1 00:00:00,000 --> 00:00:03,329 Lauren Page Black: I think this is one where um, everybody I work with knows 2 00:00:03,329 --> 00:00:05,460 how much I dislike this test in the er. 3 00:00:05,460 --> 00:00:08,309 I think, um, it's now synonymous with, you know, me. 4 00:00:08,579 --> 00:00:14,670 Um, but I think this is a perfect example of a great test in a different location. 5 00:00:14,909 --> 00:00:18,750 Um, I think procalcitonin can be really helpful, particularly to 6 00:00:18,750 --> 00:00:23,009 our upstage colleagues, colleagues for antibiotic deescalation and, 7 00:00:23,009 --> 00:00:25,109 and a few other, um, scenarios. 8 00:00:25,109 --> 00:00:25,980 However. 9 00:00:27,389 --> 00:00:32,610 As a surrogate decision maker for antibiotic initiation, it 10 00:00:32,610 --> 00:00:35,610 has never been shown to perform well in the emergency department. 11 00:00:35,969 --> 00:00:39,210 The long answer is part of that's for a number of reasons. 12 00:00:39,480 --> 00:00:43,980 They peak, you know, 1248 hours after the onset of infection. 13 00:00:44,250 --> 00:00:47,130 Um, granted, I don't know when onset of infection was. 14 00:00:47,130 --> 00:00:51,000 Nobody really does in the er, but the point is it may rise too late 15 00:00:51,000 --> 00:00:52,800 for it to be helpful in the er. 16 00:00:53,039 --> 00:00:57,659 It also has really limited sensitivities in really important subgroups for us. 17 00:00:57,659 --> 00:01:01,050 So like a though, what's really good for lung infections, it's not really 18 00:01:01,050 --> 00:01:04,110 great for atypical lung infections, and we know plenty of people 19 00:01:04,110 --> 00:01:05,610 who have gotten sick from those. 20 00:01:05,639 --> 00:01:11,350 Um, it also doesn't perform as well, um, for other infections like, 21 00:01:11,369 --> 00:01:14,519 you know, skin soft tissue and, and immunocompromised patients. 22 00:01:14,759 --> 00:01:15,119 So. 23 00:01:16,170 --> 00:01:19,019 And several studies looked at this and looked at, you know, how could it 24 00:01:19,019 --> 00:01:22,590 augment gestalt And it has never once been shown to outperform, outperform 25 00:01:22,769 --> 00:01:26,460 physician gestalt especially when studied in the emergency department environment. 26 00:01:26,760 --> 00:01:30,150 Um, I will put a caveat here that I'm talking about adults. 27 00:01:30,179 --> 00:01:35,579 Uh, the pediatric world, I will, that discussion is, is very different. 28 00:01:35,789 --> 00:01:39,450 Um, but in adult patients, if you think they need antibiotics, like 29 00:01:39,510 --> 00:01:40,839 you should order antibiotics. 30 00:01:40,839 --> 00:01:45,599 And if you don't think they're septic, you can just doc, you can just document that. 31 00:01:45,900 --> 00:01:48,720 Um, if you think, you know, their vital sign abnormalities are 'cause 32 00:01:48,720 --> 00:01:51,630 they have a GI bleed or tamponade or something else, and I don't 33 00:01:51,630 --> 00:01:52,950 think you need a procalcitonin. 34 00:01:53,250 --> 00:01:58,110 Um, in fact, I think that's a inappropriate use of a procalcitonin. 35 00:01:58,380 --> 00:01:59,760 Um, in that scenario. 36 00:01:59,760 --> 00:02:03,170 I mean, just like outside of a few specific situations, you don't really 37 00:02:03,170 --> 00:02:09,659 need a VBG on coding patients, um, to tell you that their pH is bad. 38 00:02:09,750 --> 00:02:13,320 Um, you know, I think this is one of the things where you just have to. 39 00:02:14,070 --> 00:02:18,090 Anchor on your clinician, clinical gestalt and, and it's okay to do that, 40 00:02:18,220 --> 00:02:18,340 Sam: Good, 41 00:02:18,340 --> 00:02:18,450 Lauren Page Black: And 42 00:02:18,450 --> 00:02:20,789 the evidence suggests that's the best in this scenario. 43 00:02:21,195 --> 00:02:21,525 Sam: good. 44 00:02:22,365 --> 00:02:26,775 And then when it comes to imaging, this is all just guided by your 45 00:02:26,775 --> 00:02:31,545 examination and your concern for occult infection areas where you might 46 00:02:31,545 --> 00:02:34,695 not be able to see it as best as you can get from history and physical. 47 00:02:35,250 --> 00:02:37,320 Lauren Page Black: Yeah, nothing has really changed about this 48 00:02:37,320 --> 00:02:38,880 in the, in the past few years. 49 00:02:38,940 --> 00:02:41,820 Um, there was, I think a brief period of time people were 50 00:02:41,820 --> 00:02:43,170 talking about medical pan scans. 51 00:02:43,170 --> 00:02:45,760 I certainly don't think the evidence supports us doing that right now. 52 00:02:45,760 --> 00:02:46,070 Who knows? 53 00:02:46,070 --> 00:02:47,340 what I'll be saying in a handful of years. 54 00:02:47,610 --> 00:02:53,159 Um, what I will say is I do think, um, judicious use of, of imaging can really 55 00:02:53,159 --> 00:02:55,199 help us find sources of infection. 56 00:02:55,409 --> 00:02:58,110 I think we should have the particular population. 57 00:02:58,110 --> 00:03:02,429 I do think we should have a pretty low threshold for, in particular abdominal 58 00:03:02,429 --> 00:03:04,619 imaging is, is is the elderly patient. 59 00:03:04,619 --> 00:03:07,440 And I think we all know that, you know, if they have, 60 00:03:07,689 --> 00:03:07,779 And 61 00:03:07,779 --> 00:03:09,659 I, I I think if they have. 62 00:03:10,590 --> 00:03:15,719 A pretty unremarkable ua and it's like, eh, that could be a UTI. 63 00:03:15,719 --> 00:03:19,199 But they look like absolutely terrible. 64 00:03:19,349 --> 00:03:21,539 Um, you know, that those are the patients where I think anchoring 65 00:03:21,539 --> 00:03:23,190 on the UA may be inappropriate. 66 00:03:23,190 --> 00:03:27,239 And it's probably best to at least consider abdominal imaging, especially 67 00:03:27,239 --> 00:03:31,079 because, you know, sicker elderly patients, immunocompromised patients 68 00:03:31,079 --> 00:03:32,909 may not localize infections as well. 69 00:03:32,909 --> 00:03:36,659 I mean, I think we all probably have, know, several cases of this 70 00:03:36,659 --> 00:03:38,130 we've seen over, over the years. 71 00:03:38,190 --> 00:03:41,579 Um, so I'd say I would have a low threshold, especially with the general 72 00:03:41,579 --> 00:03:45,630 ease in most ERs of obtaining CT imaging, of considering abdominal imaging, 73 00:03:45,960 --> 00:03:49,170 um, in elderly and immunocompromised patients bellies particularly. 74 00:03:49,170 --> 00:03:52,409 'cause often there's a source control procedure there, um, that can change 75 00:03:52,409 --> 00:03:56,299 management, or I won't say often, but enough of the time that it's relevant. 76 00:03:56,299 --> 00:03:56,849 Sam: It's relevant. 77 00:03:56,969 --> 00:03:57,360 Perfect. 78 00:03:58,664 --> 00:04:01,605 Okay, then let's get into that CMS bundle for a second. 79 00:04:01,634 --> 00:04:05,984 'cause now we're into that kinda initial management, that first few hours period. 80 00:04:06,254 --> 00:04:09,884 Uh, where are we in that requirement for the bundle? 81 00:04:09,884 --> 00:04:11,619 Has that changed at all in the last few years? 82 00:04:12,734 --> 00:04:16,004 Lauren Page Black: It has changed a little bit in, in the past few years. 83 00:04:16,064 --> 00:04:22,004 Um, what I first wanna say about the bundle is, you know, not everybody 84 00:04:22,004 --> 00:04:26,174 with the bundle requires 30 ccs per kilo by CMS, which I think, 85 00:04:26,534 --> 00:04:29,474 um, sort of the way the bundles are written, it can be confusing. 86 00:04:29,474 --> 00:04:33,344 But essentially there's a severe sepsis bundle, is SEPs, which 87 00:04:33,344 --> 00:04:34,514 is what we now call sepsis. 88 00:04:34,514 --> 00:04:37,184 So if you think somebody has organ dysfunction in the setting of an 89 00:04:37,184 --> 00:04:40,964 infection, you need to order blood cultures prior to giving them antibiotics. 90 00:04:41,294 --> 00:04:44,684 You need to order a lactate and you need to repeat it. 91 00:04:44,684 --> 00:04:46,064 That's the six hour part of the bundle. 92 00:04:46,064 --> 00:04:50,564 If it's greater than two and you need to give antibiotics, um, 93 00:04:54,104 --> 00:04:55,875 as reasonably early as possible. 94 00:04:55,875 --> 00:04:57,044 It's really within the first 95 00:04:57,219 --> 00:04:57,889 Three hours. 96 00:04:58,304 --> 00:05:00,974 though though, they have this caveat, ideally within the first 97 00:05:00,974 --> 00:05:03,494 three hours, what they hold you to is three hours, and I think that's 98 00:05:03,494 --> 00:05:05,324 reasonable for that patient population. 99 00:05:06,524 --> 00:05:11,294 Um, then, if they're hypotensive or if they have a lactate greater 100 00:05:11,294 --> 00:05:15,464 than four, that's what triggers the 30 ccs per kilogram fluid bolus. 101 00:05:15,524 --> 00:05:22,304 So if they, you know, have pneumonia and they have a new oxygen requirement 102 00:05:22,964 --> 00:05:26,054 and you know that's technically sepsis, that's organ dysfunction, hypoxia in the 103 00:05:26,054 --> 00:05:29,804 setting of an infection, that patient doesn't necessarily need 30 ccs per kilo. 104 00:05:29,984 --> 00:05:32,834 Then if they become hypotensive or lower lactate comes back at four, that would 105 00:05:32,834 --> 00:05:35,024 trigger the 30 cc per kilo fluid bolus. 106 00:05:35,264 --> 00:05:39,224 In the past few years, CMS has pushed out some updates that give us some 107 00:05:39,224 --> 00:05:41,204 ability to have some discretion there. 108 00:05:41,414 --> 00:05:45,944 So resuscitation based on ideal body weight is acceptable for patients 109 00:05:45,944 --> 00:05:47,944 whose BMIs are 31 or higher, so 110 00:05:47,944 --> 00:05:48,384 greater than 111 00:05:48,384 --> 00:05:52,634 30, and you just have to document, you know, resus resuscitation per ideal 112 00:05:52,634 --> 00:05:57,464 body weight given BMI greater than 30, they also permit, um, documentation 113 00:05:57,464 --> 00:05:59,294 of a lesser volume of fluid. 114 00:06:00,360 --> 00:06:03,180 Um, when accompanied by clinical reasoning. 