The Curbsiders (00:00.034) So, Moni. Oh, boy. Tonight, you know, we're talking a little bit about sepsis. Yes. But not to be confused with septic tanks. I know, it's so bad.

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The Curbsiders (00:39.658) Welcome back to Curbsiders. It's me, so it's a hospital medicine episode. I'm Dr. Monee Amin, joined by my ever effervescent co-host, Dr. Meredith Trubitt. How are you this evening? Doing pretty well, Monee. How about yourself? Living the proverbial dream. On tonight's show, we discuss sepsis with our guest, Moline Kang. In just a moment, Meredith will tell you a little bit more about her and the topic, but first, Meredith, will you please remind the good people in the audience what it is we do on this show?

Sure, Moni, I'd love to. We are the Internal Medicine Podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. And tonight we have a fantastic conversation with our guest, Dr. Molleen Kang. She is a pulmonary and critical care provider at Emory University. She's a physician scientist who loves data and is passionate about incorporating evidence-based practices when attending in the ICU or seeing patients in the pulmonary clinic.

at the Atlanta VA where she practices. So tonight we talked a lot about sepsis and all of the details of it. I think the most valuable or most interesting for us was some new information on like what to do with your fluids as well as pressor support on the floor. So without further ado, we can go ahead and get to it.

A reminder that this and most episodes are available for free CME credit for all healthcare professionals through VCU Health at curb Okay, we're back and we're so excited to have Molleen Kang here today. Before we get too into the nitty gritty, could you just tell us a little bit about yourself and stuff you like? A fun fact.

All right, hi everybody. Thank you for having me. My name is Malene Kang. I am at Emory University and I'm a pulmonary and critical care physician. Just finished my two years as an attending at the Atlanta VA Hospital. And fun fact, I love to bike. I purchased a Peloton during the pandemic and used it religiously. Took a little break. That has become longer, so I'm trying to get back in it.

The Curbsiders (02:52.118) So if any of your listeners have encouraging advice, I'd love to hear it. Honestly, as a Peloton writer, what I've noticed is there's definitely certain rides where I can tell like way more physicians are on it. So it's like deaf, like I'll be on there. I'll be like, oh, a hospitalist, like something else or whatever. And I'm like, I found my people and it's just really nice. And that's why I like Peloton. But they don't.

I have not found my people yet. It'll happen with time. Yeah. All right, why don't we go to another question? Tell us about just really good advice that you've gotten throughout your medical career so far.

So far, I think the best advice that I got was, don't be afraid to say, I don't know. I think that has served me very well throughout my career, even as an attending. I think, especially during training, we're being evaluated constantly, and there's this fear of sounding ignorant or not knowing enough and not going on your evaluation. But I find that...

The best I've learned during my training, and even as an attending, is when I've asked people to explain to me something and just plain said, I don't know this, please explain to me. And I think not only has it improved my learning, I think it has also served my patients better in the long run. Yeah, I think I recently had this conversation with a few learners, I'm just like, it's totally fine. In fact, I prefer it in a lot of situations.

Meredith, shall we go to picks of the week? Yeah, I feel like we might have the same one again. Well, I don't know. I don't think so, because mine is this wonderful book called Freaks, Gleeks, and Dawson's Creek by Thea Glassman. I am still a teeny bopper at heart, and it is basically a history of seven, I believe, teen soaps. It starts with the Fresh Prince of Bel-Air and...

The Curbsiders (05:06.314) It's great. I finished the Fresh Prince chapter yesterday, and I skipped one chapter for now, My Soul Called Life, moved on to Dawson's Creek because, you know, hashtag Joey and Pacey forever. Dawson's Creek is where it's at. And now everyone knows exactly how old we are. Yes, 100%.

The Curbsiders (05:28.202) Meredith, what's your pick of the week? So I think we'll do something that hasn't happened yet. But the reason why we're recording tonight and not tomorrow night is because Moni and I are actually going to go to the Blink-182 concert, which I'm super pumped about. I hope Moni is too, because I'm- You've never seen them before, right? I've never seen them live. It's like the original band. I'm really excited to see Travis Parker live and I'm completely excited.

completely comfortable going, seeing them happen to be pregnant at the same time. And totally cool with this being the kid's first concert. Oh, that is a great first concert. He's going to have a great story to tell that you will tell him. I have seen Blink before, so a little bit less excited just because I've seen Travis Barker live before, but it is the main event. It's incredible what that man can do with his hands, even after having a major plane crash and probably...

Like, was it, I think his whole spine's probably just metal at this point, titanium. Yeah. And other fun fact, um, because he's with Courtney Kardashian and we're throwing out all of these pop culture references during picks of the week. Um, they're expecting a kid too. So we're pretty much like in the same boat. It's pretty much the same. You're pretty much the same couple. I know. So with that, before we get too sidetracked, Meredith, please take us to our first case from ClashLac.

Our first case, we have Ms. Suarez. She is a 51-year-old female, and she had a recent traumatic left lower extremity injury, and she's admitted to the trauma team, and she's had multiple surgeries, grafts, everything to repair the leg. And per the notes, she's currently just awaiting subacute rehab, and you're the overnight nocturnist and get called for a rapid response. And on arrival to her room, the nurses inform you that she was doing well.

during the day shift up until they really called the rapid. But when they were doing their routine vital sign check, she had developed a new fever of 39.5, tachycardia with the rates in one tens and blood pressure of 83 over 50. So, Molleen, to kind of kick us off, what other information is really valuable for you at this point when you first arrive for that initial rapid response?

The Curbsiders (07:50.226) Well, knowing this history, but also in addition to that, if she has any other complaints. So somebody who's been in the hospital for that long, had a major surgery. I always think about pneumonia, which, you know, just because they've been laying in the bed may have some atelectasis, which may have progressed. So if she's having a cough, any shortness of breath, other things, abdominal pain.

car review assistance, but specifically related to her leg. And because she's a recent post-op patient, this sounds like an infection. And you obviously think about patients who have surgical site infections or relate surgical related infections. And lastly, if she has a Foley catheter and some post-op patients do, then I'll also think about urinary tract infections.

man, the Foley strikes again. I'm gonna move the case along a little bit. That's really helpful, because I think sometimes when you walk into the room, there's just sort of this like mass panic to do everything without really stopping and slowing down and just like talking to the patient if they're able. Sometimes mental status may not allow it, but if you can, I think talking to them and try to figure out something localizing would be helpful. And the next part of the case, your point about her recent surgery does come in handy. So...

