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?

Specializes in Emergency/Trauma/Critical Care Nursing.

3L sounds like way too much just for the fever and tachycardia when the BP is normal.

Specializes in Emergency.
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.

Found a study on this, basically indicates a temporary fix that doesn't appear to impact overall mortality rates.

http://www.nejm.org/doi/full/10.1056/NEJMoa071366

Found a study on this, basically indicates a temporary fix that doesn't appear to impact overall mortality rates.

http://www.nejm.org/doi/full/10.1056/NEJMoa071366

It definitely is only used as a short term fix to help initially.

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

It's not whether or not our monitors are capable- we don't even carry any transducers, so it's irrelevant. We don't have a lot of things....

I'm actually quite shocked that we can even do EtCO2 monitoring, to be honest.

Specializes in Emergency Room, Trauma ICU.
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.

Sounds like my ER sepsis bundle. I'm in a huge level 1 trauma ER and very very rarely do we use CVP monitors.

Specializes in Emergency.

CVP? Hell, I'm happy if the bedside tele works.

Specializes in ED, SICU.

I've worked SICU and now ED and although CVP monitoring was standard in practice, a lot of our EDPs are getting away from it. CVP can give provide some unclear indicators of intravascular volume. Pressure does not equal volume. Therefore 3L was pretty much standard. If MAP and/or urine output remained inadequate after fluid resuscitation, shock was suspected.

Specializes in Pediatrics, ER.
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?

We give fluid anyway and have a low threshold for intubation. We start 250-500ml boluses at a time and if no effect move on to levo or neo.

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