115 00:06:03,360 --> 00:06:09,180 So for example, if somebody you know has an ICD because their EF is 10%, it is 116 00:06:09,270 --> 00:06:14,309 reasonable and acceptable to document that, but it has to be pretty clear. 117 00:06:14,309 --> 00:06:17,820 So you have to document the amount of fluid you're giving and why. 118 00:06:17,820 --> 00:06:26,280 So 500 ccs of LR given instead of the 30 ccs per kilogram bolus due to 119 00:06:26,280 --> 00:06:31,320 concerns for, um, congestive heart failure, EF less than 10%, something 120 00:06:31,320 --> 00:06:33,480 along those lines or, you know, ESRD. 121 00:06:33,480 --> 00:06:36,390 But in ESRD, fluid overload, congestive heart failure, they 122 00:06:36,390 --> 00:06:37,920 give you some ability to document 123 00:06:38,030 --> 00:06:38,320 Sam: Good. 124 00:06:38,760 --> 00:06:41,130 Lauren Page Black: What I will say though is I also think this pendulum 125 00:06:41,130 --> 00:06:43,770 has swung again with fluids in the past few years where I think people are like 126 00:06:44,039 --> 00:06:47,670 terrified of fluids now and, you know, don't, don't wanna give any at all. 127 00:06:47,670 --> 00:06:51,390 And I think, you know, I think we'll hopefully see where we used to just 128 00:06:51,809 --> 00:06:54,000 give a bajillion liters to everybody. 129 00:06:54,000 --> 00:06:55,950 And I think we'll see the pen pendulum. 130 00:06:56,400 --> 00:06:56,820 Um. 131 00:06:57,390 --> 00:07:01,320 Switch back a little bit, but that is what, um, from a CMS criteria, they 132 00:07:01,320 --> 00:07:05,490 hold you to, within the first six hours, they ask you to remeasure that 133 00:07:05,490 --> 00:07:07,260 lactate if it was greater than two. 134 00:07:07,530 --> 00:07:12,180 Um, and if the patient has a lactate, still has a lactate greater than four, 135 00:07:12,180 --> 00:07:15,240 or they're still hypotensive within the first six hours, they, they ask that you 136 00:07:15,240 --> 00:07:19,650 start vasopressors, um, and reassess their volume status with like a clinical note. 137 00:07:20,369 --> 00:07:22,200 that's pretty much the extent of the bolus. 138 00:07:22,200 --> 00:07:26,490 It hasn't, I mean, the extent of the bundle, it hasn't changed dramatically. 139 00:07:26,625 --> 00:07:31,034 Sam: So if you have someone whose say, initial lactate is high, let's 140 00:07:31,034 --> 00:07:34,904 say it's five for the sake of this conversation, and then I repeat it, and 141 00:07:34,904 --> 00:07:40,274 now it's four and a half, but they're not hypotensive in the CMS six hour 142 00:07:40,274 --> 00:07:44,324 bundle, it says you should be thinking about vasopressors at this point, but 143 00:07:44,324 --> 00:07:47,414 this person is not clinically, uh, hypo. 144 00:07:47,414 --> 00:07:48,404 They're not hypotensive. 145 00:07:48,404 --> 00:07:50,324 It's not somebody I would normally start a pressor in. 146 00:07:50,594 --> 00:07:53,684 Am I, could I have to go write something in there saying this is 147 00:07:53,684 --> 00:07:55,230 why I did not start vasopressors? 148 00:07:55,799 --> 00:07:58,289 Lauren Page Black: No, uh, the vasopressor part does say just 149 00:07:58,349 --> 00:07:59,879 to maintain a map above 65. 150 00:07:59,879 --> 00:08:02,669 So if they're maintaining that on their own, that's acceptable. 151 00:08:02,879 --> 00:08:07,079 Um, I, I, I also always think we should do the right thing for the patient and, 152 00:08:07,919 --> 00:08:09,419 you know, just fight it on the back end. 153 00:08:09,419 --> 00:08:12,690 So if they don't need pressors, they don't need pressors. 154 00:08:12,690 --> 00:08:17,069 And I, think we should always, have our first responsibility be to the patient, 155 00:08:17,099 --> 00:08:21,029 um, when those disagree with guidelines. 156 00:08:21,029 --> 00:08:24,179 But, um, no, they, they only require, it's just vasopressors 157 00:08:24,179 --> 00:08:25,649 to maintain a map above 65. 158 00:08:25,684 --> 00:08:25,974 Sam: Okay. 159 00:08:26,219 --> 00:08:29,099 Lauren Page Black: if it's not terribly different than what consensus guidelines 160 00:08:29,099 --> 00:08:35,520 are, it's just that the lactate above four requires the fluid bolus and 161 00:08:35,520 --> 00:08:38,849 they call that shock, even though we don't call that shock clinically. 162 00:08:38,849 --> 00:08:41,489 And I do, I do think that's the teeniest bit confusing. 163 00:08:41,489 --> 00:08:47,940 I'd love to see, I'd love to see, I don't know, some, um, more clarity around that. 164 00:08:48,090 --> 00:08:48,540 Sam: Yeah. 165 00:08:49,409 --> 00:08:52,589 Lauren Page Black: but, you do not have to start vasopressors, 166 00:08:52,649 --> 00:08:53,730 um, just for a lactate. 167 00:08:54,000 --> 00:08:54,180 Sam: Yeah. 168 00:08:54,180 --> 00:08:57,599 And when you say they call that shock, you mean CMS in their definition? 169 00:08:57,599 --> 00:08:58,230 Calls them? 170 00:08:58,230 --> 00:08:58,860 Call calls. 171 00:08:58,860 --> 00:09:01,079 Anybody with a lactate greater than four, that's persisting to 172 00:09:01,079 --> 00:09:04,500 be in shock when that's, you know, clinically not the case for us. 173 00:09:05,535 --> 00:09:06,075 Lauren Page Black: Exactly. 174 00:09:06,195 --> 00:09:09,705 It, it, and it's, it's really just that they use it to trigger the septic shock 175 00:09:09,705 --> 00:09:12,735 bundle, which is really the fluids and then the, if they're persistently 176 00:09:12,735 --> 00:09:14,715 hypotensive vasopressor requirement. 177 00:09:14,955 --> 00:09:18,525 Um, but yes, that would trigger their septic shock bundle, and 178 00:09:18,525 --> 00:09:22,425 those people would be captured by the septic shock abstraction 179 00:09:22,425 --> 00:09:22,665 methods 180 00:09:22,739 --> 00:09:23,159 Sam: Gotcha. 181 00:09:23,879 --> 00:09:24,150 Okay. 182 00:09:24,150 --> 00:09:28,739 Let's talk about fluid type one conversation that people love to have. 183 00:09:28,739 --> 00:09:32,879 So we're talking about some kind of, uh, fluid. 184 00:09:32,879 --> 00:09:37,230 Most of us are using either normal saline or some kind of lactated ringer. 185 00:09:37,529 --> 00:09:42,569 Uh, is there actually a preference for one over the other or evidence that might 186 00:09:42,569 --> 00:09:44,364 swing us in one way versus the other? 187 00:09:45,494 --> 00:09:47,295 Lauren Page Black: So this is still quite controversial. 188 00:09:47,505 --> 00:09:50,865 Um, I will say, you know, the last time we wrote this, salted and Smart had 189 00:09:50,865 --> 00:09:56,744 come out, um, I, and, and those two studies were pragmatic, randomized, 190 00:09:56,744 --> 00:10:01,755 controlled trials where they switched out the fluids in, um, every month and, 191 00:10:01,815 --> 00:10:07,875 you know, looked at mortality and then, um, make 30, um, and, and did see a 192 00:10:07,875 --> 00:10:12,885 slight difference in Make 30, which was a composite outcome in favor of balanced 193 00:10:12,885 --> 00:10:13,585 crystalloids 194 00:10:14,295 --> 00:10:17,685 However, and since I think the last version of this paper was published, they 195 00:10:17,685 --> 00:10:21,375 then did a subgroup analysis of patients with sepsis that I think was well done. 196 00:10:21,375 --> 00:10:24,375 It was pre-planned, it was clearly pre-planned in their protocol, and 197 00:10:24,375 --> 00:10:28,405 they found a mortality difference, um, in favor of balanced crystalloids 198 00:10:28,425 --> 00:10:29,744 rather than normal saline. 199 00:10:29,925 --> 00:10:32,715 So I, that's pretty compelling to me, even though it wasn't a 200 00:10:32,715 --> 00:10:34,775 randomized study in that group. 201 00:10:34,775 --> 00:10:36,494 in Particular, it's a well-planned. 202 00:10:37,290 --> 00:10:40,380 Secondary analysis of a population that makes sense to 203 00:10:40,380 --> 00:10:44,010 look at this in, and there's a mortality benefit in favor of lr. 204 00:10:44,010 --> 00:10:50,639 So I think, you know, in, in general, I, I think LR does outperform 205 00:10:50,639 --> 00:10:53,430 normal saline based on the best quality of the evidence we have. 206 00:10:53,430 --> 00:10:54,300 I think it makes sense. 207 00:10:54,300 --> 00:10:58,050 Physiologically it's, you know, no longer really difference, uh, 208 00:10:58,110 --> 00:11:00,300 has a huge difference in cost. 209 00:11:00,300 --> 00:11:03,030 So in, in my personal practice, I, I lean on lr. 210 00:11:03,030 --> 00:11:05,460 I'm also married to a surgeon and they, there's nothing they 211 00:11:05,460 --> 00:11:06,710 hate more than normal saline. 212 00:11:06,710 --> 00:11:07,260 So maybe 213 00:11:07,530 --> 00:11:11,460 maybe it's partially that, but for, for sepsis, I feel far more strongly. 214 00:11:11,460 --> 00:11:14,449 I think this is a case where we should be using balanced crystalloids 215 00:11:14,465 --> 00:11:15,570 instead of normal saline. 216 00:11:15,905 --> 00:11:18,869 Sam: And that that subgroup analysis you talked about in sepsis 217 00:11:18,869 --> 00:11:21,690 patients, was that those with septic shock or just all comers? 218 00:11:21,690 --> 00:11:22,230 Sepsis. 219 00:11:22,710 --> 00:11:25,619 Lauren Page Black: It is at le it was their ICU cohort arm. 220 00:11:25,619 --> 00:11:26,880 So they were the sicker patients. 221 00:11:26,880 --> 00:11:28,260 So whether or not they were. 222 00:11:29,100 --> 00:11:32,220 know, intubate, intubated in, in the ICU or in septic shock. 223 00:11:32,220 --> 00:11:35,790 It was, it was the sicker patients, um, that they did 224 00:11:35,790 --> 00:11:37,110 show that mortality benefit in. 225 00:11:37,350 --> 00:11:44,040 But mortality benefits are hard to see in sepsis, so I'm just because of the 226 00:11:44,040 --> 00:11:45,450 number of patients you have to enroll. 227 00:11:45,450 --> 00:11:49,980 And so I, I feel like it's a pretty compelling, a pretty compelling result, 228 00:11:50,010 --> 00:11:51,810 however, it is in the sickest patients 229 00:11:51,860 --> 00:11:52,150 Sam: Okay. 230 00:11:52,514 --> 00:11:52,845 All right. 