mmuh icu ed teaching sepsis

sepsis

where’s the controversy

fluids goals

fluids

give more give less

fluids

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

“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.”

goals

CVP

cardiac output

BP

lactate[jones 2010]

ScvO2[rivers 2001]

ARISE PROMISE PROCESS

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

the interventions

EGDT protocol

protocol based on expert consensus

usual care

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

rivers 2001

process 2014

kaukonen 2014

the bottom line

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