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Banter At The Bedside
Banter at the Bedside dives into the real stories of healthcare — the ones that happen behind the curtains, between shifts, and at the bedside. Hosted by frontline professionals, each episode brings together voices from across the healthcare spectrum to share their perspectives — from laughter in the breakroom to the moments that change everything. Whether you’re in scrubs or just curious about life inside the hospital, join us for honest, thoughtful, and sometimes hilarious conversations about what it really means to care for others.
Banter At The Bedside
Septic Shock 101: The History, Science, and Controversies of Sepsis Care
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Sepsis remains one of the most common and deadly conditions healthcare providers encounter, but do how much of the evidence do you know?
In Part 1 of our sepsis series, critical care physician Dr. Michael joins Abby and Kaleigh to break down the history of sepsis management, the rise of Early Goal Directed Therapy, and how decades of research have shaped modern septic shock treatment.
We discuss:
- The origins of the Surviving Sepsis Campaign
- The controversy surrounding fluid resuscitation
- When antibiotics matter most—and why timing is critical
- Early vasopressor use and the death of "Levophed, Leave 'Em Dead"
- Steroids in septic shock
- Why modern sepsis care looks very different than it did 20 years ago
Whether you're a nurse, APP, physician, student, or simply curious about critical care medicine, this episode provides a practical and entertaining deep dive into one of healthcare's most important topics.
This episode is intended for educational and entertainment purposes only and does not constitute medical advice.
I knew she was about to say something.
SPEAKER_01I was like, oh god. And it was we came they came up with 30 mls per kg and they made it up.
SPEAKER_03Hi everyone and welcome back to banter at the bedside. We are the show that brings all different views of healthcare to the conversation so we can see everyone's side. And it should feel like those conversations at the workstation at 3 a.m. Today we are here for a very exciting episode on education with Dr. Michael back, and we are going to be talking about septic shock. Last time we covered cardiogenic shock and we got some questions on the TikTok about septic shock and if we were going to cover that. So we brought him back to do some education. And me and Kaylee are going to be here to ask him all of those questions he loves. As always, this is for entertainment purposes only. This is not medical advice. Please seek the care of your own medical professional. We don't represent any entity at all. All of our thoughts and opinions are our own. I'm Abby. I'm one of your main hosts. I am a nurse practitioner of eight years in critical care. And I'm joined by our other main co-host, Kaylee, an ICU nurse of 18 years now.
SPEAKER_05Hey everybody, welcome back.
SPEAKER_03And then again, we are joined by Dr. Michael, and he has been a doctor for 17 years. We just made him calculate it. He did not realize he had hit such a high milestone. So he is a critical care emergency medicine trained doctor, and he has worked in many big facilities in cardiac care, medical ICU, and cardiovascular surgery ICUs. And he is even a program director of a fellowship. So he is a wealth of knowledge when it comes to this stuff. So welcome back, Dr. Michael.
SPEAKER_01Thank you. Thank you for having me. Yeah, I'm happy to start talking about septic shock. It's actually one of the things that I really like to talk about, even though I mainly work in cardiac ICUs. It's one of my like favorite subjects. Just because I think it makes a lot of sense and it's interesting to see how like we've progressed over that time period. The first thing I'd probably talk about is the history of it. I think it's really interesting to see like where we ended up, how we ended up here.
SPEAKER_02Yeah.
SPEAKER_01So 1989 was the first time that uh we defined sepsis. So obviously. And when Taylor Swift was born. Oh god.
SPEAKER_05I knew she was about to say something. I was like, oh god.
SPEAKER_03Sorry. 1989. I'm the year of my mother.
SPEAKER_01Sorry. So yeah, this guy, Roger Bone, defined sepsis like as we know it now. Uh, which is just crazy to me that I, you know, had been alive for a number of years before um before we even like formally defined sepsis. Like it was always like a thing from an infection standpoint, but to have that that definition for it. The next big thing that happened was in 2001 was Manny Rivers early goal directed therapy. I don't know if that rings any bells for you guys, but this was uh huge back then. This was in Detroit. And what he did was he created early goal directed therapy. And his overall thing was if you identify somebody that is in septic shock, uh, what you want to do is uh start like giving them fluids and you want to give them like two or three liters of fluids until they get to a CVP of eight to twelve. So he recommended that you put a central line in. And then he said, if you need to like intubate them, sedate them, like knock down all that other stuff to be able to do it with it. So if you could imagine taking these people that were septic shock and then like being more aggressive in terms of like intubating and sedating, but giving them a bunch of fluid, targeting a CBP of eight to twelve. Once you reached that target of eight to twelve, then you would start vasopressors if you were still hypotensive, but you would use a lot of fluid up front. And then he said the next thing you want to do is uh is check a central venous gas. Uh, and so the idea was from an oxygen carrying capacity, you have your auction delivery, you have your auction consumption. And so your mixed venous should be 65 to 75 percent, uh, whereas like your central venous would be well, in septic shock, it's kind of variable, but around that same type of a goal with it. And if it was less than uh 70%, I believe, with it, then they actually recommended transfusing to a hematocrit of 30%. So if you think about like doing a hemoglobin of 10. And then if you still had a low mixed venous, then he would recommend uh anotrope, like dobutamine. And then after you did all that, it says at the very bottom of his algorithm, admit to the hospital. So he wanted all of this stuff done in the emergency department, like this whole process of things done in the emergency department. Yeah.
SPEAKER_05In 2001?
SPEAKER_01In 2001.
SPEAKER_032001. I was I was in the fifth grade. That was the year I learned how to roller skate.