231 00:11:52,845 --> 00:11:54,585 So lactated ringers it is. 232 00:11:54,645 --> 00:11:59,115 And then, uh, there is a part of the bundle that requires a repeat assessment. 233 00:11:59,115 --> 00:12:03,525 So what does that have to look like for CMS to be satisfied? 234 00:12:03,525 --> 00:12:05,565 And then what should it look like for us clinically? 235 00:12:06,540 --> 00:12:06,780 Lauren Page Black: for 236 00:12:06,780 --> 00:12:07,500 CMS 237 00:12:08,460 --> 00:12:13,319 It is a documentation of intravascular volume status and tissue perfusion. 238 00:12:13,469 --> 00:12:16,710 I think for us clinically, I think it's just going to the bedside and 239 00:12:16,710 --> 00:12:20,069 reassessing the patient, not the computer, and make sure, um, they 240 00:12:20,069 --> 00:12:21,480 actually look better or don't look worse. 241 00:12:21,480 --> 00:12:25,349 Which I think, you know, sometimes you go in and, you know, maybe none of the fluids 242 00:12:25,349 --> 00:12:26,819 are going in, maybe it's in their AC and 243 00:12:26,940 --> 00:12:27,389 Sam: Hmm. 244 00:12:27,420 --> 00:12:29,819 Lauren Page Black: you know, they've got it kinked up and the fluids are, you know, 245 00:12:29,819 --> 00:12:31,619 largely still in the bag or something. 246 00:12:31,650 --> 00:12:35,670 Um, so I think, I always think it's wise to go back in a few times and check on 247 00:12:35,670 --> 00:12:39,665 these patients that are a bit tenuous and have a high probability of decompensating. 248 00:12:40,590 --> 00:12:40,860 Sam: Good. 249 00:12:41,790 --> 00:12:42,060 All right. 250 00:12:42,060 --> 00:12:44,010 And then let's talk about antibiotics. 251 00:12:44,010 --> 00:12:48,599 So, uh, timing of antibiotic administration, you mentioned earlier, but 252 00:12:48,599 --> 00:12:54,030 there is a requirement in the CMS bundle, at least some requirement for time. 253 00:12:54,179 --> 00:12:58,619 And then clinically, do we have good evidence that even for a subset of 254 00:12:58,619 --> 00:13:01,770 populations, it might be best to just give 'em as soon as we can? 255 00:13:02,639 --> 00:13:02,909 Lauren Page Black: Yeah. 256 00:13:02,909 --> 00:13:04,829 So if they are, I think that's a great question. 257 00:13:04,829 --> 00:13:06,420 CMS will hold you to three hours. 258 00:13:06,449 --> 00:13:09,329 Um, that's still what, um, the guidelines hold you to. 259 00:13:09,329 --> 00:13:12,329 I think that gives us a fair amount of time to get some 260 00:13:12,329 --> 00:13:13,949 idea of a source of infection. 261 00:13:13,949 --> 00:13:15,810 So I actually think that's pretty reasonable. 262 00:13:16,049 --> 00:13:16,569 Um, 263 00:13:16,649 --> 00:13:18,029 Sam: Can I clarify there for one second? 264 00:13:18,029 --> 00:13:21,659 Is that three hours from when they arrive, or three hours from when 265 00:13:21,694 --> 00:13:23,775 you recognize them to have sepsis 266 00:13:24,480 --> 00:13:25,049 Lauren Page Black: it's three hours. 267 00:13:25,049 --> 00:13:26,159 Thank you for clarifying. 268 00:13:26,159 --> 00:13:27,409 Three hours from sepsis recognition. 269 00:13:27,585 --> 00:13:28,275 Sam: recognition? 270 00:13:28,344 --> 00:13:28,634 Okay. 271 00:13:29,159 --> 00:13:33,869 Lauren Page Black: um, and, and there are some nuances here, just like on the 272 00:13:33,869 --> 00:13:36,119 backend with, with what that's called. 273 00:13:36,359 --> 00:13:40,469 Um, so you know, sometimes if A BPA goes off and you click like sepsis suspected, 274 00:13:40,469 --> 00:13:44,790 I think in some, I think that can start your timer actually in some scenarios. 275 00:13:45,149 --> 00:13:45,690 Um. 276 00:13:46,904 --> 00:13:49,665 But it's the time of sepsis recognition in general. 277 00:13:49,665 --> 00:13:53,895 So you have three hours from that to, to, um, order antibiotics. 278 00:13:54,134 --> 00:13:58,304 I will say the time to antibiotics mortality difference is in the patients 279 00:13:58,304 --> 00:14:00,764 with hypoperfusion or hypotension. 280 00:14:00,884 --> 00:14:04,634 So in those patients, I would go ahead and start them early on because 281 00:14:04,634 --> 00:14:06,645 they have a clear mortality benefit. 282 00:14:06,974 --> 00:14:11,744 Um, and so if they're very sick, I would either start broad spectrum 283 00:14:11,744 --> 00:14:15,254 antibiotics or target to what your best idea is clinically. 284 00:14:15,494 --> 00:14:18,944 Um, but those patients, I think we should be pushing whether that means, 285 00:14:19,004 --> 00:14:22,694 you know, physicians are doing lines themselves, et cetera, in order 286 00:14:22,694 --> 00:14:24,525 to get them antibiotics early on. 287 00:14:24,764 --> 00:14:28,304 Um, but for the rest of the patients, you have some time to, 288 00:14:28,364 --> 00:14:31,724 to, determine the most appropriate 289 00:14:32,275 --> 00:14:33,025 antibiotic 290 00:14:33,429 --> 00:14:38,704 I, I will say there is some change as the surviving sepsis 291 00:14:39,294 --> 00:14:39,814 campaign 292 00:14:39,814 --> 00:14:40,944 also re-put 293 00:14:41,364 --> 00:14:41,624 out 294 00:14:42,570 --> 00:14:47,160 Our one bundle, which is confusing again because it's nomenclature is 295 00:14:47,160 --> 00:14:54,540 fairly similar to the CMS bundle where I, I think the goal was to 296 00:14:55,410 --> 00:15:00,000 administer antibiotics earlier on if the patient has evidence of shock. 297 00:15:00,000 --> 00:15:01,560 And I do think that's important. 298 00:15:01,740 --> 00:15:03,990 I think the nomenclature around that is a little confusing. 299 00:15:03,990 --> 00:15:08,010 I also think it perhaps misjudges the complexity of the emergency department 300 00:15:08,160 --> 00:15:11,610 where one hour is pretty, uh, pretty hard. 301 00:15:11,850 --> 00:15:18,060 Um, I think that may be easier to do in environments where people 302 00:15:18,060 --> 00:15:19,320 already have lines, et cetera. 303 00:15:19,320 --> 00:15:23,460 But, um, if, if you think they're septic from the time they walk in, you know, 304 00:15:23,460 --> 00:15:27,450 an hour is still sometimes a little hard to get all this stuff going. 305 00:15:27,660 --> 00:15:32,579 Um, but there, there is some more discussion from consensus guidelines, 306 00:15:32,670 --> 00:15:37,800 but again, not the CMS metrics, um, that are pushing for an hour. 307 00:15:37,800 --> 00:15:40,270 If sepsis is, is definite or probable, I would. 308 00:15:41,489 --> 00:15:45,659 Personally just keep doing what we all think is best for the patient. 309 00:15:45,899 --> 00:15:50,040 Um, but I think that nomenclature is a bit confusing because it so closely mimics cms 310 00:15:50,040 --> 00:15:54,599 step one, but CMS step one has not changed their guidelines off of three hours. 311 00:15:54,665 --> 00:15:58,174 Sam: Okay, and that's three hours, regardless of whether they're in shock 312 00:15:58,174 --> 00:16:01,409 or whether they're just have plain old sepsis and they're stable as can be. 313 00:16:02,125 --> 00:16:02,614 Lauren Page Black: Exactly. 314 00:16:02,909 --> 00:16:05,699 I mean, it does say like with, you know, within one hour if possible. 315 00:16:05,699 --> 00:16:08,669 And, and I think some of that is because in those sicker patients we should be 316 00:16:08,669 --> 00:16:14,639 pushing for earlier pa earlier, um, earlier initiation of antibiotics. 317 00:16:14,639 --> 00:16:21,089 But even if you're pretty sure they're septic, um, if they don't have shock or 318 00:16:21,089 --> 00:16:23,250 hypoperfusion, you really do have time. 319 00:16:23,279 --> 00:16:26,339 The evidence suggests you have some time to figure out the 320 00:16:26,339 --> 00:16:27,810 appropriate antibiotic choice. 321 00:16:28,020 --> 00:16:30,270 And I think that's also beneficial to the patient. 322 00:16:30,270 --> 00:16:34,169 'cause we all know the patient who's gotten like four different antibiotics. 323 00:16:34,935 --> 00:16:37,215 know, what we initially thought and then it changes. 324 00:16:37,215 --> 00:16:41,055 And so I, I think there does have to be some sort of judicious balance 325 00:16:41,055 --> 00:16:45,465 between antibiotic stewardship, um, in the right patients and, and 326 00:16:46,215 --> 00:16:47,865 prompt antibiotic administration. 327 00:16:47,865 --> 00:16:50,415 And I think those things are intention sometimes, and I think that's 328 00:16:50,415 --> 00:16:52,215 where some of the controversy is. 329 00:16:52,215 --> 00:16:57,585 And I think, um, the benefit of early antibiotics clearly outweighs, know, 330 00:16:57,585 --> 00:17:01,755 the risk in the sicker patients who have low blood pressures, who even if 331 00:17:01,755 --> 00:17:04,845 they're not requiring vasopressors, but if they're intermittently hypotensive, 332 00:17:05,115 --> 00:17:09,705 um, or you know, they have, you know, evidence of severe hypoperfusion. 333 00:17:09,705 --> 00:17:14,034 I do think we should promptly give those people antibiotics, but I think, um, we 334 00:17:14,034 --> 00:17:16,755 should consider antibiotic stewardship in some of the other populations. 335 00:17:16,755 --> 00:17:20,445 And, and wait two, or we can wait two hours, you know, for 336 00:17:21,675 --> 00:17:22,845 the x-ray to actually come back. 337 00:17:23,099 --> 00:17:23,670 Sam: Perfect. 338 00:17:24,179 --> 00:17:24,389 Okay. 339 00:17:24,389 --> 00:17:27,810 And then when it comes to picking the correct antibiotic, there's a great. 340 00:17:28,620 --> 00:17:29,280 Table. 341 00:17:29,280 --> 00:17:34,800 It's a very large table, but table five in the article talks about, uh, the infection 342 00:17:34,800 --> 00:17:37,350 by type and then recommended antibiotics. 343 00:17:37,350 --> 00:17:41,400 And, uh, if they're, uh, penicillin, allergic, or anaphylactic, really, 344 00:17:41,610 --> 00:17:43,500 uh, then, then some alternate choices. 345 00:17:43,500 --> 00:17:45,810 So it's all late, it's all laid out there for you. 346 00:17:46,170 --> 00:17:48,960 Uh, you know, everybody likes to give rocephin just off the bat. 347 00:17:48,960 --> 00:17:51,780 It stops the clock and it's what we have in the Pyxis machine and 348 00:17:51,780 --> 00:17:53,010 it's very easy to administer. 