She tells you that she's been feeling increasingly weak over the last 24 hours. She's been feeling feverish since chip change and really hasn't had an appetite. She doesn't have any cough, shortness of breath, dysuria, abdominal pain, nausea, vomiting, or diarrhea, but she does note ongoing pain in her left lower extremity after the surgery and has noted a development of a new rash near the anterior and lateral aspect of her upper thigh. Her physical exam's really only notable for the skin belay over that site, the post-op site.

So, you know, I think that's helpful, but this is also a situation where I'm out of, a rapid response is called, or whatever that equivalent is at your hospital. And so I kind of just, before we get into like testing and stuff, want like kind of a, what would be helpful in like just logistically running a rapid response? Like what sorts of things are helpful? I think depends on your institution. So how,

The Curbsiders (10:16.602) At my institution, for instance, there is a critical care nurse who always responds, which is excellent because they can help you get IV started, but also know how to give medications that you may need to give urgently. Certain ICU nurses are also able to put in I.O. access, or advanced practice providers who may respond may be able to do that.

depending on the institution, you may have a physician who might respond. So that's always helpful as well. Having the patient's actual nurse be there is the most helpful part because just getting that history figuring out what medications the patient got this today, earlier today, and, you know, somebody who knows where things are in the unit and then usually having a charge nurse around or the nurse manager around because...

If there's something not available right away in the room, they can call for help and they know how to mobilize stuff. So these are usually important people. And then a respiratory therapist, in case there is a respiratory issue going on, that's usually also very helpful. So really needs to be a team of people, but those are people I would say are essential. Yeah, no, what I like is that you did list essential people because what you did not say.

is every nurse on the floor needs to be present for the rapid response, which I feel is sometimes. So actually that's the question that I think a lot of us have is like, how do we do crowd control other than like, asking people to leave, like what tasks and sort of things that should you just be like assigning right off the bat? So you're right. There are many times I've walked in and there's just, a hallway full of nursing staff leading to the room and then a whole bunch of people in the room.

My first job when I get in is to figure out who's who and who really needs to be there. So, you know, I think having the ICU nurse there and maybe one or two other nurses, because we're probably doing a lot of things to the patient. So having two or three nurses there is probably sufficient for the most part. I think having somebody like a nurse manager or a charge nurse outside the door.

The Curbsiders (12:38.402) who can communicate things and call for things is helpful. And then, like I said, having the essential people in, but everybody else got to leave just so that we can rapidly assess the situation and communicate a little bit more clearly. Yeah, and I think that that's really helpful. Again, crowd control is so important because I feel like I stop having the ability to think when there's just too many people, you know? It's just like so many people around.

I guess moving now that we have the people in the room that we need. I was kind of wondering if you could go through, you know, obviously this patient looks sick on paper, but like, what are some of the scoring systems and like that sort of thing that we use or maybe should stop using when we're trying to really for triage purposes, I think, honestly. Yeah. So I think I'm going to give away my age because back when I started my training,

We still use the SIRS criteria a lot, which has fallen somewhat out of favor. So for just to recap for folks who may have forgotten, SIRS is temperature greater than 38 or less than 36 degrees Celsius, heart rate greater than 90, respiratory rate greater than 20, or PACO2 less than 32.

and a white count greater than 12,000 or less than 4,000 or 10% bands on the most recent CBC. So, if you had... So, that's SIRS, and if you met two of these criteria, plus you had a source for infection that used to be the old definition for sepsis. So, SIRS criteria was not very specific, and that's why it has fallen out of favor.

So as you can imagine, a lot of our patients in the hospital probably meet SIRS criteria at some point in their hospital stay. So especially a post-op patient who's probably in pain, I would imagine her heart rate probably goes up and she's a little tic-a-nic because of that pain. So she meets two out of those criteria right away, doesn't necessarily mean she has an infection because of that.

The Curbsiders (14:59.018) I think that's the reason it had fallen out of favor. Then came sepsis three definition, which was life-threatening organ dysfunction caused by a dysregulated host response to an infection. And to help screen people for sepsis, people had recommended or the...

definition had recommended using QSOFA, which is the short form of the SOFA score. It's quick to use. You use altered mental status, tachypnea, and systolic blood pressure less than 100 as your criteria. And while we all started using it, it came out that it was not the most sensitive. It's very specific, but not very sensitive. So you could miss people with infection easily.

There are other scoring systems like news and muse, which are a little bit more involved. I know certain hospitals that use that as a dashboard for everybody in the hospital who's connected to it. And certain rapid response teams actually monitor that dashboard and respond anytime the dashboard alerts them to a patient who may be getting sicker or may need a transfer to higher level of care.

or just simply just needs attention. Those news and news perform a little bit better than QSOFA and so you can use them, but they're not as quick. So you need to have your handy cell phone and an app to look at those. So I will be honest, I...

While I would love to look, use news and muse all the time, it's usually, you don't have time to pull that up and start calculating. And a lot of, you know, what we're gonna do with patients is sometimes just clinical judgment. And when you, like in the hospitals that are using that for like their rapid response trigger teams, do they know how they, like what was on that score triggering that rapid response? You know, what was scoring them high enough? Are they getting to the rapid?