SPEAKER_01So that wow. So that was uh that was like a big thing though, because he sh he took he took a mortality of his like 60% mortality and dropped it down to like a 30% mortality. Wow. And and that was huge news for like this is how we're gonna start treating sepsis. And so three years later in 2004, they came out with the surviving sepsis campaign and all these surviving sepsis guidelines and did this whole thing with it. And it was like early goal directed therapy, early goal directed therapy. 2008 was just like a rehash of early goal directed therapy of us doing all this stuff. And then again, every four years, they were coming out with new ones, and then in 2012 did the same thing, and we didn't really deviate much from it from like recommendations, people were deviating from it because you know, this would be a whole nother podcast for me to get into fluids. I'll briefly talk about it, but like a CVP of eight to 12 is just not, it showed that it was not helpful, not recommended. Transfusing to a hemoglobin of 10, that was obviously not recommended. Dobutamine and septic shock was not recommended. There were so many things that were not recommended. And I think one of the issues with what he did was he did like 20 new things, right? Like he did all of this stuff. Yeah. And then he said things got better. And then people started being like, well, it did they did we need all of them? Maybe it was just like two of those things that were helpful, or maybe only like three of those things that were helpful. You know, we we proved that eight to 12 CBP didn't work. We proved that a hemoglobin 10 was bad. So maybe, maybe it really wasn't all those things, maybe it was just some of those things. Yeah. And so in 2014, 2015, that there was a huge trial across the entire world. So uh they looked at early goal directed therapy versus do whatever you want. And in the US, it was called the process trial. In Europe, it was called the promise trial, and then in like Australia, New Zealand, it was called the Arise trial, but they were all the same study, just you know, different parts of the world. And they all got published, I think, within a year of each other, and they all showed the same thing that there was no difference between early goal-directed therapy and do whatever you want. And people, people were like, oh, they started kind of trashing on Manny Rivers, which I don't agree with, because one of the things that that us doing whatever we want now versus us doing whatever we want then before Manny Rivers is very, very different, right? Like he taught us like jump on stuff early, do all this stuff in the emergency department. And so our do whatever we want now is like way different than it was the before.
SPEAKER_03I mean, we also know that there's a lot of like do whatever you want, but you don't need like you touched on you don't need a hemoglobin of 10. So it's like, okay, well, you're you you may want to do that, but you know you're not going to. So, but like 2001, they didn't know that. I'm assuming I get I was in this so yeah, like I mean, do whatever you want, but there's so much more medicine and science that we know. So yeah, I mean, I and don't I agree with you. Don't don't shit on Manny, my boy.
SPEAKER_05At least he's out there doing something. What were y'all doing?
SPEAKER_03I mean, 60 to 30 percent, that's crazy.
SPEAKER_01Well, one of the arguments was what patients was he taking care of that there was a 60 mortality and like the non-intervention arm uh versus because like nationally sepsis like uh mortality is like 30 percent. So they were like, who who was he taking care of that they were just dying at a at such a high rate? But I mean, he progressed things a really, really long way, and and we've come a long way. Like we, you know, like in the emergency department, it's like if you're hypotensive, then you're gonna get a lactic immediately, you're gonna get sent to a higher acuity area, you're gonna get all these things. And so it's different now, but we just kind of took away all the other stuff to be able to get it in there. And so 2016 was also the year they redefined sepsis. So they came out with the new surviving sepsis guidelines, but they also tried to redefine sepsis. And and it's interesting because I I agree with it, but we still don't do it in most hospitals. So the argument was the current definition was there were three categories. There was like sepsis, severe sepsis, and septic shock. And so sepsis was SERS plus an infection source or whatever, and then severe sepsis would be like signs of organ dysfunction, and then septic shock would obviously be like refractory hypotension, lactic, whatever you want to do with it. Their argument was, and we saw this in emergency departments, whenever you make the sepsis diagnosis so broad, you're gonna capture a lot of people. But like if a 19-year-old has a sore throat, they're gonna have a fever, they're gonna be tachycardic, they're gonna have a sore throat. They meet criteria for sepsis. But that's just a normal response to having a sore throat. So if someone showed up to the emergency department and you have somebody with like a 75-year-old with multi-lobar pneumonia and a 19-year-old with a sore throat that shouldn't have gone to the emergency department, they're both qualify as sepsis. They're both getting triaged to like the more acute area because it was a big jump to jump on these people early. And so we would have like nobody in our fast track area in our entire adult ED area would be just like bottlenecked because everybody that qualified as sepsis would have to get screened through our adult ED. And so it became a big issue. And so the argument with the sepsis three guidelines was they they basically shifted everything. They said SERS was just a normal inflammatory response, and sepsis would be an abnormal inflammatory response, which is where you see signs of organ dysfunction. So and like severe sepsis became sepsis in a way, because it was like, okay, that's an abnormal response to infection as opposed to a normal response to infection. Uh, and then septic shock, they just defined it better. Because one of the concerns with septic shock from like a literature standpoint or research standpoint was they looked at 20-something papers and one thing they talked about, and all 20 papers had different definitions of septic shock. You know, like is it just going on pressers? Is it having a lactic? Is it having being hypotensive after refluid resuscitation? Is it being on vasopressors? And so they more just formalized that definition to say you're hypotensive after refluid fluid resuscitation with a lactic on vasopressors. Like they just made it more of a of an exact definition on there with it. And then they they tried to come out, they said, well, if SERS is a normal response to infection, uh, we need a different measuring system to like who's sick and who isn't sick. And they came up with Q sofa. Have you all tickles my brain?
SPEAKER_03Sure.
SPEAKER_05Yeah, it's like something organic. Sequential organ failure assessment. Yeah.
