Pressors and Sepsis

FlyingScot, RN · Jul 28, 2007

Craig I know there was a recent sudy done regarding patient outcomes with early monitoring of CVP (ie in the ER specifically) but darn if I can remember the author. I'll try to find it for you. It dealt with septic patients and early recognition of cardiovascular collapse with regard to trending CVPs. We implemented the reccomendations of the study at the ER where I used to work. Unfortunately the physicians willingness to do so was spotty. I will try to find it on-line for you but if I can't I'll get in touch with some of my friends and get the info.

glasgow3 · Dec 5, 2007

I'm looking for a good/easy reference on the progresion of pressors in sepsis. I'm going to be teaching a group of ER Nurse Residents/Interns.
I'm bing lazy and looking for things that are easy to understand, so I don't have to come up with anything myself. Yes I admit to being lazy.
Of course I also have to convince the powers that be that using CVP's in the ER when the patient is going to be there for hours before an ICU bed comes open.
/

I would recommend the Institute for Healthcare Improvement guidelines (IHI.org). Specifically, there is a section regarding pressors as part of the management bundles.

Sepsis patients on pressors need central lines and art lines----period; that said, with a CVC in place, obtaining a CVP should not be a problem.

Dinith88 · Dec 5, 2007

I would recommend the Institute for Healthcare Improvement guidelines (IHI.org). Specifically, there is a section regarding pressors as part of the management bundles.
Sepsis patients on pressors need central lines and art lines----period; that said, with a CVC in place, obtaining a CVP should not be a problem.

Thats the thing. If a patient is in septic shock it's more a matter of getting the an ER doc to place a line.

"using CVP in ER for septic shock" is simply a matter of plugging a wire into the monitor.

FlyingScot, RN · Dec 7, 2007

Thats the thing. If a patient is in septic shock it's more a matter of getting the an ER doc to place a line.

Aye, that's the rub. The literature I referred to earlier was a study done by Columbia (I think the doc was Manuel Rivera) on sepsis treatment in the ER that found that those patients who had CVL's placed AND monitored had a lower mortality rate because they were able to detect down-trending pressures before they were detected by cuff. Thereby hypotension and subsequent shock was avoided altogether and we all know that once they're shocky they're pretty much goners.

JohnW · Jan 15, 2008

Lots of hosptial now have TLCL that have a port that allows for continous monitoring of the SVO2 - I would guess that in a few years this will be the standard, as it's not that expensive and could have huge benefits. Most instuations have a target CVP that you tank to (with a goal BP), but an SVO2 lets you know if tissue perfusion is really OK

squirlkeeperCCRN · Jan 16, 2008

Our unit has developed a protocol for patients with sepsis. If they meet certain criteria the protocol is instituted. We rarely use Swans anymore, but use the sepsis protocol often. It is based on CVP, blood pressure and is complete with lots of boluses, antibiotics, and pressors. From the nursing stand point it is very hard to keep up with, very time consuming, but shows to reduce mortality greatly. It is standard procedure that if a patient is being admitted to the ICU with the diagnosis of sepsis that a line is placed and the protocol started in the ER.

platon20 · Jan 17, 2008

The protocol for early goal-directed therapy for septic shock as pioneered by teh Rivers et al group has not been implemented nationwide, because follow-up studies found that the key to improving mortality was NOT measuring central venous O2 or central venous pressures, it was giving more fluids than we used to give.

If you read the Rivers paper, the study group got about double the amount of fluids as the control group.

So you really dont need all the CVP or ScVO2 stuff, you just need to give approx 6-8L of fluids instead of the 3-4 that was customary before the Rivers study

arbley · Jan 24, 2008

I agree, Platon20. And I love that we are finally getting some protocols in place to prevent folks from heading too far down the sepsis highway before we catch on. While catching someone heading into septic shock earlier by using the various monitoring devices available to us is immensely helpful, it just doesn't play out that way alot of times. I think we all understand the basic pathophysiology involved here - the sepsis causes the entire arterio-venous container to relax and subsequently expand significantly. I've heard it said that the capacity of the circulatory system could be anywhere from 2 to 6 times larger than it was pre-sepsis (yes, that "2 to 6 times" remark is an anecdote which I can't support with research). The problem is, the volume of blood in circulation hasn't increased a bit. At this point, its been my experience that using pressors is like throwing cottonballs at a charging elephant. Pretty ineffective. The receptors that respond to the pressors aren't working right either, because they are septic too. Volume, volume, volume, volume - it takes many liters to fill the greatly expanded circulatory system. Worry about fluid overload? Nope - not now. If it becomes an issue - good - the patient finally has enough circulatory volume to maybe maintain enough blood pressure and perfusion to sustain their internal organs and brain. Now you can deal with the overload if need be. I love this stuff!

rgroyer1RNBSN, BSN, RN · Jan 24, 2008

We have specific protocols for this at my hospital and generally there already started in er.

emmycRN · Jan 24, 2008

www.sepsis.com is a GREAT reference. Also, the Institute for Healthcare Improvement (IHI) has all the guidelines for sepsis in easy to follow "bundles". Good luck on your presentation.

platon20 · Jan 25, 2008

We have specific protocols for this at my hospital and generally there already started in er.

Yes thats proven to improve mortality when therapy is initiated in the ED. Thats why the Rivers paper was particularly relevant to ED personnel and not quite as important to the ICU folks. By the time a septic patient makes it to ICU, giving fluids (even high volume fluids like the Rivers paper calls for) is usually "too little, too late"

The bottom line is that doctors and nurses need to be comfortable giving very high volume fluids to patients. A lot of folks start to object when a septic patient is given 8L of fluids, by saying that the fluid will overwhelm their system. In fact, thats true it WILL overwhelm their system and if they survive hte next 48 hours, then you will have to diurese some of that fluid off. But they are missing hte larger point. Without that fluid, you will go into MODS and be dead within HOURS, long before your body succumbs to the fluid overloading status.

Giving high volume fluids will allow the patient to survive long enough for you to diurese the fluids off later once the inflammatory cascade is brought under control.