The Curbsiders (17:13.782) and just again trying to use their clinical judgment during that. I think they do know what score pops up. They also know what is triggering it. So for example, if somebody has a low blood pressure or a high heart rate, that's usually on the dashboard that's using it. So yes, again, it doesn't necessarily mean that you have a high new score that you definitely need. You know, again, these are not 100%

percent specific. So you might come to a patient's bedside and figure out, well, actually, they just need a little bit of stabilization or a little bit of extra attention, but they're fine otherwise. So that may happen as well. Yeah, I think it's just an interesting topic. So I just wanted to highlight that Moni and I sort of wanted to do this case as someone who is already on the floor, because I do think like.

when they're coming out of the ER, that's usually fresher in your mind that they could be septic. But like you said, there's just so many different things on the differential once they're on the floor. And sometimes I think that your medicine brain overtakes and you're just like, oh my gosh, it could be 18 different things and you're trying to just justify, could it be that other thing? So I do find some of these, using news and muse for the dashboards is a super interesting modality for some of these.

hospitals. So we can go ahead and move on a little bit. So we've established, you know, she definitely seems septic, concerned about maybe this coming from her leg, because of the prior history. We'll assume that, you know, used, you know, your good doctor ICU voice and got some good crowd control in the room. And now you're starting to think, okay, like what?

other diagnostic tests could be helpful for me to kind of make the next steps for this patient. So what are some of those and what do you prioritize? So just going back to your point about patients on the floor versus patients in the ED, I think that sense of urgency about sepsis, I think it's a little missed on the floor. So I think if you are thinking about somebody who...

The Curbsiders (19:37.774) potentially have sepsis. So definitely secure stuff that you would do in the ER. So get blood cultures, get a lactic acid, and if it's elevated, that is something that we're going to trend later. You know, specifically for this patient, I'm a little concerned about the report of the rash on the upper thigh. You know, certainly could be related just to her surgical site, but I think...

as an ICU doctor, I think about high mortality things. So things like neck fash or necrotizing fasciitis come first to my brain and those are surgical emergencies. And certainly while this patient may look, just run the male sepsis right now, she could go into septic shock and just go down very quickly. And so getting a surgical evaluation on her as quickly as possible.

I know some people would like to send her for a CAT scan, but I think her blood pressure is a little bit low and I'd like to stabilize that a little bit further. And oftentimes, sometimes necrotizing pastyitis is just a clinical diagnosis and you don't always need an imaging. So just want to emphasize that sometimes they just need to take the patient to the OR once they've stabilized the patient. So I think for now I'll start with that. And then...

You know, you can repeat labs assuming she got labs that earlier, that morning at 5 o'clock stick maybe. And if this is late in the afternoon, sending your regular labs, CBC chemistry would be helpful as well. And then one of the things I had seen in the guidelines that I was just kind of confused by was Procalcitonin because I feel like Procals are like thrown out the window. But the way it's like phrased in the guidelines, it almost makes me think you should.

as if it was like a lactate, like as an inflammatory marker. But I wouldn't think about that for like Ms. Suarez, who, yeah, I'm concerned about neck fas and her too. So I think you're referring to the surviving sepsis guidelines, perhaps. So I think the recommendation, the way it's worded is, they do not recommend, they recommend against using it to decide antibiotics. So in a patient that you think has sepsis,

The Curbsiders (21:59.766) go don't use procalcitonin to guide whether or not you're going to give them antibiotics. And I think I agree with that. I don't think procalcitonin helps me decide whether or not somebody has infection or just plain inflammation. The best evidence for procalcitonin comes from lower respiratory infections and guiding antibiotic therapy. So as in you...

have somebody with pneumonia, procalcitonin was elevated. And if you're trying to decide when to deescalate or stop antibiotics, the procalcitonin trend can help you with that. But I think in this particular case, I would not wait for a procalcitonin, especially at my institution, it actually takes time to come back and that's too late. Antibiotics need to go in as soon as possible and certainly within an hour based on the guidelines. So I wouldn't wait for that.

And then for her, you sort of already referenced this when we were talking about her specifically for the neck fashion, not necessarily needing imaging to like make your clinical decision. But I think one of the things that I often see in rapids or even in codes is like someone comes in with an ultrasound to do some sort of focus. And I'm just curious is like in thinking about anyone who potentially has subsist.

Is there like utility to like, focus in that moment? Or is it like more useful at other times or things like that? I think, you know, if there is an unclear etiology of shock and you're trying to make a decision about fluid resuscitation perhaps, you know, in that case, sometimes focus can be helpful. In this case, you know, this looks like somebody who's septic.

and is now hypotensive. I think our next step is gonna be giving her fluids. So I'm not exactly, I don't think in this case it'd be that helpful. And even in cases of undifferentiated shock, POCUS is not, you know, perfect. A, it depends on the individual's ability to do POCUS, especially when it comes to your cardiac windows.

The Curbsiders (24:21.274) And just to remind people that, you know, it's better to use dynamic measures of fluid responsiveness and dynamic, I mean, things that change. So, POCA can sometimes be a very static measure just in that moment, what it looks like. And you may find somebody who has an EF that's reduced and maybe have some B lines on their lung exam that may indicate some pulmonary edema.

But that doesn't necessarily mean that you should withhold fluids from them. So fluid responsiveness is a much different analysis. And honestly, the best evidence, if you're trying to decide if somebody's fluid down, the best evidence we probably have is the straight leg raise, which requires an art line and some other devices probably. And that's best done in the ICU. So for in that moment, Pocus.

may not be very helpful, especially when you're trying to just triage the patient in rapid response. Yeah, as you're talking about this, I'm also just thinking about the logistics of bringing in the POCUS. I know that there's like the pocket ones, but still like when you're trying to get labs and that sort of thing, what I'm hearing from you is like, if you have maybe a second and other things have already started cooking, like maybe you can stick a probe on them. But those other things we talked about, like getting the lactic acid and getting...

you know, some other labs, blood cultures, and maybe some other things started, maybe are a slightly higher priority. Is that fair? Yeah, I agree. Especially like giving antibiotics and fluids. Like, I think I would not wait to do that. Because by the time you make that decision, it's still gonna take a minute for those things to come up and for the nurse to hang those. And so every, literally, that's when minutes start adding up into hours. You know, that's a good segue.

I think, in advancing Ms. Suarez's case. So she's clearly sick. We've gone through our considerations with testing. You know, we've got some labs cooking, and you mentioned, you know, antibiotics and fluids, but before we can even do that, can we talk a little bit about, like, access? Like, what kind of access? How big does a needle need to be? Where should it be? And that kind of thing. So I think a good peripheral IV, the...

