What is your hospital’s sepsis protocol? Do you tend to adjust it for CHF with low EF?

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We do have a sepsis protocol and it's not supposed to be adjusted for patients with CHF, even if they have a low EF. Of course, I do see providers modifying fluid amounts for people who have EF's around 25 or lower, and I honestly don't blame them for waiting to see if the condition is just going to stay at the SIRS stage or if it's going to progress. If i see signs that it's progressing, I will call and request that we start the fluid portion of the sepsis protocol (labs and antibiotics are always started in ER regardless).

There have been a couple of times where I've been really hesitant to ask about this though, and it's been when I have a CHF patient with super low EF and poor kidney function (as our go-to for flash pulmonary edema is lasix.) I'll still continue updating the provider on the patient's condition, but for one patient I waited until the third or fourth call to actually ask for fluids to be started.

So what is your sepsis protocol? Is it adjusted for certain types of patients? At what point do you feel like you should start getting a little pushy with providers about starting fluids? And Do you personally feel that patients should always start off with the full load of fluids, regardless of medical history?

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We tend to follow the sepsis bolus protocol regardless of comorbidities such as CHF. I actually talked in length to one of our providers about that and the general consensus was they're treating the greater of the two evils at the moment. I will also add that I haven't had a septic patient (yet) with an EF lower than 35%.

On the flip side we recently had a patient who very quickly went septic, coded, and died (of something that could have been prevented/treated operatively but pt refused although was full code).

So on a nutshell ours follow full bolus protocols and then deal with any ramifications as they happen.

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Do these patients with comorbidities get echo's routinely? Would seem to take the guess work out of giving fluid.

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There was a recent study that addressed this question which found that patients with HFrEF who were under-rescusitated (less than 30ml/kg) actually had poorer outcomes compared to those who received the full challenge. I don't recall if they capped their bolus at 3L like we do. I'd rather have to diurese a septic patient with an appropriate MAP than juggle their coronaries and kidneys with pressors.

And to expand on offlabel's post, a quick bedside echo by one of your docs should tell you everything you/they need to know, from fluid status, to volume responsiveness, to right heart pressure via TAPSE, to EF. If you're in an institution that credentials their providers for this, of course.

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Do these patients with comorbidities get echo's routinely? Would seem to take the guess work out of giving fluid.

They do. Our protocol states that we give the predetermined fluid bolus regardless of EF, though this isn't always followed.

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We tend to follow the sepsis bolus protocol regardless of comorbidities such as CHF. I actually talked in length to one of our providers about that and the general consensus was they're treating the greater of the two evils at the moment. I will also add that I haven't had a septic patient (yet) with an EF lower than 35%.

On the flip side we recently had a patient who very quickly went septic, coded, and died (of something that could have been prevented/treated operatively but pt refused although was full code).

So on a nutshell ours follow full bolus protocols and then deal with any ramifications as they happen.

This is my (and my hospital educators') thinking. If you let sepsis run it's course, it's going to kill you. Complications due to treatment are less likely to kill you, especially if we're anticipating what may happen. It's just all of this on top of ESRD that gave me pause. I just thought "man there's a lot that can go wrong either way here."

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There was a recent study that addressed this question which found that patients with HFrEF who were under-rescusitated (less than 30ml/kg) actually had poorer outcomes compared to those who received the full challenge. I don't recall if they capped their bolus at 3L like we do. I'd rather have to diurese a septic patient with an appropriate MAP than juggle their coronaries and kidneys with pressors.

And to expand on offlabel's post, a quick bedside echo by one of your docs should tell you everything you/they need to know, from fluid status, to volume responsiveness, to right heart pressure via TAPSE, to EF. If you're in an institution that credentials their providers for this, of course.

Thank you for your response! I'm going to see if I can find that study. I've been a nurse for about 6 months now, but I still feel a little shy about being pushy with stuff like that with certain providers who are a bit abrasive. I'm just going to make myself get over that.

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There was a recent study that addressed this question which found that patients with HFrEF who were under-rescusitated (less than 30ml/kg) actually had poorer outcomes compared to those who received the full challenge. I don't recall if they capped their bolus at 3L like we do. I'd rather have to diurese a septic patient with an appropriate MAP than juggle their coronaries and kidneys with pressors.

And to expand on offlabel's post, a quick bedside echo by one of your docs should tell you everything you/they need to know, from fluid status, to volume responsiveness, to right heart pressure via TAPSE, to EF. If you're in an institution that credentials their providers for this, of course.

This study probably used PTs who were actually septic, rather than PTs who just meet an arbitrary protocol.

My hospital has a ridiculous protocol. Fever and 2/3 out of the following three with a suspected source of infection.

