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sepsis

MMUH ICU ED teaching sepsis

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Prepared for a brief talk at our joint ICU ED meeting. References at emergencymedicineireland.com

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Page 1: MMUH ICU ED teaching sepsis

sepsis

Page 2: MMUH ICU ED teaching sepsis

where’s the controversy

fluids goals

Page 3: MMUH ICU ED teaching sepsis

fluids

Page 4: MMUH ICU ED teaching sepsis

give more give less

fluids

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“give exactly the amount of fluid that they need and not a drop more”

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“It is time to go back to basics and challenge our entrenched assumption that fluid resuscitation is beneficial for people in septic shock, rather than continue to argue over which fluid works best.”

Page 7: MMUH ICU ED teaching sepsis

goals

CVP

cardiac output

BP

lactate[jones 2010]

ScvO2[rivers 2001]

Page 8: MMUH ICU ED teaching sepsis
Page 9: MMUH ICU ED teaching sepsis

ARISE PROMISE PROCESS

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the details

•multi centre•RCT•blinded assessors but not patients or docs•early in the sepsis course•had to get a decent bolus of fluids before they could get in•powered with an assumption of 35-40% mortality

Page 11: MMUH ICU ED teaching sepsis

the interventions

EGDT protocol

protocol based on expert consensus

usual care

Page 12: MMUH ICU ED teaching sepsis

the results

•31 centers screening 12000 pts and got 1300•no difference in primary outcome•difference in fluids ‘significant’ but in reality <1000ml•other differences are protocol related

Page 13: MMUH ICU ED teaching sepsis

rivers 2001

process 2014

kaukonen 2014

Page 14: MMUH ICU ED teaching sepsis

the bottom line

•we seem to be getting better at this•fluids, antibiotics, source control...•paying attention matters•“keep it simple stupid”