The Curbsiders (26:46.39) Smaller gauge, the smallest gauge you can get in would be better for fluid resuscitation. So I think sometimes people jump towards central lines in certain cases. I would advise you not to do that. So when we're trying to resuscitate patients, the best flow that we get is from the shortest and fattest IV you can find, preferably above the ACE. And the reason for that is if we need to start pressors.

that is a safer way to do it. So, you know, that'll be great. Now, if a patient is a difficult stick and has no access because they lost it or whatever reason, certainly IO is an acceptable way to give medications and fluids, but I would still have somebody, it's not as fast. So I would still have, you know, your...

best nurse on the floor or your best ICU nurse try for an IBE in the arm above the AC. Okay. And you kind of alluded to it, like, especially in the situation where the patient maybe isn't quite septic, but they're on their way, antibiotics are kind of prioritized. And so can we talk a little bit about what antibiotics to pick specifically? And then we can kind of ask some other stuff.

While we're still trying to work up where the sepsis is coming from, it's better to be broad and give broad coverage and then you can always de-escalate later on. Not just in this patient, but in most patients, especially one that's been in the hospital for a while, you want to try to see if they need MRSA coverage.

you know, if they've had MRSA before, or if your hospital tests for MRSA colonization. So in my ICU, all patients get a MRSA-NIR swab that tests for MRSA PCR. So if they're colonized with it, probably a good reason to give MRSA coverage, so vancomycin. If they've had antibiotics recently, so she was being treated with antibiotics already, definitely in her case, because she's got a...

The Curbsiders (29:03.374) questionable skin infection, I think for her, definitely MRSA coverage is required. And then, you know, people in the hospital who may have, who may be dialysis patients, have chronic follies or have permacats or, you know, if they've been in the hospital, in and out of the hospital in the last three or four months. And depending, again, on how sick a patient is, you know, it's better to go broad. So MRSA coverage is one.

give vancomycin that should give you your gram-positive coverage. And then other antibiotic choice would, if they have risk factors for pseudomonas, that'll be another thing that I would go after. So whether you pick zoosin, which is, you know, the lovely combo that a lot of patients get is vancomycin and zoosin, or you can try for another pseudomonal coverage.

But there are cases where we'll give double pseudomonas coverage depending on how sick the patient is. There are guidelines for that, but I think those are the two to start with. And then for surgical patients especially, I keep in mind fungal coverage, especially if they've had abdominal surgeries and were getting things like TPN, you know, that's something else. There is something called a candida score.

In the guidelines, this is my own personal preference. I do calculate it on patients and think about it at some point. Maybe it's not the first thing that you think about when you're thinking about your antimicrobial coverage, but definitely something on my mind that I might give. But if you're just deciding in that first hour, vanxosin, vanxepipine, something like that should be good.

The Curbsiders (31:00.822) And so you can't hang all of these at once. So is there one of the like PIPtazo or Vank, does one of them get preference? Say you only have one access site and yeah, your nurses are trying to get, but you know this is actually, this actually comes up. So I was just curious if there's a method to thinking through that. I mean, you know, if you know sort of what...

the patient may have. Zosun will have some gram-positive coverage too. It will, just because it has pipercilin in it. But if you're specifically thinking about MRSA, which in this lady with skin infection I am, I think I'd prioritize those. Also, I know a lot of hospitals do slow infusion of Zosun. This is not the time for slow infusions.

And just another thing for vancomycin, you wanna go ahead and give a loading dose. So not just the regular maintenance dose, you wanna give a loading dose of 15 to 20 milligrams per kilogram weight-based dosing. So, but yeah, so I think in her case, I might prioritize vancomycin if I cannot get another access. Yeah, I mean, I think we painted like a picture for her where like...

the MRSA coverage ends up being like very top of mind. So I agree with that sentiment. I think the big talk or whatever after SHM this year was prioritizing beta lactams when you, especially if you don't know the source of the infection, so which you just said too. And then it sounds like after all of that, if you.

for her, like where you are maybe thinking about a surgical site, then after that, your fungal coverage would kind of be like the third thing to go in, is that right? Yeah, I mean, antifungals is something more like when she's maybe down in the ICU and you're thinking more detail, but if you're just thinking about first thing to give, agreed beta-lactams cover most.

The Curbsiders (33:08.738) gram positives and gram negative coverage. So it'll give you a broad enough and it'll work for it. And in case where you don't know where things are going, so I think give that first and then vancomycin followed by that. And then if still you're now you've had time and you've hopefully gotten some results back, you have a little bit more time than think about antifungals. And you mentioned double coverage, but I might've missed specific.

indications for double coverage. So in my practice, if somebody has septic shock, which is often the reason they end up in the ICU, and I think they have a gram-negative rod infection, and sometimes it's clear from the get-go. Usually I find that patients who are bacteremic with gram-negative rods tend to get sick very, very quickly.

So you often have somebody who maybe has a urinary source, you are already suspecting it, maybe they have pyelonephritis and you're thinking already along those lines and they're just very, very sick. So I may give them something like a Zosyn but then add another agent just because of how sick they are and they'll need that coverage, just maybe one dose. And so...

I know this is going to horrify some of the nephrologists on the call perhaps, but something like a gentamicin has been used before. I know people are like worried about kidneys, but hey, bad sepsis and bad septic shock also kills kidneys. So you have to weigh risks and benefits. It's been a while since we've mentioned that my brother's a nephrologist, and we'd be distraught by this conversation. So I think we covered it in a bit.

was there? Yeah, antimicrobial is pretty well. So I think naturally we should talk about fluids. So how much and then what kinds of fluids? I know that change happened between the 2016 and 21 guidelines, I think, in terms of the recommendation of what fluids to give. So like how much and what do we give? So the current guidelines recommend

The Curbsiders (35:25.422) 30 cc's per kg of fluid within the first, so this is one of those Medicare sepsis criteria's that you get judged on. So have to give that 30 cc's per kg fluid within three hours for sepsis-induced hypoperfusion or if you think somebody has septic shock. And just to remind people, septic shock, according to the new guidelines is, if they are still hypotensive requiring vasopressors and lactate greater than two,

after adequate fluid resuscitation. So if you're still in that phase where you're trying to get the initial bolus of fluids, you may want to wait and see how they respond to that. There's still weak evidence for how much fluid to give. That is always a question of debate. And I'll come back to this, but what kind of fluid to give? I think there's been a move towards more balanced

fluid, so crystalloids. Low quality data in some case, so there was a smart trial that came out in 2018. Single center study looked at, and it showed that there was lower mortality in those receiving balanced fluids versus normal saline. I think if you have the opportunity to give lactated ringers or a plasmalite.

then go ahead and give that. But if the only fluid you have around you is normal saline, go ahead and give that. I think maintaining blood pressure is more important. But if you can give balanced crystalloids, that should be given. The other thing that sometimes comes up is albumin, especially for patients who are perhaps chronically ill, have low albumin, or are perhaps patients with liver disease, liver failure.

