Modest suggestions to guide fluid administration in resource poor areas - or in resource rich areas prior to line insertion:
- Physicians of the dinosaur era used to look at neck veins. CVP can thus be estimated in 90% of people to within +/- 4 cm H2O (3 mm Hg) in about 90% of those. These skills can be resurrected. If neck veins can't be seen the hand can be elevated to the point where venous distention disappears. Vertical distance from the sternal angle + 5 cm H2O (4 mm Hg) is a reasonable estimate of CVP. Caution required especially with tricuspid regurgitation. - We can also refine bedside evaluation of the adequacy of perfusion and volume - mottled skin, acral temperature, capillary return, urine output, assessment of thirst, mucous membranes in non-mouth breathers, sometimes skin turgor. Max Weil published a paper showing a reasonably good correlation between the difference between ambient and big toe temperatures and cardiac output measured by indicator dilution technique (Temperature of the great toe as an indicator of the severity of shock. Joly HR, Weil MH. Circulation 1969, 39:131). - Poor perfusion may merit a carefully monitored fluid trial even if CVP is thought to be elevated - the mortality risk of under-resuscitation may greatly exceed that of fluid overload in many if not most clinical circumstances. Thanks Ron Elkin MD On Tue, Mar 11, 2014 at 3:13 AM, <[email protected]> wrote: > Good morning all, > I'll be traveling to Haiti in May and I was wondering if anyone out there > has examples/protocols for care of sepsis patients in those regions where > access to resources is sparse. I know that's been an aim of SSC moving > forward. Obviously, the technology in these areas would likely not permit > measurement of CVPs/ScVO2, etc, but front-loading of fluids and early > antibiotics may be feasible with some education of local practitioners. > Any ideas would be much appreciated. > > Thanks, > Rich Levrault, DO > > ------------------------------ > *From: *"Ron Elkin" <[email protected]> > *To: *"Karin Molander" <[email protected]> > *Cc: *[email protected] > *Sent: *Sunday, March 9, 2014 2:12:01 PM > *Subject: *Re: [Sepsis Groups] Lactates of 2 or greater being discharged > or admitted to the floor > > I believe the SSC data base documents a 23% mortality rate for severe > sepsis with normal lactate, normal BP at presentation. > > There are a number of observational studies in similarly ill severe sepsis > patients, including that of SSC, documenting a mortality penalty associated > with triage to the floor before transfer to ICU as compared to triage > directly to ICU. I'm aware of no studies showing equivalent or better > outcomes for severe sepsis on telemetry on the floors as compared to ICU, > even for the not-so-ill patients. I'm aware of no studies randomizing > patient assignments to ICU, step-down, telemetry, floors and home, and > certainly no publications advocating home. > > In contrast, the mortality rate at Intermountain Health was 8.7% - 9.7% > for *combined* septic shock and severe sepsis (lactates 2.0-3.9), with > triage to ICU, Miller RR et al. AJRCCM July 2013. > > I'm not sure triage to telemetry adds much outcome benefit to to placement > on the floors. The outcome benefits of ICU and step-down are perhaps more > likely related to greater frequency of vital signs monitoring (Q1-2H vs Q4H > on floors and many telemetry units) as well as triage to areas where RNs > and MDs are much more familiar with recognition and management of severe > sepsis. > > Based on the above, it seems prudent to triage all patients with severe > sepsis to ICU or stepdown whenever permitted by bed availability. While > lactate elevation and/or hypotension are important signs of mortality risk, > their absence hardly portends a benign outcome. > > Ron Elkin, MD > California Pacific Medical Center > San Francisco > > > > > On Thu, Mar 6, 2014 at 8:38 AM, Karin Molander <[email protected]>wrote: > >> Does anyone have data/article references regarding lactates of 2 being >> sent home or admitted to a floor bed rather than Telemetry bed? >> >> -- >> Karin H. Molander MD >> Mills-Peninsula Hospital >> Sutter >> >> _______________________________________________ >> Sepsisgroups mailing list >> [email protected] >> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org >> >> > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org >
_______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
