While I appreciate many points of view, I can't engage in a reasoned discussion that brings out advantages and disadvantages to certain approaches if we must toss terms such as insanity, imposition, nefarious, unacceptable, misuse, and disastrous.
It would we useful, I think, to remember that such dialogue has been used since the inception of the Surviving Sepsis Campaign's efforts to improve care 14 years ago, and the proof of the effect of such efforts is that mortality in Rivers' control arm was 46% versus 18.8 in ProCESS. Working together carefully and patiently is an important tenet of our improvenent efforts. As for the remarks below, I would simply note that the approach to antibiotics is fully supported in the 2012 SSC Guidelines, and those were endorsed by the infectious Disease Society of America. The standard of broad spectrum antibiotics for a disease that carries lethal potential if you guess incorrectly is not in dispute. Finally, the definitions if severe sepsis and shock have not changed. How one *measures* persistent hypotension after fluid administration is the issue. If the author has a measurement strategy to propose, I am certain we can carry this forward as a consideration. On Sep 15, 2015, at 11:03 AM, Ram Parekh <[email protected]<mailto:[email protected]>> wrote: Thank you, Dr. Allen, for speaking up on this insanity that is being imposed on hospitals and providers. I'll add 2 more questions, and one comment. * First, NS and LR are ok, but Isolyte is unacceptable. How is this possible? NS may cause harm, as you have already mentioned, and LR may affect trending lactates particularly in shock states, yet those are the only CMS sanctioned crystalloids, while balanced solutions like Isolyte or Plasmalyte do not qualify. * Secondly, on what evidentiary basis and by what rationale have the Severe Sepsis and Septic Shock definitions been changed? Infection + 2+ SIRS + lactate > 4mmol/L has been been the Severe Sepsis definition since the Rivers EGDT trial and was also used in the RCT triumvirate of PROMISE, ARISE, and PROCESS. Now, this Severe Sepsis criteria has been subsumed by the 'Septic Shock' definition and the new Severe Sepsis definition includes a myriad of end organ surrogates such as platelet count and bilirubin level. Again, on what evidentiary basis are hospitals and providers being held to this arbitrary definition? The best evidence we have to date uses the Rivers definition of severe sepsis and septic shock, yet this has been scrapped in favor of a more complicated and arbitrary definition. Adding complexity is not in the best interest of patient care, if that is indeed the goal. * And last, and most important, is the expectations involving broad spectrum antibiotics. This is a more nefarious reincarnation of the disastrous antibiotics for pneumonia CMS core measure. The effect this will have on antibiotic overuse and misuse will be disastrous. On Tue, Sep 15, 2015 at 12:25 PM, Allen, Gilman B <[email protected]<mailto:[email protected]>> wrote: Sean, I attended your webinar on Sepsis Core measures last week and was left with a number of concerning questions: 1. If we are using the logic that “there is no evidence to show it doesn’t hurt” to justify follow-up physical exam measures for evaluation of response to resuscitation, then why does the same logic not apply to the use of Normsol and other chloride-balanced crystalloids? I would argue that there is a growing body of evidence that normal saline may indeed “hurt” (JAMA. 2012;308(15):1566-1572.; Br J Surg 102 (1):24-36. Crit Care Med 2014; 42:1585–1591. 2. In defending the use of many of these unproven metrics of volume responsiveness and distal perfusion, you described many of these measures as a “proxy” measure of “attentive evaluation” and intensive care. I full agree, and practice this way. I believe these measures help represent a collective epi-phenomenon of intensive and regimented care. Using the same reasoning, why then is there no provision in any of this for providers to document their own rationale for diverging from some of these restrictive mandates when judged to be clinically justified. Is this not also a worthy “proxy” of intensive and attentive care? 3. When does the clock really start ticking? Our hospitals still don’t have a solid and reliable answer to this question. Is it when the physician documents their suspicion of sepsis, 3 hours after a fever and hypotension? When blood cultures are first ordered one hour after the fever? Or when an MD orders Tylenol, a CBC, lactate, and blood cultures on someone he/she suspects may be either bleeding, in pain, or possibly infected post-Op? When do these types of patients really “declare” themselves septic. The efforts to try to “capture” every element of Goal-directed care in an “all-or-none” pass/fail algorithm dooms itself from the beginning. Why didn’t CMS just start off with the 3 hour bundle, monitor how others do with the 6 hour bundle, and try to figure out where (and why) their algorithm is succeeding, or failing, to capture (and enforce) best practice? I’ve augured to my group that there is absolutely no excuse for not getting blood cultures, a lactate, and fluids on board within one hour of a high suspicion of sepsis. This is a low bar we should all be meeting, but probably aren’t. Why not simply start there, and work our way forward? Gilman B. Allen, MD Associate Professor Department of Medicine Director of Adult Critical Care Services University of Vermont / Fletcher Allen Healthcare HSRF 220, 149 Beaumont Ave Burlington, VT 05405-0075 (802)656-9004<tel:%28802%29656-9004> Fax: (802) 656-8926<tel:%28802%29%20656-8926> [email protected]<mailto:[email protected]> <image002.jpg> _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
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