It will initially, theoretically, there's the sense that it'll maintain oncotic pressure better than crystalloids, but it is very costly. And in a routine situation, there is no clear benefit. So the guidelines say if somebody is receiving large amount of fluids, then you may consider it. But I would say, especially now with more and more move towards.

The Curbsiders (37:48.65) not giving excessive fluid resuscitation, I would rather just start vasopressors sooner than keep giving patient more and more emboluses. Give that initial 30 cc's, then reevaluate. Maybe this is the time to focus the patient and see if they may need additional fluids. I would still say best evidence is for a straight leg raise if your bed allows you to do that.

and see if they're fluid responsive and give them additional fluids. But I would definitely recommend starting vasopressors earlier rather than later. And the more you fluid overload at some point the patient may end up in trouble.

So this is, I think, the million dollar question for every hospitalist. So at what point do you feel like they have received X amount of fluids, and so what is X that you feel like that was adequate fluid test and now I need to start pressure support? So if somebody's received their 30 cc per kg and they're still hypertensive.

maybe they improved for 30 minutes and now they're back down to where they were. I usually would favor starting, you know, the laser presser earlier rather than later. There is a recent trial that came out this year in New England Journal of Medicine. It's called a Clover's trial. And it showed that restrictive fluid strategy did not, which...

was their hypothesis was that it would lower mortality compared to liberal fluid strategy. So patients with sepsis induced hypotension, which is where our patient is right now, we don't know if she's essentially shocked yet, but she's definitely got hypotension, who were refractory to the initial one to three liters of fluids. They were given vasopressors with rescue fluids, or they were given one to two liters of IV.

The Curbsiders (39:57.558) boluses after that initial fluid resuscitation. So as you can see, somebody's received one to two liters of fluid as that initial fluid resuscitation, and they're still hypertensive. I would go ahead and consider starting vasopressors. And you can still.

reassess. You can still get more fluids along with the vasopressors and hopefully wean off those vasopressors if you think they're still hypovolemic. Well, Meredith, I think it's time to recap because I feel like we just covered a lot of ground. So I'm going to do everyone a favor and do a recap. So one of the things I liked that we started with was sort of managing the room and making sure that everyone that's in the room needs to be there. So, you know, probably about three nurses and including like a charge nurse who can kind of just

get things that are not in the room and helping with access and things like that, and assigning those tasks. And then I also, it's helpful to know, you know, the highest yield things that you want to send off to the lab when you're drawing blood would be like a blood culture and some, and blood cultures and lactic acid. And then obviously you're starting antibiotics and fluids and then the fluid space with the Clover's trial, you know, restrictive versus liberal fluid strategy.

didn't really seem to have much difference. And yeah, I think that's a good recap of what we just did. So I think you can advance the case. Sounds good. So Ms. S, she received three liters of fluids and got started on her broad spectrum antimicrobial therapy, but she's still tachycardic. Her blood pressures are still on the low side. And we kind of were already referencing this before,

you know, pressers on the floor kind of while you're triaging the situation, I think, especially patient is still physically on the floor. Kind of what is the practice habit or what could we think about for presser support on the floor when you might only have that peripheral access? So, I think, you know, depends again on your institution. So, you know, you may be in a

The Curbsiders (42:17.854) an ICU room may not be readily available to you. So you may have to actually, not just during that triage time, but actually have that patient on the floor with rapid response nurse managing the patient and doing ICU level of care in the floor. So that is certainly happens at a lot of hospitals. I also think it's important to point out that even if you have an ICU room available, readily available,

You want to make sure that the patient's stable before you put them in the elevator on a long trek because it has happened where patients have arrested during transfer or have arrested immediately on arrival to the ICU. So do your due diligence, make sure they got their fluids, and if they're still hypotensive, go ahead and start them on vasopressors.

The recommendation is you can certainly start them up peripherally. And again, as I said, a peripheral IV above the AC is safe enough. In fact, the Clover's trial that we had mentioned earlier, while this was not the primary endpoint that they looked at, but that trial also allowed for initial vasopressor use through peripheral catheters. And out of 500 patients who receive vasopressors through

peripheral IV, there were only two occurrences of fixer apization, which I think is like maybe they just have great IV placing nurses at these sites, but it was a multi-center study. So I really like the fact that, you know, the risk of fixer apization, which is what we worry about the most with vasopressors was pretty low. And then additionally, about 360 something patients out of

The total 1,500-something patients that they had in the trial, only 360 got central lines. Perhaps about 200-something patients who got pressures didn't even require central lines during their stay. So I think lack of a central line should not limit ways a pressure use, especially if there is going to be a delay in getting the central line in.

The Curbsiders (44:36.01) and getting the patient to the ICU, I would go ahead and just start it. And the first line choice, of course, is norepinephrine. That is the recommended. It works, and I think it's a good choice also in not just in septic shock, but also when you have undifferentiated shock, where you might think there's some cardiac dysfunction going on or maybe some, maybe cardiogenic shock. Levofed is still a good first line pressor.

And what dose do you start? This is where your ICU nurse comes in really handy, because I assume that most of the nurses don't have, most of the floors will not have LevoFed in their PIXIS system. So if your pharmacy system works well and you can get a tube there, fantastic. If not, I sometimes call down the ICU and have them send.

me, Llewafet norepinephrine up to the floor where I'm at, and my ICU nurse will start it. At most institutions, it should be based on the patient's weight, so you can add it, and you can start it at.

