An intensivist on a learning frenzy. Caring for the critically ill using evidence-based medicine.
The concept of metabolic resuscitation has been around for several years. Unfortunately, the data for the utilization of ascorbic acid, thiamine, and glucocorticoids has not been as robust as we would like. There have been challenges replicating the miraculous data seen in the first trial in every subsequent trial performed thereafter. There have been numerous …
Continue reading Hydroxocobalamin (Vitamin B12) for Septic Shock
Today, we're going to be reviewing what some might consider to be a landmark study: the CLOVERS trial. The first thing most clinicians do when a patient is hypotensive is provide IV fluids. The surviving sepsis guidelines recommend 30cc/kg in patients who are in septic shock. It often bears reminding that the objective of providing …
Continue reading More Fluids vs. Vasopressors in the First 24h of Septic Shock (CLOVERS Trial)
As much as I am not a huge fan of bombarding septic shock patients with IV fluids, I understand there is a role for fluid resuscitation.When our patients get better, though, it is time to get rid of these fluids.That is what we call deresuscitation.It is part of the 4 D's in fluid therapy: drug, …
Continue reading How Strong Is Your Deresuscitation Game in Sepsis Patients?
This is a one minute journal club-ish on Sepsis Deaths. This is not medical advice. Read the FREE article for yourself and do not trust me.Hat tip to the authors.This article was published in 2020 in the Lancet but is still relevant.Almost 49 million cases of sepsis were recorded in 2017.It is estimated that there …
I've always had a strong interest in Procalcitonin and how to use it appropriately for our hospitalized patients in the ICU. For that reason, I am creating this work-in-progress page to take a deep dive into all evidence-based clinical questions you and I may have regarding procalcitonin. This post will be continuously updated. Don't trust …
Continue reading Procalcitonin Levels: The Ultimate Guide for Use in Sepsis
The blood pressure is low, give a bolus of fluids. Many times that leads to a "nurse dose" as many of us joke about. But are we causing harm? I keep reiterating that fluid responsiveness is when you achieve an increase in cardiac index/output or an increase in stroke volume due to that fluid or …
Continue reading IV Fluid Overload: Don’t Drown your Patients!
Dinosaurs still roam the earth, I know this. They are slowly and surely retiring, though. I trained in the days where Manny Rivers and the Surviving Sepsis Campaigns pushed for Early-Goal Directed Therapy were king. Hey, there was a reason why it was so successful, EGDT decreased in-hospital mortality from 46.5% to 30.5% in that …
This article is hot-off-the-press regarding vitamin C, thiamine and hydrocortisone in refractory septic shock. This regimen is known as HAT therapy in some corners of the world. It was actually published today, 5/5/20. It is NOT a randomized control trial but at least they went through the trouble of conducting a propensity matched, before-after, case …
Continue reading IV Vitamin C in Sepsis with Thiamine and Hydrocortisone
You've heard all these fancy terms, mixed venous blood gas, ScvO2, SvO2, thrown around the ICU all the time. Here, I explain what they are. Regardless of whether you're a nurse, respiratory therapist, medical student, resident, or even a fellow, these terms may sometimes be quite confusing as everyone talks about them like, "duh, you're …
Continue reading SvO2 and ScvO2 to Guide Resuscitation in Septic and Cardiogenic Shock
This is a question that is often asked. Do we give fluids until the patient no longer "responds to fluids" or start vasopressors early? Should we start early vasopressors in septic shock or wait until fluids resuscitation is complete?Here's my bias: I dislike arbitrarily pounding patients with fluids. It causes harm. We know this. I …