SPEAKER_01Oh yeah. And so SOF was used really well in the ICU and it looked at all the different organ systems. The problem with SOFA is in order to look at the kidney, you needed a creatinine. In order to look at the liver, you needed like a T billy. You're looking at things that are require a bunch of labs to come back. So that's not great for like screening because you're not going to just draw labs on every single person that shows up. And so they came up with QSOFA, which was a quick sofa assessment. And that was looking at just the clinical ones. So they looked at blood pressure, like a systolic less than 90, respiratory rate, and then neurostatus. So like if your CNS uh from if your GCS was less than 15, and if you have a baseline GCS of like 14, it's just like below baseline.
SPEAKER_03So if you were sorry, it's quick, and then SOFA is sequential organ function assessment.
SPEAKER_05Failure. I think it's failure. I don't know. I'm clarifying.
SPEAKER_03I think it's organ failure assessment. Organ failure. Okay. So sequential organ failure assessment.
SPEAKER_01And then the quick part of it is just using the clinical one.
SPEAKER_05Okay. So you're saying GCS respiratory rate and then hypotension.
SPEAKER_01And then blood pressure. Okay. Now, if you had two of these, then you were significantly sicker, which makes sense, right? If you have two organ systems that are not functioning correctly, you already know that these people are sicker. The problem with this one was it did a really, really good job of picking out the sickest people, but it missed a lot of people. So like SIRS just included everybody, right? Like it was just like anybody that came in the door, they were like, Oh, you're positive for SIRS, you need to come this way. And then you went to the other extreme with QSOFA, and they were just like, Oh, we're we missed this person that was like that was sick, but wasn't like sick enough to be positive for Q Sofa, but they got sicker later and we were behind the game. Oh, like we need MS. Yeah, it never panned out uh during that time period with it, but it became a thing around 2016. So 2016 was like this huge thing of like this is what we're gonna be doing. Um, and it was the big three of early fluids, early antibiotics, and then source control. And so early, we'll start with early antibiotics. The true thing is like early appropriate antibiotics, because if someone has like MERSA and you give them penicillin, that is early antibiotics, but it's not gonna do anything. So it's a matter of like understanding who should get what antibiotic. And that's where the whole thing of are they at risk for health qu healthcare acquired infection or or are they just more from like the community and making sure that you get antibiotics on board early. Not just banks, then yeah. And then uh try to get if they were if you're if they're high risk for healthcare, then you would think about doing broad spectrum and all this stuff. The that is like they they came out with papers that showed uh like every hour delay in getting antibiotics, your mortality went up. Right. So if you're sitting there just like dying of a bacterial infection, the faster you get antibiotics, like the the better you're going to do. And then source control made sense. I mean, obviously you can't take somebody's lungs out if they have pneumonia, but if they have if they have like an abscess, you can drain the abscess. If they have an infected gallbladder, you can do like a a perk tube and like drain the gallbladder. If they have like a blocked kidney stone with an infected like hydro, you could do a stent, or you could do like a nephrostomy tube and like drain that infected area. So source control and like finding what the source is and is is it something we can take out or is it something that we can help by like draining? So if it's like an empyema, you can drain that as well, or these types of things with it. And then fluids was the other big thing. And it was we came, they came up with 30 mls per kg and they made it up.
SPEAKER_00Like Matt, like sounds like a man.
SPEAKER_04Yeah, 30 sounds great.
SPEAKER_01It was one of those things that's literally like a bunch of people got together like experts, and they were like, How much do you want to give? And they were like, I don't know, 30. And then everybody was like, 100%, let's do that, which is far.
SPEAKER_03Humans like threes. Part of the problem. Humans really like things in threes.
SPEAKER_01The problem with it though was like they would have people with like an EF of 5%, and they're like puffing up pulmonary edema, and you're like, oh, I have to get this 30 mls per kg in, or or they've missed dialysis for three sessions because they have like an infected perm cat, and they're like, no, we have to give them 30 mls per kg, and they like can't breathe, and you're intubating them. Uh, and it became a thing where you you would get written up or you wouldn't get reimbursed if you didn't do that 30 mls per kg, because it was like in the thing that says you have to do this. And if you looked at the level of evidence behind it, it was it was BPS, which is just best practice statement, which is literally just, yeah, that seems right. Like there's no no evidence behind it. Oh my gosh. And so those were the big three things, and that's what we did is that's what we taught. Early fluids, early antibiotics, uh, source control, and identifying people was the the main things. In 2018, they they came out with the golden hour. And the golden hour was we want to do all this in one hour. Like we want to screen them, get a lactic. If the lactic is elevated or they're hypotensive, we want to give them 30 mls per kg. We want to get antibiotics started, like, and check to see what their source is all within an hour. That's hard. I mean, that's hard to do to get like it's hard to get people out of the waiting room in an hour, let alone like try to get like a golden hour of getting all that stuff. Golden hour.
SPEAKER_05I just feel like that name could have been applied to something way better than that.
SPEAKER_03Yeah. Like true. They they took a great name for name. But also, like, just to highlight the golden hour, like it's not just those things you have to do. Like, you're not just doing those three things. Like, you also have to get the blood cultures before you give antibiotics. Like, you have to like get in the ED, you have to get them admitted into the system in an armband hooked on the monitor.
SPEAKER_05I thought when you were saying this, because you said that the mortality increases every hour that they don't get their antibiotics. Well, they some people it's really hard to get blood off of them. So delaying the blood the antibiotics to get blood cultures, yes or no?
SPEAKER_01I think it's crazy. I mean, I think if it's doable, it's do like if you can do it, if you can get it done very quickly, then yeah, obviously it increases your yield. But I've I've come back like an hour or two later and been like, uh what where are we at in this process? And they're like, Oh, we haven't done anything because they haven't come up from the lab to draw cultures. And I and it's I'm like, this is crazy. Like, no, like give give them the antibiotics. Like, yes, we may not be able to see what grows, but like the big thing is treat them. Like we wouldn't yes, we wouldn't do that forever.
