Stress dose steroids for septic shock: bolus dosing or continuous infusion

This study published just this month, November 2019, suggests that providing bolus dosing of hydrocortisone, 50mg IV every 6 hours shortens the time a patient needs to be on vasopressors compared to 200mg IV through a continuous infusion every day.

Stress dose steroids are clearly in my armamentarium in the treatment of septic shock. I tend to reach for them when I’m starting my second vasopressors, usually Vasopressin when the norepinephrine hits around 10-15mcg. I also ready for the vitamin C and thiamine at that point, too. Actually, I have a quick little bundle in the EMR where I just check off all these goodies. Sometimes I stray in different directions, of course. Every patient is different and this is not a recommendation on how you should practice. I haven’t gotten on the fludrocortisone train yet, have you?

Either way, the shock reversal is faster with the bolus dosing. This should make all my nurse followers happy as they won’t have a channel and lumen bogged down with this medication and all the compatibility questions that arise with it. Whether bolus or continuous dosing you won’t see a difference in mortality, ventilator days, adverse effects, length of stay, etc.

Also not yet another study where they don’t check cortisol levels before initiating this treatment. I’m not a fan of checking cortisol levels myself. I see it done and I ask, why?

A 🎩 tip to the authors.

-EJ

Link to FULL FREE Article

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Inferior Vena Cava Assessments with US

Ultrasound assessment of the inferior vena cava for fluid responsiveness: easy, fun, but unlikely to be helpful

This is where I stand on the matter today, November 3rd, 2020. I am open to changing my mind with new data. Guiding fluid responsiveness, as I’ve covered here, is a huge pain in the butt. But giving patients either too little fluids or too much fluids increases mortality. That little feeling inside of “just doing something” isn’t the best thing.

When I was going to through fellowship, I was trained to perform this assessment of placing the US probe on the patients subxiphoid area and digging around until the IVC was found. I got pretty good at it, but I have to admit that I also haven’t used it in 2 years. I never found it to be as useful or reliable as I initially thought it would be. It’s a tool but it has many caveats. I remember reading this article and got some confirmation bias to how I already felt about the scan.

Fortunately, this article is free and you can download it on my website, eddyjoemd.com. The article illustrates the many caveats which any clinician developing the skill to perform this scan NEEDS to know. He discusses the technical limitations, confounding factors, and reviews the evidence in both patients who are spontaneously breathing and in those who are on the vent.

I’ll repeat again, if you are a medical student, emergency medicine resident, internal medicine resident, or any clinician learning and managing patients based on this scan, you need to know the limitations of it. At least until we find the holy grail of Critical Care where we find a way to know the correct amount of fluids to give our patients. Not a drop more or a drop less.



Link to Abstract

Link to FREE FULL PDF

Millington, S.J. Can J Anesth/J Can Anesth (2019) 66: 633. https://doi.org/10.1007/s12630-019-01357-0

Incorporating Dynamic Assessment of Fluid Responsiveness Into Goal-Directed Therapy: A Systematic Review and Meta-Analysis.

Incorporating Dynamic Assessment of Fluid Responsiveness Into Goal-Directed Therapy: A Systematic Review and Meta-Analysis.

Let’s talk a little bit about resuscitation. I chose to go down this path to start off the weekend bc I frequently see patients receiving arbitrary fluid boluses for SBP less than x (we all know how o feel about using systolics on oscillometric machines), MAP less than 65, or decreased urine output. It makes us feel like we are doing something but we are actually causing harm. At the end of the day, giving fluid just to make the blood pressure pretty does not indicate fluid responsiveness. If I were to give you a liter of fluid, definitely not saline, your BP would go up. That doesn’t mean you’re fluid responsive. Using the technologies listed in this article from 2017 are a step in the right direction. If you read the validation studies for them you’ll learn that they leave much to be desired but they’re amongst the best tools we have today. I’m going to go much deeper down this rabbit hole in the upcoming months.

What do you use at your shop to measure fluid responsiveness?

Link to Abstract

Link to FULL FREE PDF

Bednarczyk JM, Fridfinnson JA, Kumar A, et al. Incorporating Dynamic Assessment of Fluid Responsiveness Into Goal-Directed Therapy: A Systematic Review and Meta-Analysis. Crit Care Med. 2017;45(9):1538–1545. doi:10.1097/CCM.0000000000002554

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Fecal Microbiota Transplant related Bacteremia

Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant




Link to Abstract

DeFilipp Z, Bloom PP, Torres Soto M, et al. Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant. N Engl J Med. 2019;381(21):2043–2050. doi:10.1056/NEJMoa1910437

Pulmonary Embolism Guidelines 2019

These are the 2019 European Society of Cardiology and European Respiratory Society Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism. I must say, these are my favorite guidelines for PE and they came out just a few weeks ago on August 31st. It seems as if PE is just on every differential, as it respectfully should be, on anyone who is hypotensive with chest pain and short of breath. You definitely have to think about it, but that doesn't mean that everyone needs a CTA of the chest to rule it out. Many times a good history and physical can rule it out.