349 00:17:53,280 --> 00:17:56,850 Uh, but there are times where you might consider giving something else. 350 00:17:57,090 --> 00:18:00,330 Uh, and so having at least one or two other medications in 351 00:18:00,330 --> 00:18:02,550 your armamentarium is helpful. 352 00:18:02,700 --> 00:18:07,890 Uh, and I think this table does a good job laying that out by source 353 00:18:07,890 --> 00:18:11,340 if you happen to know the source or at least suspect something specific. 354 00:18:12,835 --> 00:18:13,245 Lauren Page Black: Thank you. 355 00:18:13,465 --> 00:18:14,475 we hope it's helpful. 356 00:18:14,520 --> 00:18:16,170 Um, we spent a fair amount of time on it. 357 00:18:16,409 --> 00:18:19,830 Let's say the only big changes there in the past few years are, you know, 358 00:18:20,130 --> 00:18:25,320 HCAP has kind of gone away in favor of, you know, still largely giving, um, cap 359 00:18:25,320 --> 00:18:30,590 coverage to severe community acquired pneumonia, unless, um, they have prior. 360 00:18:30,590 --> 00:18:30,680 MRS 361 00:18:32,940 --> 00:18:36,090 A respiratory isolates or hospitalization and, you know, 362 00:18:36,090 --> 00:18:37,380 some of the other risk factors. 363 00:18:37,410 --> 00:18:42,990 Um, I don't really know clinically that it, that our clinical 364 00:18:42,990 --> 00:18:45,690 practice has changed a, a whole lot 365 00:18:45,690 --> 00:18:46,000 because 366 00:18:46,000 --> 00:18:46,270 of that. 367 00:18:46,270 --> 00:18:50,820 But it's, it's worth knowing that, you know, there has been some changes 368 00:18:50,820 --> 00:18:53,030 to those definitions, um, and those 369 00:18:53,030 --> 00:18:53,240 blanket 370 00:18:54,073 --> 00:18:54,893 recommendations. 371 00:18:54,893 --> 00:18:57,960 I would also say the big thing that I do think clinically has changed is 372 00:18:57,960 --> 00:19:02,130 there is a whole lot more ESBL, like community acquired, extended spectrum 373 00:19:02,130 --> 00:19:05,850 beta lactamase UTIs than there were, I feel like even five years ago. 374 00:19:06,090 --> 00:19:10,500 Um, and so if you think this suspected source is a uti, I I would spend the 375 00:19:10,530 --> 00:19:14,850 few, don't, it's still so clunky to look at old cultures, I think in, in 376 00:19:14,850 --> 00:19:19,050 most EMRs, but that is one place where I really do think work, looking at old 377 00:19:19,050 --> 00:19:20,670 cultures is particularly important. 378 00:19:20,880 --> 00:19:22,440 Um, because if they had 379 00:19:23,060 --> 00:19:23,160 an 380 00:19:23,160 --> 00:19:28,095 ESBL infection, I would, I would not give them, I. know, a beta-lactam. 381 00:19:28,095 --> 00:19:29,265 I wouldn't give them rocephin or 382 00:19:29,265 --> 00:19:30,055 cefepime 383 00:19:30,075 --> 00:19:33,255 I would, um, try to target, um, 384 00:19:36,225 --> 00:19:38,865 one of the, or one of the antibiotics to which they had 385 00:19:38,865 --> 00:19:40,275 shown to be sensitive in the past. 386 00:19:40,680 --> 00:19:44,100 Sam: Yeah, I will say I think that adds kind of two extra 387 00:19:44,100 --> 00:19:45,690 steps to your decision making. 388 00:19:45,690 --> 00:19:49,290 Like one, can you access an old culture of any sort? 389 00:19:49,560 --> 00:19:53,310 Uh, it seems like when I am consulting my infectious disease colleagues, that's 390 00:19:53,310 --> 00:19:57,000 always just, you know, the, the most significant thing they're doing is going 391 00:19:57,000 --> 00:20:00,690 and just looking at a prior culture data and then basing their best guess on that. 392 00:20:00,990 --> 00:20:04,500 And second, what it is you're allowed to give in the emergency department. 393 00:20:04,500 --> 00:20:09,180 A lot of us have the, the broad, the broadest spectrum drugs under 394 00:20:09,180 --> 00:20:11,610 lock and key, uh, by pharmacy. 395 00:20:11,850 --> 00:20:15,540 And so sometimes it requires a little call to your ID colleague and say, 396 00:20:15,540 --> 00:20:18,070 Hey, you know, their last culture showed this and I really want to give. 397 00:20:18,980 --> 00:20:20,870 Ertapenem or whatever it is, or meropenem. 398 00:20:21,080 --> 00:20:23,150 And, uh, and I need your blessing to do it. 399 00:20:23,360 --> 00:20:26,630 Uh, and it seems silly, but you know, in the days of antibiotic 400 00:20:26,630 --> 00:20:29,270 stewardship, it's just kind of another hoop you have to jump through. 401 00:20:29,270 --> 00:20:31,850 So if you have that data, that's great. 402 00:20:32,090 --> 00:20:33,889 Uh, and, and by all means use it. 403 00:20:33,889 --> 00:20:38,270 'cause, uh, yes, the resistance is, is getting ridiculous and it's 404 00:20:38,270 --> 00:20:40,130 only getting worse as time goes on. 405 00:20:40,130 --> 00:20:42,380 So, uh, when, 406 00:20:42,389 --> 00:20:43,919 Lauren Page Black: only other thing I, sorry to interrupt. 407 00:20:43,919 --> 00:20:45,929 The only other thing I wanted to say about the table to be clear is 408 00:20:45,929 --> 00:20:47,339 it's for patients who are septic. 409 00:20:47,339 --> 00:20:50,759 I'm not saying that these should be our first line antibiotics for, you 410 00:20:50,759 --> 00:20:54,029 know, patients who don't have organ dysfunction, and maybe they just have a 411 00:20:54,029 --> 00:20:55,620 few SIRS criteria and they're going home. 412 00:20:55,889 --> 00:21:00,569 Um, but it is for, um, it is for patients who are being admitted for sepsis. 413 00:21:00,800 --> 00:21:02,540 Sam: good, great, great clarifying point. 414 00:21:03,260 --> 00:21:05,150 Uh, okay, let's talk about vasopressors. 415 00:21:05,150 --> 00:21:05,610 So the. 416 00:21:06,225 --> 00:21:10,815 Uh, the article mentions, uh, norepinephrine, dopamine, 417 00:21:11,415 --> 00:21:16,935 vasopressin, epinephrine, uh, what is your favorite starting agent? 418 00:21:16,935 --> 00:21:17,775 Do you have one? 419 00:21:17,775 --> 00:21:18,404 And tell me why. 420 00:21:18,525 --> 00:21:19,245 Convince me why. 421 00:21:19,859 --> 00:21:21,355 Lauren Page Black: Um, I, I think. 422 00:21:22,455 --> 00:21:26,594 It norepinephrine should be everybody's first line vasopressor for septic shock. 423 00:21:26,864 --> 00:21:31,754 Um, I think the evidence is very strong that it is, you know, superior certainly 424 00:21:31,754 --> 00:21:35,234 to dopamine, um, for septic shock and 425 00:21:35,374 --> 00:21:35,464 has 426 00:21:35,984 --> 00:21:40,634 has not performed worse than vasopressin in any of the other studies. 427 00:21:40,844 --> 00:21:44,324 So I think norepinephrine really should be our first line agent, and I think that 428 00:21:44,324 --> 00:21:48,495 should be the, I think that's about the easiest part of septic shock is, you know, 429 00:21:48,495 --> 00:21:52,875 and there's certainly some, some nuances in, in the research world, but as far as 430 00:21:52,875 --> 00:21:58,754 the overwhelming conglomeration of the evidence, the answer is, is levophed. 431 00:21:59,054 --> 00:22:02,205 Um, and then vasopressin is, it should be your second choice 432 00:22:02,299 --> 00:22:02,590 Sam: Okay. 433 00:22:02,895 --> 00:22:03,404 And then I. 434 00:22:03,855 --> 00:22:05,294 Lauren Page Black: you know, second additional agent. 435 00:22:06,225 --> 00:22:09,435 Sam: Then if you are debating whether or not you could give this through a 436 00:22:09,435 --> 00:22:12,915 peripheral line because you haven't placed a central line yet and your nursing 437 00:22:12,915 --> 00:22:17,054 colleagues are, have this tenuous line, is it okay to just go ahead and start it? 438 00:22:17,669 --> 00:22:20,625 Lauren Page Black: It is absolutely okay to give it peripherally and I think. 439 00:22:21,105 --> 00:22:21,855 We should. 440 00:22:21,855 --> 00:22:25,214 Um, and I think, you know, in, in some days I think that's when we had to 441 00:22:25,214 --> 00:22:26,355 start a central line for everybody. 442 00:22:26,355 --> 00:22:28,694 I think that also actually delayed some people's, you know, more 443 00:22:28,694 --> 00:22:30,165 appropriate shock treatment. 444 00:22:30,165 --> 00:22:34,275 But evidence is very clear that through a large, fairly proximal 445 00:22:34,275 --> 00:22:39,464 peripheral iv, it is very reasonable to give, um, vasopressors. 446 00:22:39,525 --> 00:22:44,714 Um, and so I, I personally do routinely start them peripherally. 447 00:22:44,984 --> 00:22:48,795 You know, my personal practices is, you know, if they're on pretty high 448 00:22:48,795 --> 00:22:52,005 doses, I, I still put in the central line, but if they're just requiring 449 00:22:52,725 --> 00:22:55,694 five, you know, and this changes person to person in place to place, 450 00:22:55,694 --> 00:22:57,105 but if they're just requiring five of 451 00:22:57,105 --> 00:22:57,815 levophed 452 00:22:59,114 --> 00:23:01,725 I think it's actually perfectly fine to just send them upstairs 453 00:23:01,725 --> 00:23:03,884 with a, with peripheral pressors. 454 00:23:03,884 --> 00:23:05,234 And I think the evidence supports that. 455 00:23:05,565 --> 00:23:08,085 Um, and I think we are seeing that slowly be more and more common. 456 00:23:08,085 --> 00:23:12,014 And I think it's lovely that I think that's taken, um, one of the 457 00:23:12,014 --> 00:23:16,815 cognitive hoops out of, out of the decision to, to start vasopressors. 458 00:23:16,844 --> 00:23:17,264 Um. 459 00:23:18,255 --> 00:23:20,955 I think it's perfectly fine to start levophed peripherally and 460 00:23:20,955 --> 00:23:22,365 the evidence largely supports that. 461 00:23:22,845 --> 00:23:23,295 Sam: great. 462 00:23:23,385 --> 00:23:27,585 And if you've only got, you know, the 22 gauge in the top of the hand. 463 00:23:28,575 --> 00:23:30,375 Lauren Page Black: I would put something, I would put something 464 00:23:30,585 --> 00:23:32,505 Sam: Alright, just gonna push you outta that one. 465 00:23:32,505 --> 00:23:32,985 That's okay. 466 00:23:33,020 --> 00:23:34,275 Lauren Page Black: it's not that magical. 