I agree with the discussion that heart failure patients may require less aggressive fluid resuscitation. However, I have personally administered 2 liters to a patient with heart failure. I am the sepsis coordinator for SouthCoast Health System; we recognized this as an issue. We have implemented a Non-invasive cardiac monitoring system to assess fluid status on every septic patient. Our sepsis order sets are designed to guide fluid resuscitation by administering 500 mL to a patient with heart failure, a patient with an EF <25% and/or a patient receiving dialysis treatments. After the 500 ns has been administered within 10 minutes, the RN assesses the fluid status by using the Non-invasive Cardiac Output Monitor. This machine measures stroke volume as well as cardiac output. If the Nurse measures the stoke volume index change to be 10% or greater, the order set indicates more fluid. We will continue to monitor fluid status by this method until the stroke volume index change i s less than 10%. There are some critics to this technique; thus, we have allowed any other form of fluid assessment such as CVP readings, inferior Vena Cava (IVC) assessment done by the physician, or the Non-Invasive method.
With all other septic patients, we administer 30 mL/kg and re-assess fluid status 1 hour after the last bolus has been administered. We have applied the Surviving Sepsis recommendations to have all 30 mL/kg administered within the 3 hr window. Lisa Dumont MSN- Sepsis Coordinator South Coast Hospital System Fall River MA [email protected] -----Original Message----- From: [email protected] [mailto:[email protected]] On Behalf Of [email protected] Sent: Thursday, October 03, 2013 10:01 AM To: [email protected] Subject: Sepsisgroups Digest, Vol 77, Issue 7 Send Sepsisgroups mailing list submissions to [email protected] To subscribe or unsubscribe via the World Wide Web, visit http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org or, via email, send a message with subject or body 'help' to [email protected] You can reach the person managing the list at [email protected] When replying, please edit your Subject line so it is more specific than "Re: Contents of Sepsisgroups digest..." Today's Topics: 1. Re: fluid resuscitation in CHF or renal patients (Ron Elkin) 2. Does someone have this they can send me? (Sprague Amy L - St. Francis Hospital and Health Centers) 3. Re: fluid resuscitation in CHF or renal patients (Quinn, Thomas MD) ---------------------------------------------------------------------- Message: 1 Date: Wed, 2 Oct 2013 07:42:19 -0700 From: Ron Elkin <[email protected]> To: Terry Clemmer <[email protected]> Cc: Tracey Helmick <[email protected]>, "[email protected]" <[email protected]>, "[email protected]" <[email protected]>, "[email protected]" <[email protected]> Subject: Re: [Sepsis Groups] fluid resuscitation in CHF or renal patients Message-ID: <CAFjFL5yxQhUKcbfm7e-GRV_ieMfF5Qi=pntjo8ip1rw3whn...@mail.gmail.com> Content-Type: text/plain; charset="utf-8" I agree with Dr. Clemmer and others. If one is going to make an error with fluid in severe sepsis/septic shock, it is best made on the wet side. The mortality risk of under-resuscitation greatly exceeds that of fluid overload. On the other hand, it is helpful to avoid fluid overload when possible. Guideline care, in some respects, seems to have drifted from evidence-based to expert opinion in the hope of benefiting the majority of patients. Yet, there was no prescribed fluid bolus in the original EGDT trial. The patients received the fluid required to achieve resuscitation targets. In the EGDT group, the mean was 5L in 6 hours with quite a large standard deviation. The range was perhaps 1 to 11 L. The only bolus referenced in the EGDT study, 20ml/kg, was given only to hypotensive patients for the purpose of excluding them from the study if they responded to the fluid challenge. So one size does not fit all and not all patients, especially those with CHF or renal failure are the same. Nor will some tolerate a bolus of 30ml/kg. These are the minority of patients that are perhaps most challenging. While some fluid is almost universally required, the most fragile of these patients will greatly benefit from early close monitoring with a central line. Also, CHF requires qualification. A history of CHF is not necessarily current CHF that requires special consideration. A reduced ejection fraction is not necessarily CHF; the patient may have entirely compensated for it, but may still be sensitive to fluid loading and therefore benefit from close monitoring. Thanks just my $0.02 Ron Elkin, MD California Pacific Medical Center San Francisco On Tue, Oct 1, 2013 at 2:45 PM, Terry Clemmer <[email protected]>wrote: > Do not omit them. They need the fluid if they have hypotension or > lactate greater than 4.0. Evidence is now available that fewer will > end up on ventilators if they get adequate initial resuscitation, they > will have less renal failure and dialysis if they get adequate initial > fluid resuscitation. Remember, of 1000 ml of NS only 250 ml stays > intravascular. > Most septic patients are vasodilated and frequently dehydrated and > need fluid. Not giving fluid is dangerous, it increases mortality and > is only treating physician fear, not the patient.