The images in this article is where much of the value is. The flowcharts simplify the thought process. I encourage those of you who have the ability to learn how to do some simple echocardiography to learn the skills of at least finding the windows. You'll be able to gain a TON of information just by laying the probe on the chest. This is one of those PDFs that you should definitely have accessible and refer to it often until you basically have these guidelines memorized.

A big hat tip to the authors. Again, I LOVE this paper.

-EJ

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)

Link to Abstract

Link to FULL FREE PDF this may or may not work

Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2019; published online Aug 31.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

NPO after Midnight: What do the guidelines say?

Is your shop still using strict NPO after midnight for its surgical patients? It’s time to talk to the powers that be to have this changed, supported by evidence, of course.

The controversy of “Strict NPO After Midnight” has been ongoing for many years now as the data has suggested it’s silly but still performed. Well, the American Society of Anesthesiologists put together a task force in 2017 to put an end to the silliness. Let’s try to make the horrible experience of being hospitalized a little less horrible for our patients. #endthenpo

A 🎩 tip to the authors. Happy Sunday!








Link to article where you can download the PDF

Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration*. Anesthesiology

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Corticosteroids and GI bleeds: Do We Really Need To Worry?

Link to Abstract

Butler E, Møller MH, Cook O, et al. The effect of systemic corticosteroids on the incidence of gastrointestinal bleeding in critically ill adults: a systematic review with meta-analysis. Intensive Care Med. 2019;45(11):1540–1549. doi:10.1007/s00134-019-05754-3

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Fecal Microbiota Transplantation: So Much to Learn

Link to Abstract

Link to Full FREE Article

Dai, M., Liu, Y., Chen, W. et al. Rescue fecal microbiota transplantation for antibiotic-associated diarrhea in critically ill patients. Crit Care 23, 324 (2019). https://doi.org/10.1186/s13054-019-2604-5

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Thiamine and Renal Failure in Septic Shock Patients

Every possible option to decreased morbidity, mortality, and costs are worth looking at in my book. The study that I am reviewing at this moment was published in 2017. I am ashamed that I had not run into it until today. It's challenging to stay up to date in everything. I digress.

Some would quickly bash this study for it being small (n=70) and a post-hoc secondary analysis of a pilot study. I am not going to do that. Why not? Well first of all, I do not participate in research myself. Just reading and enjoying these studies. Also, thiamine has no side effects described in the literature. Third, it is an inexpensive medication. Fourth, if it does turn out to decrease the incidence of acute kidney injury and the need for renal replacement therapy, aren't you going to feel guilty for not adopting these strategies for your patients? I hate resorting to that but my responsibility is for patients. What happens if this data is wrong? Nothing. What happens if this data is right and no one does anything for several years? Many patients may suffer.

This article is completely free and I encourage you to download it and read it for yourself. Amongst the points illustrated by the authors, they mention that it's not only perfusion that injures the kidneys during sepsis. There are other factors listed in the article. The way that it is postulated that thiamine works for these patients is by assisting in the mitochondrial dysfunction. Data that I have found not listed in this article shows that thiamine deficiency could have an incidence between 20-70% of critically ill patients. 

What they found was 21% of the patients in the placebo arm of the trial went on to need dialysis. Just one patient, or 3% in the thiamine group went on to require this. The authors note that acidosis was the primary indication for dialysis in 66% of the patients who required it. I personally would like to dig deeper into these numbers as there is some data that thiamine administration helps decrease lactic acidosis. 

This data should make you wonder if the strategy that many clinicians take of providing more IV fluids to patients whose renal function deteriorates is the correct strategy. Are we going to look in the mirror in a decade and want to punch our past selves in the face?   

- EJ

Link to Abstract

Link to Full Article

ADDENDUM: The prospective RCT is going to be completed in July 2022. Here is the link to clinicaltrials.gov's study details here: LINK

Moskowitz A, Andersen LW, Cocchi MN, Karlsson M, Patel PV, Donnino MW. Thiamine as a renal protective agent in septic shock. A secondary analysis of a randomized, double-blind, placebo-controlled trial. Anns Am Thorac Soc. 2017;14(5):737–41.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Thiamine, Ascorbic Acid and Corticosteroids: The Mechanisms by which they should help in Sepsis

Want some nerdy stuff? Well this is some nerdy stuff! I'm taking a nice deep look at this figure. I am not going to lie to you at this moment, October 19th, and tell you I know what all this means, because I don't. But people who are more intelligent that I am have suggested that these are the mechanisms by which thiamine, ascorbic acid, and corticosteroids should help in the treatment of septic patients. I have a lot to learn.

I hope I don't get dinged for copyright stuff but honestly if this offends you, let me know. I will take it down. I will likely go deeper into this article at a later time. Wanted to share this image with you right now, though.





Link to Abstract

Link to FREE FULL Article

Moskowitz, A.; Andersen, L.W.; Huang, D.T.; Berg, K.M.; Grossestreuer, A.V.; Marik, P.E.; Sherwin, R.L.; Hou, P.C.; Becker, L.B.; Cocchi, M.N.; et al. Ascorbic acid, corticosteroids, and thiamine in sepsis: A review of the biologic rationale and the present state of clinical evaluation. Crit. Care 2018, 22, 283.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.