My only question about urine output is this: what if they develop ATN early on? They won't get any urine output. I would fear that we may give patients too much volume, which some literature suggests is harmful, trying to get a response to urine output.
What do you think? Hesham A. Hassaballa, MD, FCCP Program Medical Director Critical Care Rush-Copley Medical Center Assistant Professor of Medicine Rush University Medical Center Phone: (331) 454-6572 > On Jul 21, 2014, at 11:33 AM, "Kramer, George C." <[email protected]> wrote: > > what about urinary output? > > it is the gold standard for burn shock a type of shock with high > permeability, loss of vascular volume, depressed cardiac contractility, SIRS, > > hmm, that sound similar to sepsis. > > g > > > On Jul 18, 2014, at 11:13 AM, Richard Teplick <[email protected]> > wrote: > >> One obvious problem with the initial study (Rivers) is that SvO2 is that >> cannot possibly uniquely reflect adequacy of organ perfusion; at best it >> reflects extraction. Because of the disparity in organ blood flow and >> autoregulatory reserve, low flow to, for example, the kidneys could never be >> detected in the presence of high muscle and skin flow (both of which >> generally occur in septic shock). Moreover, elite aerobic athletes can >> reduce their PvO2 to the teens producing SvO2s < 0.3. Yet they clearly have >> adequate muscle and skin flow although gut and renal flow may be reduced and >> may have low SvO2 but this cannot be determined from the SvO2 alone. >> Moreover, giving fluid to increase cardiac output may not alter blood flow >> to vital organs. My point is that we shouldn’t blindly accept study results >> that are physiologically unsound. I am most interested in other opinions. >> >> Dick >> >> From: Sepsisgroups [mailto:[email protected]] On >> Behalf Of Ron Elkin >> Sent: Thursday, July 17, 2014 17:13 >> To: Sue Beswick >> Cc: [email protected] >> Subject: Re: [Sepsis Groups] Impact of ProCESS study on your protocols >> >> Hi Sue, >> >> The study has certainly generated a buzz. For objective, serious students of >> this disease, however, the study should raise serious concerns about >> protocol, data, and conclusions. I'm sure these will be addressed in medical >> and other nursing forums in the months to come. >> >> A few comments or questions as examples: >> >> 1) "Usual care" has been irrevocably changed since publication of the EGDT >> study in 2001, as well as guidelines from SSC supported by many of our >> professional societies. Indeed sepsis management protocols existed in many >> of the ProCESS hospitals, so the control groups, protocol-based (PB) >> standard care and usual care, were treated by physicians well versed in EGDT >> protocols. >> >> >> 2) The mortality rates in each study group were unexpectedly and remarkably >> low, around 20%, and probably not representative of the mortality rates for >> similar patients in most US hospitals. As a result of the low mortality >> rate, some question whether the study was adequately powered to examine >> differences between study groups, and whether the study is generalizable to >> 5000 US hospitals. >> >> Moreover, why abandon measures that contributed to such impressive mortality >> reductions? Are we immune to regressive behavior if practice guidelines are >> relaxed or removed? >> >> >> 3) The protocol instruction for the first 6 hours was to avoid central line >> placement, CVP measurement, and ScvO2 in both control groups, PB standard >> care and usual care, unless peripheral access was inadequate. Yet, over 55% >> of patients in these groups received them for unstated reasons. One might >> reasonably speculate they were placed for hypotension and administration of >> vasopressors. Not stated, however, is how often these lines were utilized >> for CVP measurements that confirmed or guided resuscitation. >> >> In the transcript of a recent NQF conference call, available to the public, >> an author of the study stated CVP measurements were documented in about 1/3 >> of the control patients but were not used to guide therapy as evidenced by >> the lack of followup measurements. However, almost any experienced clinician >> will act similarly on some single measurements - a patient with a CVP of 3 >> on vasopressors will almost always receive volume. >> >> Also not reported are the number of control patients with lines who had >> ScvO2 measurements, except for the few who received continuous oximetry >> lines. It also remains possible that blood sample measurements of ScvO2 were >> utilized in control patients, but this is not addressed in the manuscript. >> >> We don't know how often CVP and ScvO2 measurements were made in control >> patients with central lines before randomization. We don't know how often >> clinicians acted on CVPs estimated by bedside neck exam, vertical column >> height of blood in the lines that were inserted, or IVC dimensions and >> change with respiration. >> >> We don't know how many lines, CVPs, and ScvO2s were added in the control >> groups after the protocol instructions expired at 6 hours. It is still >> possible and beneficial to rescue an inadequate resuscitation beyond 6 hours. >> >> In short, we don't know enough about management of the control groups. >> >> >> 4) Protocol non-adherence was reported in 11.9% but information in the >> appendix suggests higher. MAP goals were achieved in only 83%. Overall >> bundle compliance is not reported. >> >> In short, we don't know enough about the quality of management in the EGDT >> group. >> >> >> 5) Not reported are statistical comparisons between all study patients with >> lines versus without, control patients with lines versus without, and each >> of the 2 control group. >> >> >> So in summary, care in any of the study groups is not adequately described, >> and care in the control groups appears to be significantly contaminated by >> EGDT. I for one do not favor protocol changes on the basis of this study at >> this time, and I know for a fact that I have a lot of company. >> >> Thanks >> >> Ron Elkin MD >> California Pacific Medical Center >> San Francisco, CA >> >> >> On Thu, Jul 17, 2014 at 6:23 AM, Sue Beswick <[email protected]> wrote: >> Is anyone adapting their protocols with the findings that came out this year >> with the ProCESS study? >> We are looking at making some changes. >> >> Sue >> >> Sue Beswick APRN, MS, CCNS, CCRN >> CNS Critical Care >> Greenville Health System >> 701 Grove Road l Greenville, SC 29605 >> Office: 864-455-4884 >> >> >> ________________________ _______________________ >> 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 This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. 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