SPEAKER_05Because from a nursing standpoint, is drilled into us to get the blood cultures, get the blood cultures, don't be for it. But like that has happened so many times where it's like, you know how it is, we can't get the blood off these people, like they're really hard, and it's been an hour or two. It's like start just start the antibiotics. We'll get to that too. We'll get them. Yeah. Like talk to your provider, but like they're really sick.
SPEAKER_03Also, if they're that sick, one dose of antibiotics is not going to truly it. I don't know. I can't imagine. Give you f negative blood cultures. You might not get two positives, but you you probably at least get one.
SPEAKER_01Yeah. I mean, it's for me, like, I I agree like to delay all that just because it's like, oh, like, yeah, that's ideal, but like we wouldn't do that with other things. If someone's in the middle of having a STEMI, we wouldn't be like, oh, we need to wait on this before we go and open up your vessel. You know, it's like open it up and then like see where everything like goes afterwards. But yeah, it's a it's a big deal. The other thing that is like the you may not have a lot of IV access in and let's say you decided to do broad spectrum and you picked vanc and zocin, even though increased risk of acute kidney injury, but just for like vancomycin, or I guess pipercin tasobactum to do that type of thing with it. But the the pipicillin tasobactum is gonna cover way more than the vancomycin. Like that's great for MERSA and gram positives, but if you want to cover like a large thing of of things, then you're gonna get more with your pipersin tasobactum. And the I'll come back and I'll be like, Do you have the antibiotics in? And they're like, Oh, we only have one IV. The vanc has to run in over however long, and it'll be like four hours later. And it's like, well, if if you had asked me and like done a choice, I would say give the The one that I think would most likely treat it if I think that I just think that there's like subtleties to getting the antibiotics in in a timely manner, knowing which one's gonna take a long time, knowing which one isn't going to take a long time with it.
SPEAKER_05Well the bank is faster. The bank is always faster than the Zosin for the most part for us. The Zosan runs over four hours.
SPEAKER_03I don't know if that's different any of the places you can run the ZOS in 30 minutes.
SPEAKER_05I think we always do it slow because assuming the patients don't have good kidney function or whatever. But also our pharmacy has clarified that we can run the Zosin together.
SPEAKER_03You can but old school nursing here. The I was taught you don't want to run antibiotics together because if they have an allergic reaction, you don't know which one.
SPEAKER_05Very true.
SPEAKER_03And then true with every medication though. It can't. It can, but you're more likely to develop an allergy like you're more likely to develop an allergy to an antibiotic than like propofol and fentanyl.
SPEAKER_05Very true. So like just saying in a pinch, if you have to. In a pinch if you have it, you know. Yeah.
SPEAKER_03But that's just what I was taught.
SPEAKER_01I think it is a big deal to understand how the processes work at your hospital and like understand like how to quickly get blood cultures, how to get those antibiotics in quickly. It it I think it does make a difference. I think we've shown that it makes a difference. Now, I can talk about it later, but if it's septic shock, then yes, it does, it definitely matters. They've actually changed the guidelines that says if it's just sepsis, they'll act you can actually delay giving antibiotics for a couple of hours to try to identify the source just so that you can give the right antibiotics. And I I think there's two reasons for that. I think one of the reasons is they don't want to just everybody in the ED to get broad spectrum because it's just going to lead to problems down the road. And then the other side of it is if it's the urine or the lungs, then you may give different antibiotics. So if you can spend some time to wait for the UA to come back or wait for the imaging to come back or something like that, then you maybe can target a certain area versus doing everything with it. I think that you do have some time to do some things if they're just septic versus septic shock, like lactic, hypotension, all that. Then you want to get it in uh within the hour and get everything started and quickly in there with it. That became like a big thing with it. Source control, I don't really have anything like additional that we've kind of come through with everything we talked about. Fluids, I I mean, I could literally talk for a couple of hours on fluids, so I'm I'm not going to do that.
SPEAKER_03Um and if people want us to bring Dr. Michael back to do the fluids, he can. And I could do that.
SPEAKER_05You want to hear about the evils of normal saline? I would love to. People are about to nerd out. People are about to be nerd all the way out.
SPEAKER_01I'm gonna I I am gonna bring it up when we talk about some of the stuff with it. But uh yeah, I mean, like the the literature shows that like balanced crystalloid does better than normal saline because it has such a high chloride load in it, 154 ml equivalents of sodium, 154 ml equivalents of chloride. It's just such a huge amount of chloride, it it drops your bicarb and they end up with a metabolic acidosis and all sorts of badness. Its pH is like five.
SPEAKER_04Yeah.
SPEAKER_01Versus like a balanced crystalloid does significantly better. Your your balanced crystalloids are going to be like your lactated ringer versus either plasmolite or normosol, depending on what you use. They're the same thing from different companies. Uh, I like normosol and plasmolite better than lactated ringer for large volume resuscitation. The reason is lactated ringer is slightly acidotic compared to the body, whereas normosol and plasmolite are slightly alkalotic compared to the body. But one of the things with large volume resuscitation is the sodium content of LR is 130. And so if you look at the osmolarity, it's on the low side of normal versus like normal saline and normal solar plasmolite are more in that like middle normal uh area of osmolarity. And so if you're giving somebody fluid, you want the osmolarity so that it stays intravascular. And so if you're giving a lot of lactated ringer, you're just gonna end up third spacing more fluid because of the lower osmolarity in it. Uh yeah.
SPEAKER_03And then also for those, for just a reminder, because we have a wide spectrum, sure osmolarity is about keeping fluid in, right? Like in our floor. Yeah, I mean with like the Yeah. Sorry. Yes. No.
