Jeannine; Thank you for your post. Be sure that anyone worth their salt had read this article in the prestigious BMJ. There are some excellent points made here. That said, please understand that this is a 'review' article, which in this case is an opinion piece with (admittedly) many citations from many important studies.
But this is where the goodness ends for me. The editorializing and perversion or frank omission of facts (similar to our most recent presidential race) is concerning. If I had been inclined to write a response piece to this article (which I was not), I would have likely pointed out the following: (just some examples - not a complete review) 1. When Dr. Marik writes this for example It is therefore very troubling that the updated Surviving Sepsis Campaign Guidelines which are now federally mandated in the USA (SEP-1 Early Management Bundle, #0500 Severe Sepsis and Septic Shock: management Bundle) require either a 'focused exam by a licensed independent practitioner', or measurement of the CVP or ScvO2, or bedside cardiovascular ultrasound, to assess the volume status of the patient with severe sepsis and septic shock.88 It should be noted that the area under the receiver operator characteristic (ROC) curve of the CVP, for predicting fluid responsive is approximately 0.5, which is considered a 'completely useless test'. 54 89 90 He fails to mention that additionally, the use of the PLR, with real-time measurement of SV response is also included in the options for assessment of perfusion optimization. The statements in the article might lead one to believe that the SSC got it all wrong, but no, they did not. Additionally, the assertion that the use of EGDT confers no mortality benefit is also incorrect - it shows no increased benefit compared to other means of vigilant patient assessment and ongoing timely response to patients' clinical trajectory. Which also means it is as good as those other methods 2. A second misleading statement is the following: It is somewhat astonishing that the ScvO2 is still being recommended to guide the resuscitation of critically ill septic patients and is being used as an indicator of the quality of care delivered.72 88 Monitoring the ScvO2 in patients with sepsis has no scientific basis, as patients with sepsis usually have a normal or increased ScvO2, 94 95 and a high (ScvO2 > 90%) rather than low ScvO2 has been demonstrated to be an independent predictor of death.96 It has long been known that super-high Scv02 values, in the face of poor clinical indicators (as opposed to improvements such as normal MAP, increased U/O e.g.) means that blood circulation, perfusion and oxygen extraction is poor, resulting in blood returning to the right side of the heart carrying unused O2. It is also true that patients with poor perfusion hyper-extract 02 from slowly perfusing blood, hence abnormal venous 02 sats are just that, abnormal. Conversely, I completely agree with the sentiment that CVP measurements are less likely to be helpful in most cases, and that a real-time measurement of fluid responsiveness, in conjunction with either a PLR (likely safer) or small fluid bolus should become standard of care. Giving fluid to a patient who will not benefit from this therapy, and may in fact be harmed by it, is not prudent. I am not speaking for the SSC, but I know that recommendations will almost always account for available therapies and standard resources. That is, how many hospitals across our country do you believe have an appropriate amount of Cheetah Nicoms (this is not an endorsement for any product) and use them with complete efficiency in a standard way for all patients? The author of this paper consistently refers to the ProCess, Arise and Promise trials. We learned a lot from each of these. Additionally, there were many flaws with these trials, the least of which was the questionable generalizability of the results. The damage done, was that practitioners took the conclusions drawn from these papers to mean that they