tubes than I will as a community attending. And sometimes of course we get the 6 hour ICU holds (which are more common in the community as well) but usually they get upstairs pretty quick.
 

UnderwaterDoc

Status Hispanicus
5+ Year Member
Jul 23, 2010
269
33
111
Lurking 100 ft underwater
Status
Attending Physician
Perhaps down the road that will change, but until it does, if you are not adhering to the guidelines and following the EDGT protocol, you are deviating from the standard of care.
I do adhere to the EGDT protocol, except I don't use CVP because it is an asinine (to borrow your own word) number that you should not be using to make decisions. You could flip a coin instead to decide if you should give the patient more fluid and that would have the same predictive value of CVP, but to each his own I guess.

There was a thread here a while ago that I'm too dumb to find talking about all the guidelines that we do not follow, because they have no impact on patient outcomes. "Standard of care" is a random goal that is rarely backed by sound evidence.

Finally, from personal experience, I have worked in four different MICUs now, none of which used CVP monitoring. I was actually rotating in our MICU when the 2012 guidelines were published and the attendings there expressed dismay that CVP made it back in, since they were hoping to be rid of this recommendation. See Weingart's discussion about the 2012 guidelines and his rant about CVP if you want more info about not using it.
 

Instatewaiter

But... there's a troponin
10+ Year Member
Apr 28, 2006
6,050
2,085
281
Washington
Status
Attending Physician
Don't use neo in spinal shock, could kill the patient. Always use dopamin or dobutamine.
Do you mean neurogenic shock? If so how's an inodilator work for a vasodilatory problem?

If your pt hits the ED doors with a map in the 50s, they should be getting a CVC that can monitor CVP and potentially PA pressures and CO depending on what type of shock it ends up being, while you are volume resuscitating them. Once the 3L or so of crystalloid are in you now can start your ideal vasopressor, which 9 times out of 10 is norepinephrine, through its appropriate CVC. The art line can wait till they get upstairs to me but if we're talking best practice, I expect you guys to have given appropriate volume resuscitation and started the pressors if needed. Both of those require a subclav/IJ.
I am going to disagree with you here. Where I am I'd say 5-10% of our patients in the ED come in with a map in the 50s. There is no reason to stick an A-line or central line in these people if they respond to your initial intervention, for instance a bolus for sepsis/distributive.

Guidelines are good as guidelines but not great for a heterogeneous population.

Swans come with a host of problems and with the exception of severe cardiogenic shock (where I think it gives you a ton of information) and mixed shock they are not all that useful.


Why do serial ECHO to measure CO when I can throw in a CCO swan through my cordis and have CO continually monitored
Because it doesn't damage the pulmonary arteries.
 

Hernandez

Paranoid and Crotchety...
10+ Year Member
15+ Year Member
May 14, 2004
21,148
6,741
381
knee deep in dog muck and crusty jugglers......
Status
Attending Physician
Takes probably 1 minute, which includes plugging the US machine in, cleaning the probe, and printing the images......
These days, I have to have a reason NOT to place a blind subclavian before placing a u/s guided IJ, I can knock out a subclavian in a few minutes.
 

Dr.McNinja

Nobel War Prize Winner
Moderator
10+ Year Member
Aug 2, 2006
9,915
6,350
381
Texas
Status
Attending Physician
Well the good news is the Process study is close to completion, so we should have numbers from a large randomized trial against EGDT arm soon.
And we all know how that trial is going to end. The Edwards won't be that much better (or at all), but will have multiple subgroup analysis to allow them to put "go ahead and use it" in the discussion instead of just doing lactate clearance.
And then it will become ingrained, like the Swan. Show me the mortality benefit of that device.
 

iridesingltrack

10+ Year Member
5+ Year Member
Dec 28, 2007
139
0
0
Status
Fellow [Any Field]
You know, and I suppose it all depends on how adversarial the relationship is with the ED and MICU (hope not very), I've often found having a quick conversation about the line to be pretty helpful to patient care because sometimes it's just better to have the ED put it in and sometimes, it's not a big deal to just have the patient sent up and the MICU guy does it. At the end of the day, some doctor needs to not be too busy to put in the line in a patient that needs it, right? :)
This. :thumbup:

A quick discussion about the line can be had with the ICU service. If the ED has time, and the ICU is actively managing a resuscitation then the ED should put in the line; else, if the ED is blowing up with two traumas, a STEMI, and this quite septic shock person, then ICU, well, it's time to step-up and help the patient. In the midst of reality, I suspect this is what we all do anyway (at least at my shop).

To my ICU colleagues: I invite you to have understanding with the ED when a patient arrives to you in a way that you may consider half-assed or requiring work-up, resuscitation, or procedures: working in both environments frequently, I have to say that more often than not I am better suited to perform a time-consuming (defined by me arbitrarily as greater than 5 min), non-emergent task in the ICU than when I am in the ED. Not always, but often. *Most* days, even the sickest ICUs are full of stably ill people that need tweaks and controlled resuscitation. In the ED, sick patients are often at their greatest distance from homeostasis for their hospitalization...most of the time.

To my EM colleagues: don't screw the ICU without telling them. If you are sending them a patient with Levo at 10 running through a peripheral, tell them what is going on. Failing to do so hurts your credibility and that of your colleagues.

Now, McNinja, feel free to return to your war against industry sponsored research...:p

Cheers,
iride
 

deuist

Stealthfully Sarcastic
Lifetime Donor
10+ Year Member
15+ Year Member
Jun 14, 2004
4,468
357
381
37
Florida
www.ryanaycock.com
Status
Attending Physician
alright stop your over reacting. I wasnt trying to be confrontational and I do not practice critical care like a mindless robot. But CVP monitoring is one of the 4 core goal measurements in EDGT and thus deviation from routinely using them because of a few papers questioning the true validity of CVP sounds asinine to me. Were not talking +/- stess dose steroid administration or whether not etomidate should be avoided in the RSI of the septics, were talking about one of Rivers main fundamental resussitaion goals. CVP/MAP/urine output/ScvO2. I personally think the body of evidence is on the whole very supportive of these targets.
All Rivers demonstrated is that if you quickly work on a patient and gives lots of fluids and abx (versus the control arm which is to place the patient in a corner and ignore him), then the patient will fare better. You're taking everything from the package and saying that we need to apply each and every item in order to be successful. And no, CVP has never been demonstrated by itself to correlate with volume status or mortality benefit.
 

RustedFox

Go to the ER now, or you'll have a stroke.
Lifetime Donor
10+ Year Member
Aug 21, 2007
3,979
3,475
281
On a box.
Status
Attending Physician
All this talk reminds me of a thread I had going last year entitled "Pressors." If anyone wants to give that a bump, it's worth the read for sure.