467 00:23:35,740 --> 00:23:35,960 Sam: All. 468 00:23:35,985 --> 00:23:39,555 Lauren Page Black: I, you know, if you've got, if you've got a reasonable 18, um, 469 00:23:40,075 --> 00:23:42,255 in the AC or something, that's fine. 470 00:23:42,255 --> 00:23:45,705 But yeah, if you've got a 22 in the hand, it's time to 471 00:23:45,989 --> 00:23:46,859 Sam: They're gonna need more. 472 00:23:47,415 --> 00:23:48,159 Lauren Page Black: you gotta get more. 473 00:23:48,975 --> 00:23:53,055 in that case too, what I tell people too is it's our nursing colleagues and 474 00:23:53,055 --> 00:23:56,185 upstairs colleagues, if that's all we've got, they, they need more access than 475 00:23:56,185 --> 00:23:57,245 that for a variety 476 00:23:57,245 --> 00:23:57,855 of reasons. 477 00:23:57,855 --> 00:24:01,545 So, um, I still certainly think there's a role for a central line. 478 00:24:01,545 --> 00:24:04,670 I just don't think we need to do it, as often as we used to. 479 00:24:05,639 --> 00:24:05,939 Sam: All right. 480 00:24:05,939 --> 00:24:07,560 Let's talk about steroids. 481 00:24:07,589 --> 00:24:11,609 So the, this pendulum has swung several times as well. 482 00:24:11,609 --> 00:24:15,029 Where are we now days with steroids, and what kinds of 483 00:24:15,029 --> 00:24:16,319 steroids are we talking about? 484 00:24:17,010 --> 00:24:18,810 Lauren Page Black: So I think this is one of the biggest changes, 485 00:24:18,840 --> 00:24:20,700 um, in, in the past few years. 486 00:24:20,700 --> 00:24:23,670 I do feel like this has gone back and forth a whole lot. 487 00:24:23,940 --> 00:24:24,360 Um, 488 00:24:24,879 --> 00:24:25,219 Current 489 00:24:25,219 --> 00:24:30,750 consensus guidelines now do recommend hydrocortisone, um, lar either a 50 490 00:24:30,750 --> 00:24:35,490 milligram bolus every six hours or continuous infusion at 200 milligrams, 491 00:24:35,790 --> 00:24:37,830 um, for patients in septic shock. 492 00:24:38,580 --> 00:24:42,150 I will say as a caveat to that, in the fine print, you know, it says 493 00:24:42,150 --> 00:24:45,690 like if they're still requiring vasopressors after four hours 494 00:24:45,720 --> 00:24:47,520 and there is some nuance to that. 495 00:24:47,520 --> 00:24:51,600 So I'm not saying the second you start five of 496 00:24:51,600 --> 00:24:51,960 levophed 497 00:24:52,620 --> 00:24:56,610 they need to be chased with like 50 milligrams of hydrocortisone. 498 00:24:56,820 --> 00:24:58,230 Um, but I do think. 499 00:24:59,205 --> 00:25:00,674 We all know what boarding is like now. 500 00:25:00,674 --> 00:25:02,685 You know, I do think if they're downstairs for a few hours, then 501 00:25:02,685 --> 00:25:06,284 they're still requiring levophed I would definitely give that to them. 502 00:25:06,585 --> 00:25:10,544 The evidence for that was not based on any mortality benefit. 503 00:25:10,815 --> 00:25:14,864 What it was based on was, there were several in the meta-analysis, it showed, 504 00:25:15,134 --> 00:25:18,764 um, improved time to shock resolution. 505 00:25:19,170 --> 00:25:23,580 Essentially in patients who received steroids, and they, the consensus 506 00:25:23,580 --> 00:25:28,950 guidelines felt that since it's a fairly low cost, low risk intervention, the 507 00:25:28,950 --> 00:25:31,080 benefits of steroids outweighed the risk. 508 00:25:31,110 --> 00:25:33,510 Um, but it did not have a mortality benefit. 509 00:25:33,810 --> 00:25:38,190 I will say, as a caveat to a second population, though, a pretty compelling, 510 00:25:38,340 --> 00:25:42,390 compelling meta-analysis of steroids in patients with severe community-acquired 511 00:25:42,390 --> 00:25:47,250 pneumonia, um, did show reduced mortality and mechanical ventilation. 512 00:25:47,250 --> 00:25:51,090 So in those patients, even if they're not requiring pressors, um, you know, if 513 00:25:51,090 --> 00:25:55,290 you're intubating somebody for pneumonia and sending them to the ICU, or even if 514 00:25:55,290 --> 00:25:58,500 you have them on high flow for pneumonia and they're not requiring vasopressors, 515 00:25:58,500 --> 00:26:00,150 I would still, um, give that person. 516 00:26:00,750 --> 00:26:04,889 Some hydrocortisone as well, um, due to the current best state and evidence. 517 00:26:04,920 --> 00:26:07,409 Um, but again, this, this one has changed quite a few times 518 00:26:07,710 --> 00:26:08,850 as sort of a cutting edge. 519 00:26:08,850 --> 00:26:13,950 I think we'll see, um, some more studies about adding fludrocortisone so adding 520 00:26:13,950 --> 00:26:17,520 some additional mineral corticoid, um, coverage in addition to hydrocortisone. 521 00:26:17,520 --> 00:26:22,680 But that's very much in the research world right now and not, um, standard of care. 522 00:26:22,680 --> 00:26:28,699 But for patients with persistent shock requiring levophed in the ED or patients 523 00:26:28,699 --> 00:26:33,210 intubated intubated high flow, et cetera, for pneumonia, I would, I would 524 00:26:33,210 --> 00:26:34,409 give those patients steroids as well. 525 00:26:35,219 --> 00:26:40,529 Sam: Now I'm curious, in your practice, are you doing that as just a protocol 526 00:26:40,529 --> 00:26:44,940 event or are you only applying that to say the ones who you know well, 527 00:26:44,940 --> 00:26:48,299 they're gonna be down here for a while, there's no ICU beds, I'm just gonna do 528 00:26:48,299 --> 00:26:50,219 this as the kind of the final thought? 529 00:26:50,310 --> 00:26:53,219 Or is it just in your protocol like, we're gonna give this and if they happen 530 00:26:53,219 --> 00:26:54,389 to be down here, they're getting it. 531 00:26:54,540 --> 00:26:57,000 If they've already gone to the ICU, then they'll just get it there. 532 00:26:57,995 --> 00:27:00,525 Lauren Page Black: My personal protocol is, I give it, but I'm 533 00:27:00,645 --> 00:27:03,495 a sepsis researcher, so perhaps, you know, I, I, and I'm mostly 534 00:27:03,495 --> 00:27:05,324 focused on shock, so I care a lot. 535 00:27:05,654 --> 00:27:13,844 Um, I think, um, I think so much is lost in handoffs regardless of best intentions. 536 00:27:13,844 --> 00:27:17,085 Not to, I think it can be hard to tell what happened downstairs 537 00:27:17,085 --> 00:27:18,404 and what was or wasn't done. 538 00:27:18,705 --> 00:27:26,835 Um, so I personally usually do it, um, unless, you know, unless there's 539 00:27:26,835 --> 00:27:31,484 a reason I, I, I, I don't think it's necessary, but, um, I, I feel like most 540 00:27:31,514 --> 00:27:35,575 patients are, I, so I don't necessarily, sometimes I start pressers a little bit 541 00:27:36,145 --> 00:27:36,755 earlier 542 00:27:37,005 --> 00:27:39,764 you know, than, than necessary if, you know, if I think they 543 00:27:39,764 --> 00:27:40,904 need it for a certain reason. 544 00:27:40,935 --> 00:27:43,094 And in that patient who, I think they just need some. 545 00:27:43,560 --> 00:27:46,439 Um, and this is like personal practice, not necessarily evidence 546 00:27:46,439 --> 00:27:47,879 based, but if I'm starting some 547 00:27:48,209 --> 00:27:48,729 levophed 548 00:27:48,749 --> 00:27:51,449 to just get them through their fluid boluses, 'cause they're 549 00:27:51,449 --> 00:27:54,330 persistently hypertensive and I think they can get off of it once 550 00:27:54,330 --> 00:27:55,499 they're more fluid resuscitated. 551 00:27:55,499 --> 00:27:57,149 I'm not, I don't give it to that patient. 552 00:27:57,149 --> 00:28:01,770 But if I think the patient's gonna stay on pressers, I usually go ahead and give it. 553 00:28:02,069 --> 00:28:07,379 But again, you, uh, the guideline was pretty clear that, you know, they put 554 00:28:07,379 --> 00:28:12,989 some four hour line on it, but this is all very consensus based and, um, I, 555 00:28:12,989 --> 00:28:19,620 I think, I think I think I agree with them, the, the evidence, you know, does 556 00:28:19,709 --> 00:28:24,629 favor shock resolution and patients who received, hydrocortisone, I think 557 00:28:24,629 --> 00:28:28,319 there's probably people who respond really well and people who aren't responders. 558 00:28:28,319 --> 00:28:32,520 And that's why we sort of see this, this mixed, mixed response. 559 00:28:32,520 --> 00:28:34,169 And I think that's probably some of the challenge of the 560 00:28:34,169 --> 00:28:35,790 heterogeneity of sepsis in general. 561 00:28:36,645 --> 00:28:37,035 Sam: Okay. 562 00:28:37,125 --> 00:28:39,855 And then let's just lastly touch on blood transfusions. 563 00:28:39,855 --> 00:28:44,445 So, you know, within the last decade we've changed to a pretty conservative, 564 00:28:44,445 --> 00:28:49,545 like restrictive blood transfusion, uh, policies in, in most hospitals where, you 565 00:28:49,545 --> 00:28:52,335 know, if your hemoglobin is not less than seven, I'm not even thinking about it. 566 00:28:52,515 --> 00:28:54,435 Is that the same for my septic patients? 567 00:28:54,435 --> 00:28:55,965 Or do I need to have a higher threshold for that? 568 00:28:57,000 --> 00:28:57,630 Lauren Page Black: We, no. 569 00:28:57,690 --> 00:29:02,279 Um, so the old like caring capacity days, you know, those have also been retired. 570 00:29:02,340 --> 00:29:08,009 Um, if, if they're not ble, if they don't have some obvious sign, like obvious 571 00:29:08,009 --> 00:29:12,120 blood loss, um, I wouldn't give them blood 572 00:29:12,345 --> 00:29:12,675 Sam: Perfect. 573 00:29:13,130 --> 00:29:13,470 All right. 574 00:29:13,540 --> 00:29:14,790 Lauren Page Black: unless their hemoglobin is less than seven, 575 00:29:14,790 --> 00:29:16,290 like the regular indications. 576 00:29:16,390 --> 00:29:16,470 Sam: Excellent. 577 00:29:17,880 --> 00:29:21,090 And then there are some special populations that were discussed 578 00:29:21,090 --> 00:29:24,240 in the paper, like the elderly, those we touched on the one with 579 00:29:24,240 --> 00:29:26,010 cirrhosis and end stage renal disease. 