why not use phenylephrine all the time

[Zanegray]

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.

We may all be busy but many of us are a single coverage doc in a community ED without the resources to do a bunch of invasive monitoring in the ED. Not to mention nursing availability and expertise. It sounds like you may be in the ICU (?). In addition to the doc's time, you need nursing care which is usually 2:1 in the ICU compared to 4:1 (on a good day) in the ED. Many of the nurses in the ED where I work would know how to measure CVP or set up an art line. And, "we're all busy" but you generally get fewer patients at a time and if you're full, you're full. That doesn't happen to us. So give the OP a break. It didn't sound like he was trying to pass the buck - it sounded like an honest question.

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[deleted109597]

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

Cheers,
iride

Apparently it isn't clear. I don't have a problem with industry sponsored research. There isn't enough government money to go around, and I'm not willing to pay more taxes just so there is. And some industry research is pretty good.
That being said, if industry sponsored research is flawed, then you have to take one of two viewpoints. Either the company is skewing the data to make more money, or the researchers are bad. Neither of those are acceptable answers.
And while ProCESS is a good goal, their hypothesis is "are OUR catheters better than what you plebes use?" Can't imagine why I would be skeptical of initial or multiple subgroup analyses of that data. Guess it's because I've been bought off by, uh, people without money. Or something.

 

[Hernandez]

Do you know details on the process study?

 

[deleted109597]

Do you know details on the process study?

Well, our residency site was one of the test sites, so yeah. And the Edwards catheter is a big part of the study, notwithstanding that they have 3 arms.

 

[Hernandez]

Well, our residency site was one of the test sites, so yeah. And the Edwards catheter is a big part of the study, notwithstanding that they have 3 arms.

I am a lowly study recruiter for the study at one of the sites, and the Edwards catheter is only pushed in the EGDT arm, which is what was actually done in the EGDT study, we've not placed a single prescept catheter in the proscedualized arm PTs

 

[iridesingltrack]

Apparently it isn't clear. I don't have a problem with industry sponsored research. There isn't enough government money to go around, and I'm not willing to pay more taxes just so there is. And some industry research is pretty good.
That being said, if industry sponsored research is flawed, then you have to take one of two viewpoints. Either the company is skewing the data to make more money, or the researchers are bad. Neither of those are acceptable answers.
And while ProCESS is a good goal, their hypothesis is "are OUR catheters better than what you plebes use?" Can't imagine why I would be skeptical of initial or multiple subgroup analyses of that data. Guess it's because I've been bought off by, uh, people without money. Or something.

Sorry. I was joking with you. I guess the intended playfulness was lost in translation from keyboard to post.

Also, to be fair to the ProCESS investigators this probably merits brief clarification: I believe the NIH is sponsoring the ProCESS study. Edwards may be doing some additional funding, or providing in-kind support, but I don't know for sure. My hospital is not in the study.

I am a lowly study recruiter for the study at one of the sites, and the Edwards catheter is only pushed in the EGDT arm, which is what was actually done in the EGDT study, we've not placed a single prescept catheter in the proscedualized arm PTs

Oh, the Edwards catheter...we use them on occasion in our ED outside of any study. I like getting the continuous measurements to guide resuscitation and not having to remember to resend an ScVO2 or lactate. I am certain that having the number constantly in my face whenever I walk by leads me do more, but that may not necessarily be a good thing.

Wow. This thread has touched on a lot of different topics.

Cheers,
iride

 

[leviathan]

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.

CVP has poor association with fluid responsiveness but not necessarily fluid tolerance. The Rivers study patients got a ton more fluid than controls by following CVP, and I think the best theory on that is that they may have got more fluid than they needed, but not so much as to lead to pulm edema or any adverse outcomes.

 

[Rendar5]

CVP has poor association with fluid responsiveness but not necessarily fluid tolerance. The Rivers study patients got a ton more fluid than controls by following CVP, and I think the best theory on that is that they may have got more fluid than they needed, but not so much as to lead to pulm edema or any adverse outcomes.

Or maybe just that they did better because they were carefully monitored and selected with a regimented treatment therapy. Just because the system as a whole worked in the study doesn't mean that every individual item in the system was effective. The Rivers study really seemed to show that early identification and early agressive intervention worked well.

 

[deleted109597]

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.

Well I was half wrong. They didn't recommend it based on multiple subgroup analysis. The ProCESS authors were actually pretty fair about their recommendations. Rivers does deserve some credit in making a new, better standard of care than was being received.

 

[anes]

Don't use neo in spinal shock, could kill the patient. Always use dopamin or dobutamine.

Anesthesiologist here. We use phenylephrine almost exclusively for blood pressure management in patients with spinal (neurogenic) shock. I can't recall any of our patients dying because of the phenylephrine.

Can you elaborate on the dangers of this drug, in this particular subset of patients?