SPEAKER_01So lower means that that LR is going to more likely continue the the leak, as I think will with like a diffusion standpoint, you'll it'll the water will go to the higher osmolarity in the interstitium versus like intravascular and you'll end up leaking water out into the interstitium more. So yeah, I mean I I I could go on for days, but the the literature shows that balanced crystalloid is is better. The literature shows that balanced crystalloid is best if you do it both in the emergency department and in the ICU. So if you only do one in one area and one in the other, you're not going to see those benefits. You're going to see the benefits if you do it throughout their entire stay. So it's an important coordination between the emergency department and the ICU that if you're going to do continued fluid resuscitation, that you do balanced crystalloids throughout their entire stay.
SPEAKER_00So that's a big thing with it. And we don't think that's a good idea. Yeah.
SPEAKER_01And so it's been a couple of pa like if you if you look at the studies, there's a lot of studies that have shown that it didn't matter between normal saline and balanced crystalloid. But the some of the issues with it is that uh if you're only giving one or two liters, it's you're not gonna really see much of a difference. Versus like the average septic shock patient back in 2015 when those studies came out got seven to eight liters over 72 hours. So at seven to eight liters of fluid, it does make a difference what you get. At two liters of fluid, it probably doesn't matter. But a lot the the US is worse than the rest of the world in terms of like over-resuscitating people with fluid. Um, we give more than the rest of the world on average.
SPEAKER_04And it's America, bigger is better.
SPEAKER_00Of course we do. We it's been harder for us to let me.
SPEAKER_01Yeah.
SPEAKER_04Sorry. My bad.
SPEAKER_05Half an hour thinking the same thing at this point.
SPEAKER_01We yeah, but we we do give slightly more, and so it does make a difference at those levels. A lot of the studies that looked at normal saline versus balanced looked at were like done in Europe, and they would give two liters over three days, and they would say there was no difference. I was like, Yeah, I mean, you're not gonna see that big of a difference at that low of a fluid level versus at a much higher one. So those were the big three things. And then we started getting into more studies. So in in 2018, we got into uh more steroid studies. Steroids became a big thing. So in 2008 was the corticus trial, and they looked at stress-dose steroids and septic shock, and it showed like less vasopressor use, less ICU days, less ventilator days, but no change in mortality. So if you like steroids, you would say, yeah, that seems I would rather have less pressors, less ICU days, less ventilatory days, all that type of stuff. And if you didn't like steroids, you would say, Well, there's no mortality benefit, so I'm not gonna do it. So it didn't change. The people that like steroids continued to give it. The people that didn't like steroids continued not to give it. In 2018, two studies came out. The adrenal trial showed the exact same thing. It showed increase like decreased uh ventilator days, decreased IC use day, decreased phasopressor use, all these benefits, no mortality benefit. And then the approaches trial came out at the same time and it showed a mortality benefit. Like it showed all that stuff, but it also showed a mortality benefit. And the only difference of the approaches trial was that they used the hydrocortisone 50 Q6, but then they also used flurocortisone, which is interesting because the reason we picked hydrocortisone is because it has a lot of mineralocorticoid activity, which is all that flutocortisone does. So you assume that the reason we're giving hydrocortisone is so we get the glucocorticoid anti-inflammatory, the mineralocorticoid system in terms of like from an adrenal standpoint, that there wouldn't be much benefit to adding on more mineralocorticoid, especially when whenever one of the biggest issues is the inflammation and not like the the whole like aldosterone system type of a thing with it. Uh, but it's it was the only one that showed a mortality benefit. So technically, if you're treating septic shock, if you want to be a purist, then you should do 50 Q6 of hydrocortisone plus fluidrocortisone.
SPEAKER_03Actually, just started working with an attending that does have me start some florina.
SPEAKER_05So, but you it's 50 Q6, you don't start and then you don't start with a bigger dose and then take it.
SPEAKER_01These weren't all the stories all the studies did. They just did 50 Q6 of hydrocortisone and then like 0.1 uh flurocortisone.
SPEAKER_05I this is weird, this is just a side note. If you're reducing your ventilator days, your ICE stay and all these other things, how is that not reducing your mortality?
SPEAKER_01They couldn't like it like whenever it comes to research, yeah.
SPEAKER_03But I mean, I'm I like steroids, so I guess I'm in the steroid side, but I I'm kind of with Kaylee. Like I mean, also just like the in the admin in me is like, well, that sounds like less VAPS could have it.
SPEAKER_05Yeah, that's something like it's still like those things all snowball into other things. Like I feel like it would be better.
SPEAKER_01That's just I mean that's statistics for you though. Since since the 1980s when we invented evidence-based medicine, there's just there is a group of people that is like if it doesn't improve mortality, then they don't want to hear about it. Like it is, it is I'm only giving things that have been shown to improve mortality. All the other stuff is like white noise, get rid of it, background stuff that's not needed. There's a lot worse than death in this world. That's all I got.
SPEAKER_05Yeah, I was gonna say I say anyway, little shriveled hands from pressers.
SPEAKER_01Sure.
SPEAKER_05Yeah.
SPEAKER_01So here's another thing. They they used to have a saying 30 years ago, 40 years ago, that was called uh leave a fed, leave them dead.
SPEAKER_05I learned that in nursing school. It was not 30 years ago, Jesus. Kaylee is not that old. I don't know, but I heard that every day, I feel like in nursing school.
SPEAKER_01So it it became like a big thing, and it made people not want to use vasopressors. And the result of that was you gave two liters of fluid, they were still hypotensive. We'll give a third liter of fluid, they're still hypotensive. Give them one more liter of fluid and see if that like gets their blood pressure up. Uh, they're still hypotensive, and then they're like, uh, start some maintenance fluids and we'll just sit, you know, like it was just like everyone was super resistant to starting vasopressors for that reason. And there's a lot of hospitals that said you can only start vasopressors through a central line, except for dopamine. I don't know how they got their rep in there to be able to, it's not like it works differently than the other stuff with it, but um, other hospitals they'd be on like 20 of dopamine through a peripheral, and they'd be like, this is fine because it's dopamine, and you're just like, it's it's not. It's natural.