SBP

HR >100

RR >20

This rules in, almost any febrile adult. Or, any fever with a pre-existing respiratory problem.

It is ridiculous.

Two moderately ill PT's come in, but one took tylenol. Neither is actually septic, but one meets criteria.

Two identically septic patients come in, but one is on a beta blocker, so he does not meet protocol.

It is a seriously flawed protocol, and when good docs ignore it to avoid causing pulmonary edema on non-septic CHF PTs. or LOLs who won't tolerate the fluid, they risk a reprimand.

I have offered to just document giving the fluid, but not give it just to save them the hassle.

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This study probably used PTs who were actually septic, rather than PTs who just meet an arbitrary protocol.

My hospital has a ridiculous protocol. Fever and 2/3 out of the following three with a suspected source of infection.

SBP

HR >100

RR >20

This rules in, almost any febrile adult. Or, any fever with a pre-existing respiratory problem.

It is ridiculous.

Two moderately ill PT's come in, but one took tylenol. Neither is actually septic, but one meets criteria.

Two identically septic patients come in, but one is on a beta blocker, so he does not meet protocol.

It is a seriously flawed protocol, and when good docs ignore it to avoid causing pulmonary edema on non-septic CHF PTs. or LOLs who won't tolerate the fluid, they risk a reprimand.

I have offered to just document giving the fluid, but not give it just to save them the hassle.

That is such an ill-thought-out protocol that's costing those poor CHFers so much more money!

Our protocol is that if 2 or more of their vitals are off without any other changes from the patient's baseline, we check their vitals more often. If things continue worsening in addition to an organ system change (like change in mentation for example) we draw labs. Then if WBC or lactic is off, we start the protocol. So at least when my patients are on the protocol, there's good reason.

I wonder who came up with that protocol at your hospital. It sounds like they're trying to play it ultra safe, but they really are risking those CHF patients' health. Goodness. Are the antibiotics started too? Because that's a great way to gift a patient with a yeast infection for no reason.

ETA: Sorry I wrote that incorrectly. We draw the labs and then start the initial fluid bolus and antibiotics while waiting for the results.

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This study probably used PTs who were actually septic, rather than PTs who just meet an arbitrary protocol.

My hospital has a ridiculous protocol. Fever and 2/3 out of the following three with a suspected source of infection.

SBP

HR >100

RR >20

This rules in, almost any febrile adult. Or, any fever with a pre-existing respiratory problem.

It is ridiculous.

Two moderately ill PT's come in, but one took tylenol. Neither is actually septic, but one meets criteria.

Two identically septic patients come in, but one is on a beta blocker, so he does not meet protocol.

It is a seriously flawed protocol, and when good docs ignore it to avoid causing pulmonary edema on non-septic CHF PTs. or LOLs who won't tolerate the fluid, they risk a reprimand.

I have offered to just document giving the fluid, but not give it just to save them the hassle.

Sounds like your institution is using a bastardized version of a SOFA score, which has been retrospectively invalidated several times in 2016. Good luck, wield lasix.

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Thank you for your response! I'm going to see if I can find that study. I've been a nurse for about 6 months now, but I still feel a little shy about being pushy with stuff like that with certain providers who are a bit abrasive. I'm just going to make myself get over that.

Definitely find the literature and read it. And read other papers, old and new. Learn more about the physiology of sepsis, of heart failure, and of the treatments. Don't talk out of school because you definitely don't know what you don't know yet. I've done sepsis fluid resuscitation with everything from crystalloid to albumin to blood.

It's nuanced. Pushiness without a foundation of knowledge in the subject matter will just make you typify the worst stereotypes that doctors have about nurses.

When your knowledge tank runneth over, it won't be "pushiness" when you advocate for a deviation from the protocol. It will be confidence.

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Definitely find the literature and read it. And read other papers, old and new. Learn more about the physiology of sepsis, of heart failure, and of the treatments. Don't talk out of school because you definitely don't know what you don't know yet. I've done sepsis fluid resuscitation with everything from crystalloid to albumin to blood.

It's nuanced. Pushiness without a foundation of knowledge in the subject matter will just make you typify the worst stereotypes that doctors have about nurses.

When your knowledge tank runneth over, it won't be "pushiness" when you advocate for a deviation from the protocol. It will be confidence.

This is so true and I appreciate the advice. I'm part of a nurse residency program, and our educators have actually told us to, and I quote, "be pushy about the sepsis protocol." Basically, if a patient has sepsis, we're technically supposed to tell the providers that they need to start the fluids simply because it's hospital policy and to state that our sepsis protocol is based on evidenced based practice. The only thing they've really told us though is that research backs our protocol. It would definitely be a good thing for me to familiarize myself with the research.

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