0.02, it just depends on how septic they are. And you can just, but you need to make sure they're in a setting where you're monitoring their vitals and if somebody is able to titrate up or titrate down for that matter, you don't want the patient to hypertensive either. So just start it. And our ICU nurses can also mix LevaFed very quickly. So they don't need to wait for pharmacy for that to happen. This was all very helpful, but I'm just gonna say in med school,

They made it seem like if I even looked at a patient with a bag of norepi with their peripheral in mind, that they would necrosis off their limbs. So this is very helpful information. I mean, I will say in practice, I mean, this trial is great because I think it validated what we do in practice in the ICU all the time. So when patients come in, I mean, yes, we are very good at putting in central lines and I love putting in central lines. I have fellows who love putting in central lines, but sometimes,

The Curbsiders (46:50.666) We have other priorities. We have other sick patients too. So you may not be getting that central line right as you hit the door in the ICU. Other things may need to happen. And if the patient's hypotensive, they will get Levofed peripherally, or norepinephrine, sorry, peripherally, for a good bit of time before we'll get that central line in. And sometimes, you know, they may need norepinephrine very transiently.

You may actually, if the antibiotics finally kick in, you have good source control, for example, they may be able to wean off those pressors completely. So you may, and I think that's what happens in regular cases where you may not end up reading a central line at all. So I think we use it a lot. Now, if there is a IV in the foot, that is...

Probably not my preference to start vasopressors on. Certainly we've done it with IOs, but I would say again, get a good IV above the AC, not a foot IV or one in your hand. Those I think are more likely to exacerbate and cause problems. That was my other question, so you can give it through the IO too if that's the access you have.

If that's the only access you have, especially in cases where, you know, the patient has coded, I have given, you know, you push happy through it, and that's a much bigger dose in the bolus one, you can give it. Assuming at that time, IO is not my preference. It's not the same as when I'm giving vasopressors to an IV in the arm. I will...

during this time I would prioritize that central line to get better access because that IO can only deliver so much. So if you need fluids, you need pressers, you need antibiotics, you need more lumens. So that's the time that if we cannot get any other access, I am prioritizing a central line in that case. And my last question on the pressers is, is Nora, like patients on the floor, I'm the hospitalist, I have access to an ICU.

The Curbsiders (49:06.366) Is norepinephrine really going to be the only one that I would consider starting? Or is there any scenario where you would be using a different presser for sepsis? If you cannot get norepinephrine up to you as quickly as you want, start whatever presser you can start. So in my cord cart in our hospital system, we have something called dopamine.

which was widely used back in the 1980s. We have moved on since then, but that's what's available. So if we need to start something right that minute and we cannot wait for the LevoFed or norepinephrine to come up to the floor, just start and hang that and get the blood pressure up. You can switch it out once you have the LevoFed available.

Other scenarios, same thing with epinephrine. If sometimes we can just mix an epinephrine drip. So if that's what's available to you, go ahead and hang it. Especially if you have your friendly anesthesiologist anywhere close by, they're excellent at mixing it up. But also your ICU nurse should be able to mix up a lot of these strips, because they do it on a regular basis. So whatever you can get your hand on, just go ahead and start it. And then we can always switch it out to norepinephrine when they...

when we have it available or they're down in the ICU. This stresses me out. I feel like I would be calling you like all the time, being like, what am I allowed to do and not allowed to do? Because just like Moni said, like I'm just the same ischemic, like necrotic like arm is going to fall off and it's going to be because I started the random bag of like dopamine. Oh man, dopamine. That really is a throwback. I remember that was the one you just kind of sprinkled on at the end.

even when I was training, which was a long time ago. Yeah. I mean, we do use dopamine. If somebody has right heart failure, so somebody with pulmonary hypertension and floor right heart failure, dopamine is something that we will preferentially use sometimes, but in most settings, if patient's blood pressure is low, you've given them fluids, you're giving them more, but they clearly need vasopressor, start whatever you have peripherally.

The Curbsiders (51:25.846) hopefully with good access. And again, happy to come in and put in a central line if you think, you know, hey, we don't have enough access. We have this one IO and I don't wanna keep using it. Happy to come in and put in a central line and take care of the patient. And hopefully by the time you're starting pressers, the ICU is already on board and coming over to evaluate the patient if they haven't already.

Yeah, I think that's kind of the key point too, is like at this point you should be having like all of your critical care support, kind of jointly making those decisions with you. Agreed. Yeah, cause they're probably in route or borderline about to move like you said, once they're stabilized. So you're sort of in the process of like the transfer of care anyway. So I think...

With that, the next set of things we're going to talk about is all of the supportive measures that we should be doing kind of concomitantly that we don't always think about. So O2, so Miss S doesn't have a primary lung thing that we're worried about, but are there any specific O2 requirements we should be trying to meet or is it just kind of the same as if anything else was going on?

So, so far, no great trial data or evidence to guide this if what your O2 goals should be in sepsis. I also want to point out that be careful about what your monitor is reading on the pulse ox on your monitors, because if these patients are hypotensive, they clearly have poor perfusion, that pulse ox may not be capturing it, especially on the floors, unless you have

devices that we use in the ICU, such as forehead monitors or more of your ear ones that get plugged in, they may be a little bit better. But sometimes if a patient is truly in bad shock, you may not get anything and then you're relying hopefully getting them better perfusion and getting better numbers. So just that's one caveat.

The Curbsiders (53:41.55) There's no evidence. So I say for most acutely ill patients, you can target anything above 92% greater or equal to 92%. If they have a pulmonary issue and let's say ARDS, then 88% is the threshold that we look for at the very least. And then in situations...

where, you know, maybe they're in acute hypoxic respiratory failure, obviously not this patient. But I remember reading that, and I don't think I'd realize this or remembered it if it was taught to me, but it seems like high flow, like this is obviously we're hopefully transitioning to the ICU, but it seems like high flow nasal cannula is preferred over non-invasive. Is that, did I read that wrong?

Again, depends on the situation. So I think if you're thinking about ARDS, yes, high flow nasal canals. So, and when I talk about high flow as a pulmonologist, I'm talking about things and I'm gonna reference some devices that are brand name like AirVo or Vapotherm in some instances. So these are like very high flows. So I'm talking 50 liters per minute flows and you can give almost 100% FiO2 through those.