SPEAKER_05It the body makes it.
SPEAKER_01Yeah. But uh so things that we learned was you can absolutely do peripheral levafed. Same rules as with other like caustic agents, like make sure you have a good IV, all those types of things. Yeah, there was a trial that was the sensor trial that actually looked at early LeviFed use. So not like when they walk in the door, but like early, like you gave a liter or two of fluid, you've given your 30 ml per kg. Go ahead and start vasopressors. And it actually led to faster resolution of shock, better blood pressure control or like goals for your sepsis, less arrhythmias because they weren't just sitting there like tacky to 120, 130 while they were like super septic, and overall did better in like six or seven categories, didn't show an improved mortality, but everything else was like faster resolution of a lot of a lot of things. But it also just showed its its safety, it didn't worsen mortality, it just didn't prove that it and it was it was definitely better mortality, but it just wasn't statistically significant to say that it that it improved mortality on there with it. And so I am always on board for starting uh basopressors early. Like you've given a liter or two of fluid, you're still hypotensive, just go ahead and start it. If you keep trying to avoid doing it, you're just gonna lead to over-resuscitation and give too much fluid with it on there. Yeah. Other things that came about was uh the controversy of albumin. So albumin's always been a big deal on resuscitation. There was a trial back in the day called the SAFE trial uh that looked at albumin versus normal saline, which was an interesting study because they used 4% albumin. This was not not done in the US. Okay. And when they looked at it, albumin at 4% is actually a little bit hypotonic. And so you're comparing a isotonic solution to a slightly hypotonic solution, uh, and then trying to say, are they the same? And as you would expect, it was worse in people that were like trauma patients and TBI patients and like neurotype stuff where osmolarity makes a difference.
SPEAKER_04Yeah.
SPEAKER_01And so everyone took that and was like, albumin's bad. Now I will tell you that albumin's expensive.
SPEAKER_05I've never seen 4% albumin in my life.
SPEAKER_01No. But so if you ask the question, should you use albumin as a resuscitative agent? It's never been shown. There's been a couple of meta-analyses, meta-analyses recently that have shown that it may improve mortality. The big thing to take away from it is because it's on cotic pressure with like proteins as opposed to osmolarity from like fluids, is that it it stays intravascular longer. I don't know if you guys have heard why give albumin is just gonna leak out in six hours. Have you guys heard that before? Does that ever come up? No. No, no, no. So I would hear that a lot. They would say, like, what's the point of giving albumin? It's just going to leak out in six hours. And there is a study that actually looked at that and showed that in people in septic shock, if you gave them 5% albumin, it would kind of disappear, leak out of the system within six hours. In that same study, a liter of normal saline leaked out in 52 minutes. So it was just like, well, if you're gonna argue that you shouldn't give albumin, then you definitely should argue that you shouldn't give fluids because it's the same argument of things leak out whenever you're in septic shock, you're leaky and you do a whole thing with it.
SPEAKER_03Um specifically normal saline, though. We don't like normal saline.
SPEAKER_05We don't give normal saline ever.
SPEAKER_01But it it was a big deal. And so uh there's a huge group of people that say you shouldn't use albumin. And I would agree that you shouldn't use albumin as a resuscitative fluid because it just has never been shown to be superior and it's way more expensive. The I do use albumin as like oncotic pressure. Like the way to keep fluid in your vessels is to have oncotic pressure, is to have protein. If you think about a cirrhotic, they lose their albumin, they lose their protein in their blood, and then they end up with like ascites and pleural effusions and edema and all that type of stuff because they have no proteins in their blood because they have liver failure. And so we give them albumin when we drain their ascites so they don't get a huge fluid shift. We give them albumin because it helps keep fluid intravascular. So there's again, I could go into like an hour's conversation of fluid, but like once your alb your albumin makes up 75% of your oncotic pressure, it makes up all those like proteins that want to keep things intravascular. Once your albumin drops below about two, two and a half, uh, you start spontaneously third spacing. So if you're in septic shock and you're leaky and you're third spacing because you have a low albumin, that's even worse. So if you if you're resuscitating somebody in septic shock and they have an albumin of four or three and a half, I don't think you need to give albumin. You're probably fine. But if you're resuscitating somebody in septic shock and their albumin's two, then I give like hyperoncotic albumin, like 25% albumins, not as a resuscitative fluid. I give it as a they need proteins to keep my resuscitative fluid intravascular. So I I don't use albumin as a resuscitative fluid. I do use albumin in septic shock patients in a like a small specific population.
SPEAKER_05Like an accessory. Yeah.
SPEAKER_01And if you give people five liters of fluid, the same way your hemoglobin drops from like 12 to 10, your albumin will drop when you give that much fluid. And so you may start with an albumin of three and a half, and then the next day your albumin's 2.1 because you gave five liters of fluid and you just diluted it down. And so you may need to give some some like 25% albumins to kind of draw all that stuff back in. So that's how I look at it with it. But it is a controversial topic with it. The other big topic that came with it was using hyperosmolar fluids, so like hypertonic bicarb. You could even consider like hypertonic saline. Um so they did around this same time, they did it every episode I'll have PTSD somehow.
SPEAKER_04Jesus. We haven't said landing bed yet. Okay. So the sorry, Michael. Oh, you're good. I'm not sorry. I live that shit. They're always picking on it.