580 00:29:26,310 --> 00:29:31,470 Uh, other than the fact that, you know, those with cirrhosis may have that 581 00:29:31,500 --> 00:29:36,285 persistent lactic acidosis, um, and that they're risk because they're, you 582 00:29:36,285 --> 00:29:37,980 know, relatively immunocompromised. 583 00:29:37,980 --> 00:29:40,680 What, what else do we need to know about our cirrhotic patients? 584 00:29:42,895 --> 00:29:45,540 Lauren Page Black: I, I think it's, you know, still maintaining a high index of 585 00:29:45,540 --> 00:29:48,449 suspicion because I think sometimes some of their vital signed arrangements in a 586 00:29:48,449 --> 00:29:52,080 lot of those more complicated populations, you know, can be attributed to their, 587 00:29:52,350 --> 00:29:55,540 um, disease state, but may actually 588 00:29:55,620 --> 00:29:55,710 not 589 00:29:56,159 --> 00:29:57,330 not be normal for them. 590 00:29:57,390 --> 00:29:57,840 Sam: Hmm. 591 00:29:57,929 --> 00:30:02,370 Lauren Page Black: you know, And I think recognizing that, um, some of 592 00:30:02,370 --> 00:30:05,609 our complicated patient populations, you know, may have more subtle 593 00:30:05,609 --> 00:30:09,479 signs of organ dysfunction and still having a, a high index of suspicion. 594 00:30:10,545 --> 00:30:16,094 Sam: Yes, I can recall several cirrhotic patients who like live at a systolic 595 00:30:16,094 --> 00:30:22,755 blood pressure of 91 and then have like zero capacity for any kind of infection, 596 00:30:22,755 --> 00:30:24,554 and then will syncopize immediately. 597 00:30:24,554 --> 00:30:27,495 So I'm always worried about my cirrhotic with syncope and 598 00:30:27,495 --> 00:30:29,145 going, well, you live at 91. 599 00:30:29,145 --> 00:30:31,514 I mean, there's really not a whole lot of pressure left. 600 00:30:32,085 --> 00:30:32,445 Uh 601 00:30:32,850 --> 00:30:35,700 Lauren Page Black: and I think, you know, remembering the, the unique infections 602 00:30:35,700 --> 00:30:37,380 that can happen in those populations. 603 00:30:37,380 --> 00:30:41,160 So I think, you know, making sure you look for SBP in the right patients, you know, 604 00:30:41,340 --> 00:30:45,750 considering, um, in ESRD patients who are on peritoneal dialysis considering, 605 00:30:46,020 --> 00:30:51,219 you know, whether or not they have, um, SBP or, you know, related to pd. 606 00:30:51,219 --> 00:30:55,740 I think, looking you know, at lines for patients who, uh, have indwelling lines 607 00:30:55,740 --> 00:31:00,810 for dialysis and just keeping a high index of suspicion for unique sources that I 608 00:31:00,900 --> 00:31:02,610 impact some of these patient populations. 609 00:31:02,850 --> 00:31:03,330 Sam: Perfect. 610 00:31:05,040 --> 00:31:05,190 All right. 611 00:31:05,190 --> 00:31:06,420 I'm gonna pause here for one second. 612 00:31:06,420 --> 00:31:09,870 The last section is on cutting edge and controversies. 613 00:31:09,870 --> 00:31:12,884 Is there anything you're passionate about or want to talk about here? 614 00:31:13,830 --> 00:31:18,780 Lauren Page Black: Um, I would say I think we should at least have 615 00:31:18,780 --> 00:31:26,370 some acknowledgement that, um, CMS sep one, it has some challenges. 616 00:31:26,400 --> 00:31:28,470 Um, and I think as we. 617 00:31:29,160 --> 00:31:31,680 You know, see it slated to become a pay for performance measure. 618 00:31:31,680 --> 00:31:33,090 It's, it's pretty complicated. 619 00:31:33,090 --> 00:31:36,000 And I think, um, there are some things that are intention. 620 00:31:36,000 --> 00:31:40,380 I think we're increasingly seeing this, like one size fits all approach 621 00:31:40,380 --> 00:31:44,310 to sepsis being questioned, I think rightly so in the research community. 622 00:31:44,490 --> 00:31:46,710 I think honestly, some of these clinical trials failed not because 623 00:31:46,710 --> 00:31:49,890 the interventions, I'm not the only person who thinks this, not because the 624 00:31:49,890 --> 00:31:52,710 interventions themselves didn't work, but we just don't know who to use them in. 625 00:31:52,890 --> 00:31:55,530 There's probably some patients who respond better to some of these 626 00:31:55,530 --> 00:31:56,790 things and some patients who don't. 627 00:31:56,790 --> 00:31:59,790 And when we study them as a whole, you know, the effect washes out. 628 00:31:59,940 --> 00:32:03,090 But there probably are people who may have some benefits to some of these things. 629 00:32:03,090 --> 00:32:05,940 You know, same with clovers and restrictive versus liberal fluids. 630 00:32:06,210 --> 00:32:08,940 There might be, you know, some patients who really do need 631 00:32:08,940 --> 00:32:10,350 a restrictive fluid approach. 632 00:32:10,350 --> 00:32:12,540 We just don't know exactly who those are right now. 633 00:32:12,540 --> 00:32:13,230 So I think. 634 00:32:14,250 --> 00:32:17,670 Uh, that cms, sep one still retains this one size fits all approach, 635 00:32:17,670 --> 00:32:20,969 I think is, is challenging in light of the current evidence. 636 00:32:21,000 --> 00:32:25,529 Um, I think the lack of nuance regarding fluids, though I think 637 00:32:25,529 --> 00:32:27,150 most patients can handle some fluids. 638 00:32:27,179 --> 00:32:30,659 Um, but the lack of nuance to that definition, um, the tension with 639 00:32:30,989 --> 00:32:34,679 antibiotic administration, especially as we see some pushes from consensus 640 00:32:34,679 --> 00:32:40,889 guidelines to move it earlier, I think, um, you know, doesn't represent the 641 00:32:40,889 --> 00:32:42,719 individual nature of patients that well. 642 00:32:42,719 --> 00:32:47,100 And I think emergency medicine providers are, you know, smart enough that we can, 643 00:32:48,509 --> 00:32:51,060 you know, have some individualization to our approach to the patient. 644 00:32:51,060 --> 00:32:52,350 And I think there is some tension there. 645 00:32:52,350 --> 00:32:58,620 And I, you've seen, um, our society, our EM, societies, um, 646 00:32:58,650 --> 00:33:00,659 make some statements, you know. 647 00:33:02,565 --> 00:33:05,685 Questioning whether or not some of these things need to be, be updated. 648 00:33:05,955 --> 00:33:09,435 Um, and I think it's at least worth having, you know, some of that discussion 649 00:33:09,435 --> 00:33:13,860 about what is the best thing for patients in light of what we know in 2025. 650 00:33:15,225 --> 00:33:15,945 Sam: That was perfect. 651 00:33:15,975 --> 00:33:16,185 Okay. 652 00:33:16,185 --> 00:33:19,545 I'm just gonna, for the purposes of Lindsay who's gonna be editing 653 00:33:19,545 --> 00:33:22,725 this, I'm just gonna speak a little introductory sentence to 654 00:33:22,725 --> 00:33:24,105 put at the beginning of all that. 655 00:33:24,105 --> 00:33:25,485 'cause that was very well stated. 656 00:33:25,815 --> 00:33:31,395 Uh, I'll say, okay, so we're at the end of our time and we spent a lot 657 00:33:31,395 --> 00:33:34,034 of time talking about CMS sep one. 658 00:33:34,395 --> 00:33:36,554 Uh, Where in the future. 659 00:33:36,554 --> 00:33:42,045 Are there some areas maybe, uh, for advancement or improvement in SEP 660 00:33:42,045 --> 00:33:46,755 one as we look towards, uh, better applying it to populations in sepsis? 661 00:33:47,835 --> 00:33:49,395 And then we'll cut to your answer, Lindsay. 662 00:33:49,605 --> 00:33:54,585 Uh, and, and then do you wanna mention anything about methylene 663 00:33:54,585 --> 00:33:56,804 blue or hydroxycobalamin or any of that kind of stuff? 664 00:33:57,405 --> 00:33:57,975 You don't have to. 665 00:33:58,605 --> 00:33:59,025 It's okay. 666 00:33:59,145 --> 00:34:00,465 Lauren Page Black: think those are pretty fancy. 667 00:34:00,465 --> 00:34:02,505 Um, they're there to, for completeness, but they've 668 00:34:02,505 --> 00:34:03,825 never been looked at in the ed. 669 00:34:04,124 --> 00:34:04,544 Sam: Perfect. 670 00:34:05,444 --> 00:34:06,614 All right, then I'll close this out. 671 00:34:06,645 --> 00:34:11,114 Thank you so much for coming on the podcast, sharing your wisdom with 672 00:34:11,114 --> 00:34:13,214 us, and also for being an author. 673 00:34:13,395 --> 00:34:18,164 This is a fantastic article, so thank you and your other co-authors 674 00:34:18,344 --> 00:34:19,725 for taking the time to write it. 675 00:34:19,725 --> 00:34:23,864 I think it does a tremendous job summarizing where we are in sepsis 676 00:34:23,864 --> 00:34:28,574 today in 2025, and I really look forward to hearing more from all of you. 677 00:34:28,874 --> 00:34:31,275 Uh, and I hope you'll come back on the podcast and share your 678 00:34:31,275 --> 00:34:32,655 wisdom with us again in the future. 679 00:34:33,429 --> 00:34:34,754 Lauren Page Black: thank you so much for your time. 680 00:34:34,754 --> 00:34:35,339 It was fun. 681 00:34:37,094 --> 00:34:38,444 Sam: All right, I'm gonna stop this and we're gonna. 682 00:34:38,484 --> 00:34:40,404 Lauren Page Black: everybody I work with knows how much I 683 00:34:40,464 --> 00:34:41,964 dislike this test in the ER. 684 00:34:41,964 --> 00:34:44,017 I think it's now synonymous with me. 685 00:34:45,813 --> 00:34:48,823 Sam: Hi everyone, and welcome back to another episode of EMplify. 686 00:34:48,843 --> 00:34:50,393 I'm your host, Sam Ashoo. 687 00:34:50,718 --> 00:34:52,938 Before we jump into this month's episode, I wanna say 688 00:34:52,938 --> 00:34:54,588 thank you for being a listener. 689 00:34:54,738 --> 00:34:57,888 I want to encourage you to rate us in whatever app you're listening 690 00:34:57,888 --> 00:35:01,488 in so that lots of other people can also benefit from listening. 691 00:35:01,698 --> 00:35:05,748 And I wanna remind you that EB medicine.net is your one-stop shop 692 00:35:05,748 --> 00:35:09,618 for all things emergency medicine, pediatric emergency medicine, 693 00:35:09,828 --> 00:35:11,538 and evidence-based urgent care. 694 00:35:11,838 --> 00:35:15,768 And if you happen to be going to this year's American College of Emergency 695 00:35:15,768 --> 00:35:20,268 Physicians Scientific Assembly in Salt Lake City, I highly encourage 696 00:35:20,268 --> 00:35:22,158 you to come by and say hello to us. 697 00:35:22,398 --> 00:35:25,158 We will be at Booth 1 3, 7 7. 