So those are good adjuncts. We're giving a good amount of oxygen to somebody who's very, very hypoxic, but they don't carry, they don't have a lot of peep or for really patients who are really hypoxic and they may require a little bit more alveoli to be open at all times. You want that peep to be delivered. Of course, positive pressure ventilation is one way of doing it,

your CPAP or BPAP, or you do it through invasive mechanical ventilation. But high flow oxygen canals don't give that. So if you have somebody who is going the ARDS route, you can try high flow nasal canals first. It's just a lot more comfortable for a patient, but then if they're not doing well with that, or if their work of breathing is really excessive, maybe try a non-invasive first.

The Curbsiders (55:58.642) And then, of course, if somebody has pulmonary edema or in any sort of cardiac etiology that might be causing pulmonary edema, then a non-invasive in that case, I think, would be more useful compared to a high flow nasal canola, just to push that fluid out. Yeah, I feel like my comfort with high flow was at its all-time high on the floor during COVID and has since waned. We use it a lot.

And, you know, those were, I think, good patients to have them on because they didn't necessarily require a lot of positive pressure at that point. They just required a lot of, they were just very hypoxic. And so they came, it came in really handy to have that. And I, this is segueing into a different topic, but ARDS at some point, I think they're going to revise their definition, hopefully, and take this into account because currently the definition requires you to have a PEEP of.

greater than equal to five to call something ARDS. But clearly, I think there's some debate about that. Okay, I think we've covered floor level oxygenation about as well as we should. So this next part's kind of the smorgasbord as I like to call it. There's a whole litany of things that get brought up in sepsis, some of which I recall using, some of which have come and gone in vogue and whatnot.

Steroids, that one I think still probably has some utilization, but in the acute, like rapid situation, how useful are steroids? So I think on a floor, probably not the first thing that's coming to my mind, unless you tell me that this is somebody who has adrenal insufficiency diagnosed already, and which is very few and far in between cases. So unless that's the case, and you know this about the patient.

Steroids are not something that I'm thinking on the floor. Certainly in the ICU, that is something that we do use. Now, they have been shown to accelerate resolution of shock, but clearly has no effect on mortality. So, and then, you know, there are some side effects associated to it. So steroids do cause neuromuscular weakness in the wrong run. So we...

The Curbsiders (58:23.49) typically reserve it when, you know, the guidelines recommend if you are on a norepinephrine dose of greater than 0.25 micrograms per kick per minute. So if you're at that level of LevaFed, you should consider adding steroids. And this is also the time that I'm considering adding a second presser, which is usually vasopressin. So...

If I'm adding a second presser around that time, I will probably go ahead and put them on stress-to-steroids, which my preference has been hydrocortisone 50 every six hours. There are other steroid formulations that have been used and steroid infusions that have been used. Again, no effect on mortality, so that's why it's not as prioritized, but certainly something that I think about.

in patients who have severe, very bad shock and are requiring more than one pressor. So some of the things that go with steroids, obviously stress ulcer prophylaxis and then glucose control is probably very relevant. So I think we can sort of remember that and hopefully they're in the ICU when this is happening. So I'm really not thinking about it. And then, you know, with sepsis and, you know, always thinking about VTE risk. So making sure there's prophylaxis for that.

A couple of my fan favorites, honestly, vitamin C. How do we feel about that? High dose vitamin C. Yeah, I know. Back when we were giving people vitamin C like crazy. So my institution was a part of the VICTIS trial. And that is the randomized control trial that studied vitamin C along with thymine and hydrocortisone.

compared with placebo, and it actually did not show any mortality benefit. And it was actually terminated early for administrative reasons and may have been underpowered, but really did not show any benefit. And the surviving sepsis guidelines recommend against it. So they recommended against it even before the trial was, trial results were out. But the quality of evidence prior to that was pretty low.

The Curbsiders (01:00:46.802) evidence, but now we have this trial that came out. So it's really fallen out of favor. And I can't remember the last time I gave somebody vitamin C. Also, fun fact, if you give somebody vitamin C, you cannot use accue checks or glucometer checks. We're checking their glucose levels. It's incorrect. So you need to actually draw it on patients. So it also adds a logistical hurdle for patients, patient care.

Is that overall, because you're giving them a certain dose of vitamin C? Yeah. I do not recall if it's dose-related, but certainly when we were doing the trial, those patients could not just get regular acu-checks. So if they have an art line or whatever access they have, we were checking blood through that. Yeah. And I think, you know, in our own nutrition, also something we think about. And then the high dose vitamin C actually is like a nice segue into like...

Just very briefly, AKI management, and then the utilization or need for bicarbonate, because the AKIs resulted from the high dose vitamin C. I will say that probably they will have some pre-retinal etiology if they were a little bit hypovolemic, but if they were also in septic shock, they probably are gonna progress to something called ATN.

Normally, in the immediate setting, so on the floor, they're not gonna be acidotic because of septic or septic shock resulting in AKI right that minute. They don't become that acidotic from that right away. What I do see happen is if they have respiratory reasons. So somebody who is in profound septic shock, completely up-tunded, cannot protect their airway, their PCO2 may climb up to 100 and then their pH is like 7.0.

So if that's the scenario, which often does happen, so if you walk into a room, somebody's floridly septic, you're giving them fluids, you've hung the vasopressors, and they need to be intubated. So yes, you can intubate them, but realize that they're probably profoundly acidotic. And in that case, before you start that trek to the ICU, I may sometimes, and...

The Curbsiders (01:03:08.154) Sometimes we'll draw an ABG and get that very quickly. There are POCT available, ABG, to tell you exactly what their pH is. And then I may give a push-up by carb just to stabilize them. And hopefully if they've been intubated, that PCO2 will go away and their pH will get stabilized. But as they do get into AKI, they will slowly, and if it does not get better,

start to have electrolyte disturbances or acidosis, especially if they're in really bad shape. And then that's the case, bicarb pushes for immediate stabilization. But if they're really acidotic, I tend to go for renal replacement therapy. So this is when we're putting in another catheter and going for dialysis. You can do bicarb drips. Those are usually

for temporizing measures, you're giving a lot of fluid to somebody. And so I don't wait, like if somebody's really going bad, I prefer to talk to my nephrologist early and start them thinking about dialysis early and just, you know, hang that bicarb while I'm trying to get the line in, get the continuous renal replacement started. Those things take some time.