SPEAKER_01So they they actually did a trial called the bicar ICU trial. A vial of bicarb is 8.4% sodium bicarb, so it's super concentrated. And they did a trial where they they diluted it in half. So they used 4.2% bicarb and they gave it in boluses. And but the bicar ICU, the first trial showed a mortality benefit if you gave hypertonic bicarb in acidotic patients with renal failure that were in septic shock. Now, a more recent study in the last year or two is the bicar ICU2 trial that was unable to replicate that. But I really like using hypertonic bicarb in patients that I feel like are volume responsive. So oftentimes I'll push like an amp of bicarb if they're very acidotic or have a low, low bicarb. And if their blood pressure shoots up, then that's them being very responsive to that 8.4%, that high osmolarity concentration of bicarb. And then I actually will do hypertonic bicarb in that situation, even though the most recent literature like couldn't prove the mortality benefit with it in that in that situation. So a lot of the things you're gonna look at whenever you look at the surviving sepsis guidelines are gonna be based on like all these studies that I talked about. The other things that came up that are not related to treatment are kind of like the sepsis warning systems. So, SIRS, they kind of tried to go away from that. It QSOFA, they decided didn't work because it didn't capture enough people. And so most hospitals use either Muse or News. So the EWS of both of those are going to be your early warning systems. So it is a way of saying, hey, this person is positive for an early warning system for sepsis. And those were found to be superior to QSOFA, and they're a little bit more specific than SERS. So most hospitals should be probably using either news or Muse. Most hospitals that I've worked at have you have used Muse uh specifically, but I don't I've never worked at one that used the other that I can speak to between the two of them. But those are the recommended systems to identify those people.
SPEAKER_05We use Muse for inpatients, but I think in ED, doesn't it still give you a certain th they still talk about SERS in there, even though the the the argument is still true?
SPEAKER_01That's why I said, like, even though we redefined sepsis in 2016, we're definitely not doing that. We're still looking at at SERS with an infectious source. Uh and then another thing is kind of monitoring, like how do we decide if we're what we're doing is working? And that's whenever you get into like volume. Responsiveness and you also get into like how do you tell if your shock's getting better? Like, other than like your heart rate's getting better, your blood pressure's getting better. But the idea was do you trend the lactic, right? If your lactic was six and now it's four and now it's two, you know, or like clearing the lactic, even though they try to not have you say that term, you're you're kind of just getting out of shock. You're not like clearing the lactic by giving fluid, you're just resuscitating them so that they no longer are making lactic as opposed to like clearing the lactic. Uh, but there was a big study that they just came out with a uh a repeat study, the Andromeda shock trial was a really big study where they actually looked at lactic improvement versus cap refill for your goals for fluid resuscitation. So you would give fluids until either your lactate normalized or you would give fluids until you had a normal cap refill. And it showed a mortality benefit if you just did it to cap refill and not to improvement in lactic. The the repeat study proved the same thing over again, like 10 years later.
SPEAKER_05Really?
SPEAKER_01Yeah. I guess I mean, and that's easy. Yeah, it it's very specific and like how how long you have to hold it down and then how you let go and how you like it's it, you know, it's not just like let me just push on their finger and see what happens. Like there is like a a specific definition for it, but it's about to just start pressing on fingers all the time.
SPEAKER_04So I'm glad you said that.
SPEAKER_05You're gonna be like, hey, you look, I did it, and they're good. And it's like, yeah, put a lactate and check and make sure it's like well, why not? Obviously.
SPEAKER_01So, but when they did it, it did show, and the the idea was you you're you're prone to over-resuscitating somebody. If someone has a lactic of 10 and now they have a lactic of six, their lactic is getting better. So maybe you don't need to give two or three more liters of fluid to like fix that lactic. You can just be like, okay, they're resuscitated, right? Like you don't have to continue to give it until it's until it's less than a little bit.
SPEAKER_05I'm gonna draw another one in two hours.
SPEAKER_01So yeah, yeah, yeah. So if it's trending down, then you may be okay. And then the other big thing is volume responsiveness. How do you decide if you want to give more fluids, right? We talk about the starling curve and where you're at on the starling curve of like saying as you give more volume, you should improve your preload. And when you improve your preload, you improve your stroke volume. When you improve your stroke volume, you improve your cardiac output. So the idea was it's if you're on the ascending limb of the starling curve, then you should be volume responsive. If you're on the kind of plateau or descending limb of the starling curve, then you're not going to get better whenever you whenever you get fluid. How do you determine that? Right. Like you can't just like look at the person and say, okay, this is where they're at on the starling curve. And so there's a the it's controversial in how you want to look at it. So passive leg raise was big for a long time. Um and passive leg raise, I like, I think it's helpful. So the idea is when you put their feet above their heads, it sends an extra 250 mls of blood back to their heart and you see if they respond to it. Now, I like that because you're not giving more fluid to test what your thing is. The part that doesn't work out so well is in the study, they had a bed where the feet actually could go up to 45 degrees and actually do a passive leg raise. I've seen people do a passive leg raise where they grab them by the ankles and like put their feet up in the air, and the patient's like, ow, ow, ow, ow. And then they'll be like, oh, their blood pressure went up. And I was like, Yeah, their blood pressure went up because they're in pain, not because they were like responsive to the volume that you're giving from it.
SPEAKER_05Yeah, you just tore their hamstring, dude. They ain't been in that position here.
SPEAKER_01Yeah, they'll be like trying to bend them in half and be like, their blood pressure's so much better.
SPEAKER_03So it's everyone can be bent in half every once in a while.