698 00:35:25,238 --> 00:35:29,053 That's 1377 from September 7th through September 10th. 699 00:35:29,308 --> 00:35:30,778 Come by, say hello. 700 00:35:30,778 --> 00:35:32,548 We'd love to see you face to face. 701 00:35:32,848 --> 00:35:36,538 And now let's jump into this month's discussion on sepsis with 702 00:35:36,538 --> 00:35:41,658 Dr. Lauren Page Black, whom I think you will find to be just an amazing 703 00:35:41,688 --> 00:35:44,028 resource for all things sepsis. 704 00:35:46,564 --> 00:35:47,913 Lauren Page Black: Hi, my name is Lauren Black. 705 00:35:47,913 --> 00:35:50,854 I'm an assistant professor of emergency medicine at Northwestern 706 00:35:50,854 --> 00:35:54,977 University Feinberg School of Medicine where I am regular ER doctor. 707 00:35:54,997 --> 00:35:57,217 I also teach residents and med students. 708 00:35:57,217 --> 00:36:00,357 And I am also a sepsis researcher funded by the NIH. 709 00:36:00,552 --> 00:36:01,062 Sam: Awesome. 710 00:36:01,182 --> 00:36:06,342 And you are one of five authors for the August 2025 emergency medicine 711 00:36:06,342 --> 00:36:10,362 practice article on updates and controversies in the early management 712 00:36:10,362 --> 00:36:12,462 of sepsis and septic shock. 713 00:36:12,462 --> 00:36:16,812 So this is kind of a specialty niche for you, something you're passionate about. 714 00:36:17,512 --> 00:36:18,587 Lauren Page Black: Yes, it was a big group. 715 00:36:18,587 --> 00:36:19,697 Big topic, big group. 716 00:36:19,727 --> 00:36:21,497 And so thankful for all the co-authors. 717 00:36:21,497 --> 00:36:22,577 Hope I represent them well. 718 00:36:22,767 --> 00:36:26,387 It is myself and Dr. Faheem Guirgis, one of the other senior authors are 719 00:36:26,387 --> 00:36:28,587 both NIH funded sepsis researchers. 720 00:36:28,587 --> 00:36:32,237 So, it's pretty dear to my heart, so that's why I keep picking it. 721 00:36:32,372 --> 00:36:32,792 Sam: Good. 722 00:36:32,942 --> 00:36:33,332 Good. 723 00:36:33,502 --> 00:36:37,852 I'm always surprised by the sepsis statistics, honestly. 724 00:36:38,052 --> 00:36:42,502 And when we talk about epidemiology, number of cases a year, mortality 725 00:36:42,502 --> 00:36:46,082 rates those things always tend to jump off the page at me. 726 00:36:46,262 --> 00:36:50,272 And so when I'm looking through this article again, no surprise, but the 727 00:36:50,272 --> 00:36:53,542 number of cases of sepsis in the nation. 728 00:36:53,542 --> 00:36:57,832 You know, Here we're talking about 850,000 cases in the US coming through 729 00:36:57,832 --> 00:36:59,872 EDs that are related to sepsis. 730 00:36:59,872 --> 00:37:04,219 And depending on how sick you are, severe sepsis to septic shock, 731 00:37:04,219 --> 00:37:06,589 mortality can be as high as 40%. 732 00:37:06,669 --> 00:37:07,989 That's really significant. 733 00:37:08,689 --> 00:37:09,769 Lauren Page Black: It is really significant. 734 00:37:09,769 --> 00:37:14,269 And, in addition to its human toll, with exactly like you said, at least 735 00:37:14,269 --> 00:37:17,539 a 10% mortality for general sepsis, as you get to septic shock, four 736 00:37:17,544 --> 00:37:18,909 out of every 10 patients will die. 737 00:37:19,099 --> 00:37:21,924 It's also one of the most expensive reasons for hospitalization in the 738 00:37:21,924 --> 00:37:26,494 United States and is unfortunately the ultimate common pathway for a lot 739 00:37:26,494 --> 00:37:27,754 of people who die in the hospital. 740 00:37:27,754 --> 00:37:30,544 Some estimates are, it's up to one out of every three hospital deaths 741 00:37:30,724 --> 00:37:32,684 ultimately are attributed to sepsis. 742 00:37:33,294 --> 00:37:37,924 Sam: And therefore the big effort from government agencies, hospital 743 00:37:37,924 --> 00:37:43,599 associations, specialty organizations, to try and focus on things like tools 744 00:37:43,599 --> 00:37:48,219 to help us detect sepsis early and early goal directed therapy, and all this effort 745 00:37:48,219 --> 00:37:52,689 that we put into detecting it and treating it as quickly and early as possible. 746 00:37:52,689 --> 00:37:53,049 Right. 747 00:37:53,749 --> 00:37:55,842 Lauren Page Black: Yes, which has been met with a lot of challenges 748 00:37:55,842 --> 00:37:59,172 because sepsis is far more of a syndrome than a discrete disease. 749 00:37:59,222 --> 00:38:02,599 For many diseases, the patients themselves are different. 750 00:38:02,599 --> 00:38:05,899 That's not unique to sepsis, but sepsis is far more of a syndrome, 751 00:38:05,899 --> 00:38:08,659 and the fact that the infection types are different, the patterns 752 00:38:08,659 --> 00:38:10,189 of organ dysfunction are different. 753 00:38:10,309 --> 00:38:13,969 And ultimately this leads to a lot of heterogeneity and a lot of really 754 00:38:13,969 --> 00:38:18,139 different presentations, some subtle organ dysfunction for some patients that 755 00:38:18,139 --> 00:38:21,549 makes it really hard to screen for and, honestly, something a lot of the times 756 00:38:21,549 --> 00:38:26,939 we can recognize it after the fact, but it is hard upfront sometimes to recognize 757 00:38:26,999 --> 00:38:28,559 that the patient themselves is septic. 758 00:38:28,559 --> 00:38:31,795 But certainly, especially for the more severe patients with of 759 00:38:31,795 --> 00:38:35,755 hypoperfusion or hypotension, time really is important in recognizing 760 00:38:35,755 --> 00:38:37,345 and treating sepsis in those patients. 761 00:38:38,045 --> 00:38:43,360 Sam: And then from the government standpoint and from the definition 762 00:38:43,360 --> 00:38:48,160 standpoint, there's been a significant period of change, I'd say in the 763 00:38:48,160 --> 00:38:52,390 last 10 or more years, where we kind of keep evolving the definitions. 764 00:38:52,390 --> 00:38:53,620 Where are we now on that? 765 00:38:54,020 --> 00:38:56,807 Lauren Page Black: Yeah, that was one of my biggest goals in the paper we 766 00:38:56,807 --> 00:39:00,097 wrote that pairs with this podcast is one of my goals was to really reinforce 767 00:39:00,097 --> 00:39:03,977 and clarify the difference in consensus definitions and what the most updated 768 00:39:03,977 --> 00:39:07,817 consensus definitions are, as well as clarify where those are similar 769 00:39:07,817 --> 00:39:12,847 and different than CMS sep-1, which is the government quality bundle that 770 00:39:12,847 --> 00:39:14,527 hospitals are held accountable to. 771 00:39:14,767 --> 00:39:17,517 So, first I'll take on consensus definitions. 772 00:39:17,517 --> 00:39:19,687 So, that has changed quite a bit. 773 00:39:19,737 --> 00:39:24,967 Sepsis is a dysregulated host response to an infection characterized by 774 00:39:24,967 --> 00:39:28,537 organ dysfunction in the setting of a suspected or confirmed infection. 775 00:39:28,757 --> 00:39:32,250 So what the simple version of that means is if somebody has an infection or 776 00:39:32,250 --> 00:39:36,780 suspected infection and evidence of organ dysfunction, they're considered septic. 777 00:39:37,060 --> 00:39:41,980 So prior to sepsis three, sepsis was really defined by SIRS criteria 778 00:39:42,160 --> 00:39:45,640 with a second category called severe sepsis and a third septic shock. 779 00:39:45,830 --> 00:39:48,784 In sepsis three, sepsis infection plus organ dysfunction is really considered 780 00:39:48,784 --> 00:39:51,266 sepsis now . Severe sepsis went away. 781 00:39:51,386 --> 00:39:54,492 Septic shock maintains mostly its similar definition. 782 00:39:54,492 --> 00:39:58,488 It's a vasopressor requirement to maintain a MAP above 65 with 783 00:39:58,488 --> 00:40:01,721 evidence of hypoperfusion usually considered a n elevated lactate. 784 00:40:02,021 --> 00:40:05,691 As the sepsis three definitions change partially because as we all know, SIRS 785 00:40:05,711 --> 00:40:08,381 is not very sensitive or specific. 786 00:40:08,581 --> 00:40:11,521 Old people don't necessarily mount a thermoid or leukemoid response 787 00:40:11,671 --> 00:40:12,931 the same way young people do. 788 00:40:12,931 --> 00:40:16,111 SIRS is, in a lot of ways, representative of a appropriate 789 00:40:16,111 --> 00:40:17,371 host response to an infection. 790 00:40:17,371 --> 00:40:19,441 If you or I got the flu, we'd have SIRS criteria. 791 00:40:19,651 --> 00:40:22,651 It doesn't necessarily mean we have organ dysfunction, and it certainly 792 00:40:22,651 --> 00:40:25,861 doesn't mean we have a dysregulated host response to an infection. 793 00:40:26,051 --> 00:40:31,131 By the same token, the elderly patient or the immunocompromised patient 794 00:40:31,371 --> 00:40:34,731 may not mount a white count, may not have a fever, but they may have 795 00:40:35,061 --> 00:40:38,781 pretty significant renal dysfunction intermittent hypotension, et cetera. 796 00:40:38,781 --> 00:40:40,251 That patient is clearly septic. 797 00:40:40,441 --> 00:40:43,306 Those of us with the flu need some ibuprofen and, you know, to move on. 798 00:40:43,556 --> 00:40:46,826 And so the definitions changed largely because of that nuance. 799 00:40:46,946 --> 00:40:51,396 I think what makes it difficult is the CMS sep one bundle has some slight 800 00:40:51,725 --> 00:40:53,760 differences with the consensus guidelines. 801 00:40:53,760 --> 00:40:56,320 And I think that adds a lot of confusion to the topic. 802 00:40:56,410 --> 00:40:59,883 Though the CMS sep one bundles technically still rely on a SIRS 803 00:40:59,903 --> 00:41:03,043 based definition, there's really only two bundles you fall into. 804 00:41:03,043 --> 00:41:06,633 So it's the severe sepsis bundle, which again, very closely mimic 805 00:41:06,633 --> 00:41:10,263 sepsis three sepsis definition, as well as the septic shock bundle. 