**** > > ** ** > > Terry P. CLemmer, MD Director of Critical Care Medicine**** > > LDS Hospital**** > > Salt Lake City, Utah 84143**** > > ** ** > > Professor of Medicine**** > > University of Utah School of Medicne**** > > Salt Lake City, Utah 84143**** > > ** ** > > Phone: 801-408-3660**** > > Fax: 801-408-1668**** > > [email protected]**** > > ** ** > > *From:* [email protected] [mailto: > [email protected]] *On Behalf Of *Tracey > Helmick > *Sent:* Tuesday, October 01, 2013 12:41 PM > *To:* [email protected] > *Cc:* [email protected]; [email protected] > *Subject:* [Sepsis Groups] fluid resuscitation in CHF or renal > patients*** > * > > ** ** > > Our institution continues to monitor and assess our Sepsis patient data. > We are having difficulty meeting the new 30ml/kg recommendations for > fluid resuscitation. We are finding that some of our outliers are the > patients with CHF or renal failure. Is this a common barrier and if > so, what are other institutions doing to assure those patients are > receiving adequate fluid resuscitation without causing harm to the > patient? Should we omit those patients from our data collection?**** > > ** ** > > Respectfully, **** > > ** ** > > Tracey Helmick RN, CCRN**** > > Meadville Medical Center**** > > MMC Severe Sepsis Team Nurse Champion**** > > [email protected]**** > > ** ** > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.o > rg > > -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20131002/e217fe24/attachment.htm> ------------------------------ Message: 2 Date: Wed, 2 Oct 2013 15:08:15 +0000 From: "Sprague Amy L - St. Francis Hospital and Health Centers" <[email protected]> To: "[email protected]" <[email protected]> Subject: [Sepsis Groups] Does someone have this they can send me? Message-ID: <[email protected]> Content-Type: text/plain; charset="us-ascii" I would like a copy of this. Thank you, Amy Amy L. Sprague MSN, RN, ACNS-BC, CCRN Clinical Nurse Specialist~Critical Care Franciscan St. Francis Health 8111 S. Emerson Avenue Indianapolis, IN 46237 Office (317)528-6800 [email protected] "People grow through experience if they meet life honestly and courageously." Eleanor Roosevelt, U.S. first lady ________________________________ The information contained in this e-mail and any accompanying documents is intended for the sole use of the recipient to whom it is addressed, and may contain information that is privileged, confidential, and prohibited from disclosure under applicable law. If you are not the intended recipient, or authorized to receive this on behalf of the recipient, you are hereby notified that any review, use, disclosure, copying, or distribution is prohibited. If you are not the intended recipient(s), please contact the sender by e-mail and destroy all copies of the original message. Thank you. -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20131002/364ed871/attachment.htm> -------------- next part -------------- A non-text attachment was scrubbed... Name: Picture (Device Independent Bitmap) 1.jpg Type: image/jpeg Size: 631 bytes Desc: Picture (Device Independent Bitmap) 1.jpg URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20131002/364ed871/attachment.jpg> ------------------------------ Message: 3 Date: Wed, 2 Oct 2013 10:35:42 -0500 From: "Quinn, Thomas MD" <[email protected]> To: "[email protected]" <[email protected]>, "[email protected]" <[email protected]>, "[email protected]" <[email protected]> Cc: "[email protected]" <[email protected]>, "[email protected]" <[email protected]> Subject: Re: [Sepsis Groups] fluid resuscitation in CHF or renal patients Message-ID: <[email protected]> Content-Type: text/plain; charset="iso-8859-1" Agree! That's what they make ventilators for. Acute renal failure from ATN is much worse. Treat the shock! Thomas Quinn, MD Medical Director, Critical Care Services Maury Regional Medical Center Columbia, TN ________________________________ From: [email protected] [[email protected]] On Behalf Of [email protected] [[email protected]] Sent: Tuesday, October 01, 2013 3:51 PM To: [email protected]; [email protected] Cc: [email protected]; [email protected] Subject: Re: [Sepsis Groups] fluid resuscitation in CHF or renal patients No, they do not exclude. I tell our house staff that the patient will die of Septic Shock WAY before they will die of fluid overload-so give the full recommended amount, keep them from dying from Septic Shock, and worry about taking the fluids off later!!! :) Susan M. McKinney, RN Clinical Quality Coordinator For Sepsis Clinical Documentation Specialist Rapid City Regional Hospital 605-719-4428 605-484-7381 [email protected] From: [email protected] [mailto:[email protected]] On Behalf Of Tracey Helmick Sent: Tuesday, October 01, 2013 12:41 PM To: [email protected] Cc: [email protected]; [email protected] Subject: [Sepsis Groups] fluid resuscitation in CHF or renal patients Our institution continues to monitor and assess our Sepsis patient data. We are having difficulty meeting the new 30ml/kg recommendations for fluid resuscitation. We are finding that some of our outliers are the patients with CHF or renal failure. Is this a common barrier and if so, what are other institutions doing to assure those patients are receiving adequate fluid resuscitation without causing harm to the patient? Should we omit those patients from our data collection? Respectfully, Tracey Helmick RN, CCRN Meadville Medical Center MMC Severe Sepsis Team Nurse Champion [email protected]<mailto:[email protected]> ________________________________ Regional Health's mission is to provide and support health care excellence in partnership with the communities we serve. Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments. 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