SPEAKER_01But they so it if you do it correctly and you do it past it, like if you do it where they're not in pain and you take your time and you do it, I think it is helpful. But like just be aware that if you're like grabbing people's ankles and like doing that, that you you're not necessarily testing for volume responsiveness appropriately. Yeah. The other big controversy is like ultrasound using their IVC. And I think it's hard. Everyone's IVC is variable. Like a normal CVP is zero to five, uh, like in everyday life. And so if we checked everybody normally, your IVC would vary. Having a variable IVC and change, it's like how we pump blood back to our body so that we from like against gravity from our feet back to our heart, like we have a variable IVC. That doesn't mean you need fluid. In somebody who's in septic shock who has a variable IVC, they are probably volume responsive. It doesn't mean they need fluid, it just means they're probably volume responsive. But then people got into the idea was well, if they're intubated, are they passively breathing? Are they actively breathing? That could make it falsely variable if they're actively breathing. If they're intubated, it needs to be 10 mls per kg or six mls per kg doesn't work, or all these, like it has to be 30% variable or 50% variable. Like all of these studies were doing all of these things that made people it made people just not want to do it. They were like, it's too complicated. I don't like looking at IVC variability to assess volume responsiveness. And that's fine. Like I think it's a tool. I don't think it's like the end all be all on there. I really like ultrasound. Um, so I will like look at people. I think extremes are helpful. If your IVC is completely collapsed, uh, yeah, they probably are volume responsive. If their IVC is huge and pulsatile, they probably don't. Anything in between, you could you could have five different people argue five different points. I think it's harder to to do it on those things with it. There's a pulse pressure variation or stroke volume variation. So I thought be my next question. Oh yeah.
SPEAKER_05What was the like in terms of using you could touch on it because that's something that like, you know, if they do have an A line or whatever, like we can see that happening in real time and like easily like come report it to you. So I was just gonna ask you that.
SPEAKER_01Yeah, it you can look at somebody's A line. And if you do like if you remember back to your calculus classes, you know, and you remember your integrals, if you do an area under the curve of your A line, then that actually will give you your stroke volume. We obviously don't do that, but it's the idea of you can quantify their stroke volume based on their arterial line. And if you see variability in their A line with breathing, like their their amplitude of their A line changes, gets like wider and sh and shorter or taller and shorter. It it shows that every time you breathe, you're partially collapsing your SVC and your IVC. You're decreasing blood return to the heart. When you're decreasing blood return to the heart, you're dropping their stroke volume. And you can see that drop in stroke volume by that change in the pulse pressure. So that you can actually like watch that in real time and say, look, I every time they breathe, they have a change in their uh in their A line, they're probably volume responsive. Now, companies have taken that and you can actually put an arterial line in. You can hook up their machine to their arterial line and it will calculate that stroke volume for you, and it will tell you if they have stroke volume variability. So, a common one that's used in a lot of hospitals is like the Vigileo flow track, and you would hook it up to it, and it'll actually give you a starling curve. And if your stroke volume variation is greater than 13%, then that means you're probably on the ascending limb of the starling curve and volume responsive. If it's less than 13%, you're probably on the plateau or descending limb and you're likely not to be volume responsive. Those are probably the most common ways of doing stuff with it. There's some more, there's some like other ways, but I would say those are the most used ones for like monitoring resuscitation and making sure that you're not like over-resuscitating with fluid. So it it just makes you want to say, like, we're good, we don't need to give more fluid, so we don't have to like get all that fluid off later. Yeah. Um, so I that that's kind of where we're at. So in 2020, they came out with more sepsis guidelines. 2022, 2022, they came out with more sepsis guidelines. They just came out with a a new iteration of the sepsis guidelines, and nothing's really changed over the last four years. I was excited to see like what the new guidelines were, but they they basically just reworded what they did. So we showed they looked at fluids, the 30 mls per kg, and they actually found out there's no benefit to 30 mls per kg. It's all patient dependent on there, which makes a ton of sense. So they they they changed their verbiage to just say like you consider 30 mls per kg, you know, and they put things in parentheses and they underline stuff to be like consider or likely would help. You know, and they put all these like things in front of it that would just make it so that you had more wiggle room, which I like. I like the idea of not getting a report card at the end of your month and being like, you got a C because you gave 29 milliliters per kilo on this person, blah, blah, blah, or like whatever. It was more like for this patient, we assess them. They were not volume responsive, we didn't give them volume, or like having some variations of stuff that you can do with it. And it quantified things back then too, uh 22 and 26 more was like if they're just septic and they're not in septic shock, you can take a little bit of extra time to like do figure out really what you need to do, as opposed to like if they're in septic shock, like a lactic greater than four, a hypotensive on pressors, try to get everything done as quickly as possible. Try to do that hour. The sepsis guidelines have always had like a three-hour bundle and a six-hour bundle where they said you need to reassess them at the three-hour mark and reassess them at the six-hour mark and actually document all of these things, like what's their blood pressure, what's their vital signs, what's their lactic, what's their blah, blah, blah, to show that you've resuscitated them. Basically, is like a don't forget about them. Like, yes, you want to do all this stuff up front, but you need to re-evaluate. Are they getting better? If they're not getting better, then you maybe need to do a deeper dive. Are we missing like an intra-abdominal abscess, or are we missing something else that's going on that you're maybe didn't realize in your first go-around with it? And then the six-hour bundle as well to be able to do it. So that's that's kind of like the I don't know, I I that's much more of the stuff that I don't like as much. I know I just wanted this whole thing about it, and like that's all the evidence-based literature and the guidelines and like why we do what we do, and blah, blah, blah. But to me, it's just memorizing a lot of stuff. I really like going into the physiology behind it and saying, like, why do we do the things that we do? And so I'll spin the next little time to like go over the physiology about why this stuff is helpful.
SPEAKER_02Hi, everyone. The rest of Septic Shock Management is going to be coming to you next week. Make sure you hit the like, follow, button, leave us some comments, send us an email with your questions for Dr. Michael at Anterathebedside.com. We're excited to continue to learn in this way. Like, we are all sitting at the nurses station together learning with Dr. Michael. Until next time, bye-bye.
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