Sepsis

Specialties Emergency

Published

Hi folks, just curious, how many liters of fluid do your docs typically try before starting pressors? At what point do they make the determination to place a central line? Also, do you ever hang more than one liter at a time?

MunoRN, RN

8,058 Posts

Specializes in Critical Care.

Ideally whether or not to start is pressors is based on CVP and BP, so a central line is required not just for pressors but also just to know if you need pressors.

Of course the ideal and reality aren't always the same, and is many cases of early sepsis a central line may not really be necessary. There is some evidence coming out to suggest that fluid resuscitation is of limited benefit beyond a certain amount, around 3 liters according to one study, and pressors should start regardless of the CVP after 3 liters of fluid resuscitation. But we're probably a long way from the actual treatment bundles changing which say to bolus to a CVP of >8 in an unintubated patient, and if the map remains

What I usually see is if a patient seems to have the potential to not require pressors, we give 1 liter fluid bolus and if the BP is still not up to goal range then a central line is placed and pressors are started. CVP is then used for determining fluid needs from that point forward.

Obviously if a patient presents with "full-blown" sepsis with an SBP in the 60's then there's no waiting to see what a fluid bolus does, a central line placed from the get-go.

Anna Flaxis, BSN, RN

1 Article; 2,816 Posts

We do not have the technology to implement CVP monitoring in my ER. Whether the patient gets a central line placed promptly (or at all) depends on which physician is working. We don't have "bundles"- we're a small community hospital and treatment is very much directed by the physician.

Your information was helpful regardless. In attempting to advocate for appropriate patient management in my ER, the more information I have, the more effective I can (hopefully) be.

Altra, BSN, RN

6,255 Posts

Specializes in Emergency & Trauma/Adult ICU.

Agree with MunoRN's post above: treatment is not necessarily a linear path from BP ---> fluid ---> pressors.

Good info here: Surviving Sepsis Campaign | Guidelines, and in many widely used clinical reference sources, such as Up To Date.

Speaking very generally, however, I would say that in the last 3-4 years I have seen a shift toward early use of CVP monitoring, toward a higher index of suspicion of sepsis in the presence of abnormal vital signs, and away from what had sometimes been viewed as a fluid vs. pressors dilemma. The septic patient will often need both, as fluid resuscitation alone may not hold off the effects of poor organ perfusion quickly enough ... but there is also little benefit from "squeezing an empty tank".

Angelsmom354

9 Posts

Our bundle includes 2 IV's, blood, paired blood cultures and a lactate. Fluid resuscitation is 30ml/kg. Maintain MAP >60. If after 2-3 Liters, MAP 2 every 2 hours until normal.

I will typically hang 2 liters simultaneously, by pressure bag, as long as not already in heart failure (lungs clear).

We use central lines, typically, for poor vascular access or when need for pressors arises.

We don't CVP monitor in the ER either.

Specializes in Emergency/Trauma/Critical Care Nursing.

I'm generally pretty comfortable with sepsis treatment and basic pathophysiology, but I was wondering, if a pt comes into the ED who is septic, but also happens to be have significant CHF, fluid overloaded, wet lungs, etc., does your facility still attempt any sort of bolus? Or do you just go straight to pressors? I can't remember having had this specific type of situation happen yet, but was just curious what you all do or would do?

Angelsmom354

9 Posts

I'm generally pretty comfortable with sepsis treatment and basic pathophysiology, but I was wondering, if a pt comes into the ED who is septic, but also happens to be have significant CHF, fluid overloaded, wet lungs, etc., does your facility still attempt any sort of bolus? Or do you just go straight to pressors? I can't remember having had this specific type of situation happen yet, but was just curious what you all do or would do?

Most of our docs will still do a half or whole liter bolus then consider pressors, if bp/MAP low. With sepsis, most patients are still dehydrated. Still have to "fill the tank".

thelema13

263 Posts

Specializes in ED.

Most of our docs stick with 1-2 litres as a bolus, and I have given 8 litres before. Our cardio and infectious disease docs agree, give more fluid and place BIPAP if you are causing HF or respiratory distress.

Has anyone else noticed once you start abx, the pressure goes in the toilet and you end up playing catch-up until you get them in the ICU? Read a study somewhere sometime that stated there is a massive release of endotoxins once abx are initiated, and extreme hypotension ensues. Does anyone's facility have pressor guidelines without CVP monitoring capabilities?

MunoRN, RN

8,058 Posts

Specializes in Critical Care.

I'm curious what sort of monitors people are using that aren't capable of CVP monitoring?

Specializes in Emergency/Trauma/Critical Care Nursing.

My last facility, a 120 bed ED level 1 trauma center, routinely used CVP monitoring and the Vigileo for Scvo2 monitoring (one of our attendings was the internationally renowned sepsis guru Emmanuel Rivers). However, my current facility, a 38 bed ED, community hospital, never does it. The nurses are given annual education on CVP monitoring but it doesnt matter because they never get to use it. It seems that their motto is "Get them to the ICU asap", which frustrates the heck out of me. Sometimes its like pulling teeth to get a central line period.

Loo17

327 Posts

Lately the providers have been giving a dose of Solu-cortef for sepsis to improve blood pressure initially. It has worked every time and been especially helpful when the patients could not tolerate several liters of fluid prior to initiating pressors. They often do not place central lines in the department (when they do it takes a long time) but they do draw gases routinely.

NurseHotFlash

96 Posts

Sepsis protocol mandated a 3L bolus, be given

to pt who had high temp, and tachycardia. His BP was WNL. Developed pulmonary edema and had to be intubated. Wondering if too much fluid was given. What do y'all think?

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