So hopefully you're temporizing things with it, but if they really need dialysis and they need dialysis, then you should do that early. Any other smorgasbord you want to talk about? No, I think that's good. Just kind of bringing it home. We know these patients are very sick, so I think it's important to think about two things, prognosis and then the utility of palliative care. I think those are two that I think are good to end on. Yeah, so, you know, somebody has septic shock.

The mortality for that in a lot of studies is upwards of 40%. So, you know, that is a bad prognosis for a lot of patients. And, you know, oftentimes the areas that I see that we can do better on the floors are patients that you know are not going to do well in the long run from the moment that they were admitted to the hospital. So these are...

The Curbsiders (01:05:30.286) chronic nursing home patients or patients who are very elderly with multiple comorbidities who've been in and out of the hospital or are bed bound and just you know that they're not going to do very well. And so while they may have or if they've been in the maybe they came out doing okay came in doing somewhat okay but now due to various complications have had a prolonged hospital course. You know they may be doing.

okay for now awaiting placement, but as it often happens, just the day before they're supposed to go out and get discharged, they get septic and require transfer to the ICU at that point. So I think getting palliative care involved and having those goals of care discussions early, knowing that if a complication like this happens.

they're not going to do very well in the long run. And having those conversations early and having that documented, especially with family, is very important. Because the time that they're crashing or somebody's having a rapid call on the floor, those are really not ideal situations where we want to be having those conversations. I mean, we do have those conversations. Don't get me wrong, sometimes, you know, while we're doing all of the things that we've talked about, somebody's also calling.

the family and trying to have these discussions and trying to decide. But sometimes we can't wait, you know, for the family to get on the phone and we just need to. So like if somebody needs to be intubated and their full code from everything else that we've read, then I'm going to go ahead and do that. So I think in that case, I think those are areas where I feel that hospital is.

know you guys are very busy on the floor, you have tons of patients, and maybe there's some comfort in having seen that patient every day and knowing that they're doing okay, but just having it on the back of the mind that if they're sick enough to be in the hospital, they are sick enough to get a complication and end up in the ICU, and maybe that's not the best place for them because that 40% is an average mortality risk.

The Curbsiders (01:07:42.414) For somebody who's elderly and has a whole bunch of comorbidities, that risk is probably much higher. This whole episode we were kind of painting like a rapid response situation. I think when you call the family and you update them in that moment that, you know, patient's not doing well, it's a lot for them to take in and for them to adjust to the rate that you're having to make decisions. It's really difficult for the families to make any of those decisions.

timeframe that you really need it. So I wholeheartedly agree that like the earlier the conversations happen in the hospital course, it just sets everyone up for more success later to really know what the patient and the family's like goals are. Yeah, and you know, the other situation that I also come across not so infrequently is where the hospital has done the greatest job and had this conversation and

and family were aware and there's great documentation that they do not want to be resuscitated and would not want to be intubated. But then when a rapid gets called, somebody calls the family and now the family says, no, we want everything done. And so there's that rapid reversal. And hopefully the conversation is great enough, but this still happens.

And in that case, you do the best that you can. And so certainly it has happened where we've done everything. And then when we've talked to the family again, after they've had a chance to come in and, you know, see the patient and sometimes all people want is to see their loved one once before they expire. And I also like to warn people that while we may continue to do everything that we can to.

to treat their underlying issue, to keep their heart going, as people like to call it, but it's no guarantee that they're not gonna arrest in the near future. And so while we try to give families every opportunity come say that final good-bye, which is very important for patients, it's family members, sometimes it's just not possible. And so there is great training from

The Curbsiders (01:10:00.762) various societies about how to have these conversations, especially in a setting like a rapidly evolving setting. And, but a lot of it is practice and a lot of it is also experiences, just knowing what things are important at any given time. So sometimes if a patient's really sick, you prioritize treating them and then while conversations with family continue. So I think that's a good place for us to not keep you here all night.

about this. So do you have any take-home points, Malene, for the audience that you want to make sure they took away from the episode? On the floors, keep your eyes and ears open towards patients developing sepsis. Identify that early. And once you have that suspicion, go ahead and give your antibiotics early. I cannot. I think that's one of these. There's one thing you take away from this entire talk. It is

try to get those antibiotics in the first hour as soon as you can. Don't wait for your test results to guide your antibiotic administration. And then fluids, go ahead and get them started. Don't be afraid of vasopressors. You can start them peripherally. You have my blessing with backup from evidence from latest trials about the safety of doing that.

And then, you know, call your friendly ICU intensivist, who we're available and happy to help and take that care of that patient over. Awesome. And anything you wanna plug? I know this is a slog to go through these guidelines that we just mentioned, but I think it's worth every once in a while to go through them and...

read them and keep your eye out for all the things that we keep changing every once in a while. But there are certainly for folks who are in higher admin positions, some of these guidelines are important criteria from Medicare perspective. So they're worth knowing to make sure that you on the floor are carrying it. So even if you get a patient from the ED.

The Curbsiders (01:12:15.418) you know, making sure you're trending that lactate and things of that nature that are important. So it's worth a glance. At least read the highlighted recommendations. You don't have to read the entire evidence behind it. Great. Thanks, Malene. Thank you.

The Curbsiders (01:12:33.582) So this has been another episode of The Curbsiders bringing you a little knowledge food for your brain hole. Yummy. Still hungry for more? Yep. Join our Patreon and get all episodes ad free plus twice monthly bonus episodes at patreon.com slash curbsiders. You can find show notes at thecurbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox, including our Curbsiders Digest recapping the latest practice changing articles, guidelines, and news and internal medicine.

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And to our whole Curbsiders team, our technical production is done by the team at Podpaste, Elizabeth Proto runs our social media, and Stuart Brigham composed our theme music. Until next time, I've been Monia Meaden. And as always, I'm Meredith Trubit. Thank you and good night.