didn't have to do much of anything for septic shock patients other that what is considered 'usual care'. Unfortunately usual care, in many ICUs in our country, (> 60% of which are in community hospitals) means going home and going to bed and checking in the morning. To be sure there were also limitations in the Rivers trial, most notably that it was not multi-centered. I am not sure that the low and slow enrollment noted in the above mentioned trials, (meaning an inability of the participating centers to actually adhere to the study protocol) actually gives us any great confidence. Or that the protocol arm meant to reflect 'usual care' was in fact usual. The point that I am trying to make is that it is incumbent upon all of us to adopt new evidence-based practices. As part of that process, we must be discerning readers of not only opinion pieces, but even well-done, multi-center, RCTs. Especially when the tone of a paper sounds more like a stump speech. IMHO Thanks, MARY ANN BARNES-DALY MS RN CCRN DC | Clinical Performance Improvement Consultant Quality & Clinical Effectiveness Team | Office of Patient Experience Sutter Health -2200 River Plaza Drive, Sacramento, CA 95833 Mobile 916.200.5604| Office 916.286.6717 | [email protected] "You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete." ~R. Buckminster Fuller From: Sepsisgroups [mailto:[email protected]] On Behalf Of Jeannine Gerolamo (Abington) Sent: Monday, November 21, 2016 12:25 PM To: [email protected] Subject: [External] [Sepsis Groups] Sepsis IVF requirements - interesting article All, Has anyone read this article? It provides an interesting perspective regarding use of IVF versus vasopressors for sepsis. Dr. Townsend- do you think CMS would ever take this into consideration regarding SEP-1? http://emcrit.org/wp-content/uploads/2015/10/Br.-J.-Anaesth.-2015-Marik-bja_aev349.pdf<https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Femcrit.org%2Fwp-content%2Fuploads%2F2015%2F10%2FBr.-J.-Anaesth.-2015-Marik-bja_aev349.pdf&data=01%7C01%7Cbarnesm4%40sutterhealth.org%7C0c1af05d699f4188f35508d412da4f7d%7Caef453eadaa243e0be62818066e9ff63%7C0&sdata=UVmy4HjAkwzv17%2FZG8ljeUB1pmoP1ZsjLIQp%2Fbzmq%2Bo%3D&reserved=0> Jeannine Gerolamo (Fahy), MSN, BS, RN Safety/Quality Specialist The Center for Patient Safety and Healthcare Quality 215-481-4334 (Office) 215-481-3510 (Fax) [email protected]<mailto:[email protected]> [cid:[email protected]]<https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.abingtonhealth.org%2F&data=01%7C01%7Cbarnesm4%40sutterhealth.org%7C0c1af05d699f4188f35508d412da4f7d%7Caef453eadaa243e0be62818066e9ff63%7C0&sdata=Q2JftnOcnQLlEAACLg3QaHIKYd0OQewNQyleyNoi1Rw%3D&reserved=0> [cid:[email protected]] <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.facebook.com%2FAbingtonHealth&data=01%7C01%7Cbarnesm4%40sutterhealth.org%7C0c1af05d699f4188f35508d412da4f7d%7Caef453eadaa243e0be62818066e9ff63%7C0&sdata=tK5UYdJsOaATJYpA43QftOzEJRfkDlmEEkXxbiXFz28%3D&reserved=0> [cid:[email protected]] <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Ftwitter.com%2FAbingtonHealth&data=01%7C01%7Cbarnesm4%40sutterhealth.org%7C0c1af05d699f4188f35508d412da4f7d%7Caef453eadaa243e0be62818066e9ff63%7C0&sdata=LM0FGO4%2BhfiARns3BSeJ0Hjz9lL43ysZGCqyY8Ap6Tw%3D&reserved=0> [cid:[email protected]] <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.youtube.com%2FAbingtonHealth&data=01%7C01%7Cbarnesm4%40sutterhealth.org%7C0c1af05d699f4188f35508d412da4f7d%7Caef453eadaa243e0be62818066e9ff63%7C0&sdata=KIblYVcGNVbGrT2UJkW0dRMeDfqBqT6qMoqYU4LdpCs%3D&reserved=0> [cid:[email protected]] <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Finstagram.com%2FAbingtonHealth%2F&data=01%7C01%7Cbarnesm4%40sutterhealth.org%7C0c1af05d699f4188f35508d412da4f7d%7Caef453eadaa243e0be62818066e9ff63%7C0&sdata=7R%2Fy5cpug%2FW%2B3lVDn%2FEazxbhI%2F22eQIdSR%2FcCiHBS7M%3D&reserved=0> The information contained in this transmission contains privileged and confidential information. 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