806 00:41:10,443 --> 00:41:14,823 One of the differences there though, is CMS sep one defines septic shock 807 00:41:15,033 --> 00:41:19,173 as hypotension, even if they're not on vasopressors or a lactate greater than 808 00:41:19,173 --> 00:41:21,340 four, even if they're not on vasopressor. 809 00:41:21,340 --> 00:41:25,150 So that's what triggers the septic shock CMS bundle of the fluid 810 00:41:25,150 --> 00:41:27,550 requirement component of the bundle. 811 00:41:27,680 --> 00:41:31,730 But since those definitions are slightly different, I think that does add some 812 00:41:31,730 --> 00:41:35,890 confusion, which is one of the reasons we tried to clear that up, in table 813 00:41:36,070 --> 00:41:39,820 two a little bit, highlighting the sepsis three definitions, the fact 814 00:41:39,820 --> 00:41:43,930 that severe sepsis is no longer a contemporary term, and compare it with 815 00:41:43,930 --> 00:41:48,020 the CMS sep one core measure definitions to hopefully add some clarity there. 816 00:41:48,665 --> 00:41:53,925 Sam: Yeah, so, the CMS world is where hospital core measures come from 817 00:41:53,925 --> 00:41:57,525 and how hospitals are ranked and how their performance is measured. 818 00:41:57,525 --> 00:42:01,095 And still very important to us in the emergency department because if a 819 00:42:01,095 --> 00:42:05,165 hospital's being measured by it, we will be measured by it as well as willing 820 00:42:05,165 --> 00:42:06,815 participants in that relationship. 821 00:42:07,055 --> 00:42:11,645 But then we also have the specialty society definitions, kind of like 822 00:42:11,645 --> 00:42:13,325 the clinical side of medicine. 823 00:42:13,565 --> 00:42:16,778 And that's more, I wanna say that's more research based. 824 00:42:16,778 --> 00:42:19,958 But is it more really just consensus opinions that have changed over 825 00:42:19,958 --> 00:42:23,168 the last 10 years, or is there good evidence that's driving that change? 826 00:42:23,868 --> 00:42:25,518 Lauren Page Black: I think that is a loaded question. 827 00:42:25,648 --> 00:42:26,958 I think both. 828 00:42:26,958 --> 00:42:29,028 I think a lot of it is consensus based. 829 00:42:29,028 --> 00:42:32,618 And then I do think there's some really good evidence that drives some of it, 830 00:42:32,618 --> 00:42:37,248 but a lot of it certainly is consensus based especially where the evidence just 831 00:42:37,428 --> 00:42:39,678 doesn't completely answer our questions. 832 00:42:39,928 --> 00:42:42,751 And they're both controversial in their own regards and actually they 833 00:42:42,751 --> 00:42:46,341 both had a lot of commentary by our emergency medicine societies 834 00:42:46,911 --> 00:42:48,351 they are a bit challenging. 835 00:42:48,565 --> 00:42:53,775 I do think they mostly overlap in the patient cohorts describing in both, but I 836 00:42:53,775 --> 00:42:57,645 do think it is a little bit confusing that they use slightly different terminology. 837 00:42:57,945 --> 00:42:59,055 I think that does make it hard. 838 00:42:59,055 --> 00:43:04,235 But yes, I do think we are obligated to be aware of both what the consensus 839 00:43:04,235 --> 00:43:07,675 guidelines and the society group say as well as the core measures. 840 00:43:07,725 --> 00:43:11,851 Sam: Yeah so then when we're doing our charting and we're talking about hospital 841 00:43:11,851 --> 00:43:16,771 core measures, and we want to clarify with our hospital administrator colleagues 842 00:43:16,771 --> 00:43:22,141 what we're talking about, we're usually referring to CMS sep one or sep one 843 00:43:22,141 --> 00:43:28,081 criteria, which haven't changed in over a decade and are still based on very early 844 00:43:28,081 --> 00:43:30,271 consensus opinions of what sepsis is. 845 00:43:30,521 --> 00:43:35,171 And then when we're talking with, say, our critical care colleagues and 846 00:43:35,171 --> 00:43:39,111 we're talking about early detection of sepsis, more clinical things, we're 847 00:43:39,111 --> 00:43:41,441 using the sepsis three definition. 848 00:43:41,441 --> 00:43:44,801 This is now as of 2021. 849 00:43:44,861 --> 00:43:45,791 Is that the right year? 850 00:43:45,986 --> 00:43:46,946 Lauren Page Black: 2016. 851 00:43:47,246 --> 00:43:49,016 There have been some updates since then. 852 00:43:49,316 --> 00:43:53,113 Though I do think SIRS is just hard to you know, separate ourselves from this. 853 00:43:53,203 --> 00:43:59,280 I think the ease of its use early on, I think makes it hard for people let it go 854 00:43:59,346 --> 00:44:00,476 Sam: Yeah that's right. 855 00:44:00,476 --> 00:44:03,806 Lauren Page Black: So I think we still see a lot of reticence to sort of let 856 00:44:03,806 --> 00:44:05,206 that one have had its time in the sun 857 00:44:05,256 --> 00:44:05,636 Sam: Yeah. 858 00:44:06,731 --> 00:44:09,221 Lauren Page Black: But again, I do think, CMS only holds you to a severe 859 00:44:09,221 --> 00:44:10,541 sepsis and a septic shock bundle. 860 00:44:10,541 --> 00:44:13,991 And severe sepsis is essentially the sepsis three consensus 861 00:44:13,991 --> 00:44:15,011 definition of sepsis. 862 00:44:15,011 --> 00:44:18,931 So I think the confusion is mostly semantic rather than actually describing 863 00:44:18,931 --> 00:44:20,295 terribly different groups of people. 864 00:44:20,645 --> 00:44:23,615 Sam: Yeah, and I think you guys did a great job explaining that in the article. 865 00:44:23,615 --> 00:44:27,575 So if you're listening and you have access to this article I highly recommend 866 00:44:27,575 --> 00:44:31,785 you go just read that one little section on definitions and terminology. 867 00:44:31,835 --> 00:44:33,155 It's very well laid out. 868 00:44:33,305 --> 00:44:37,415 Now in there, there's a discussion about screening tools as well. 869 00:44:37,415 --> 00:44:43,235 So today, in 2025, do we yet have any good screening tools for sepsis? 870 00:44:43,665 --> 00:44:47,041 Lauren Page Black: No, I think they all have strengths and weaknesses. 871 00:44:47,231 --> 00:44:50,565 We still don't have a perfect screening tool. 872 00:44:50,681 --> 00:44:54,611 I'm sure all of us have a hospital BPA that goes off all the time. 873 00:44:54,611 --> 00:44:57,111 And think that's a hard sell to tell clinicians these things 874 00:44:57,111 --> 00:44:58,221 aren't working perfectly. 875 00:44:58,491 --> 00:44:59,511 They're not working perfectly. 876 00:44:59,511 --> 00:45:04,261 It's one of the areas I do think will hopefully be addressed by advanced 877 00:45:04,261 --> 00:45:09,011 analytic methods and machine learning and some EHR based predictive algorithms. 878 00:45:09,711 --> 00:45:13,791 Though some of those are running and currently available, their 879 00:45:13,791 --> 00:45:15,511 performances have been largely mixed 880 00:45:15,581 --> 00:45:16,001 Sam: Mm-hmm. 881 00:45:16,141 --> 00:45:19,275 Lauren Page Black: And so I don't think any one of those is functioning perfectly. 882 00:45:19,275 --> 00:45:21,735 I'm optimistic that will change in a few years. 883 00:45:21,915 --> 00:45:24,285 What I will say went away as a screening tool and the most 884 00:45:24,285 --> 00:45:25,695 recent updates were qSOFA. 885 00:45:25,725 --> 00:45:29,858 So if you read this paper or were hearing about that a little bit 886 00:45:29,858 --> 00:45:35,961 ago, that has largely been retired due to its suboptimal performance. 887 00:45:36,041 --> 00:45:40,475 But I do think all of the screening tools have some degree of something 888 00:45:40,505 --> 00:45:43,768 left to be desired with regard to sensitivity and specificity. 889 00:45:44,468 --> 00:45:48,698 Sam: And I see like a common problem with them is that some rely heavily on 890 00:45:48,698 --> 00:45:51,338 data that we're not gathering in the ED. 891 00:45:51,638 --> 00:45:56,438 And others that seem to parse that out then become less sensitive or 892 00:45:56,438 --> 00:45:58,658 less specific and just not as helpful. 893 00:45:58,658 --> 00:46:04,948 And most of our EHR or AI related tools seem to just scrape for 894 00:46:04,948 --> 00:46:08,818 SIRS criteria, which in and of itself is not sufficient either. 895 00:46:09,088 --> 00:46:11,808 So, there's no sweet spot yet that we have. 896 00:46:11,808 --> 00:46:14,633 Lauren Page Black: What I will say is I think clinicians are pretty good at it. 897 00:46:14,805 --> 00:46:17,171 And I think part of the problem is none of these have really outperformed 898 00:46:17,171 --> 00:46:20,861 clinician gestalt, which we've seen for other diseases and syndromes as well. 899 00:46:20,981 --> 00:46:24,251 And what I tell the residents when I'm working with them is if you think 900 00:46:24,251 --> 00:46:27,911 somebody has an infection, ask yourself, do they have new organ dysfunction? 901 00:46:28,011 --> 00:46:31,631 And if they do, you should treat 'em as septic, and then if they've got new 902 00:46:31,631 --> 00:46:34,721 organ dysfunction, ask yourself if you think it's secondary to an infection. 903 00:46:34,721 --> 00:46:38,091 And if they do, you should presume they're septic or at least go on 904 00:46:38,091 --> 00:46:40,161 a expedition for why they're not. 905 00:46:40,381 --> 00:46:43,021 And clinicians seem to be pretty good at that. 906 00:46:43,261 --> 00:46:46,651 The tools have not performed better than our ability to do that. 907 00:46:46,716 --> 00:46:47,106 Sam: Yeah. 908 00:46:47,226 --> 00:46:47,466 Yeah. 909 00:46:47,496 --> 00:46:48,546 They're not making us better. 910 00:46:48,636 --> 00:46:49,116 Not yet. 911 00:46:49,731 --> 00:46:50,101 Lauren Page Black: Not yet. 912 00:46:50,166 --> 00:46:50,286 Sam: Okay. 913 00:46:50,391 --> 00:46:51,021 Lauren Page Black: In my opinion. 914 00:46:51,021 --> 00:46:53,781 Some people might have more optimistic outlooks, but it's 915 00:46:53,781 --> 00:46:55,311 not one that I personally hold. 916 00:46:55,626 --> 00:46:55,986 Sam: Good. 917 00:46:56,226 --> 00:46:56,466 All right. 918 00:46:56,466 --> 00:46:58,746 Well that's table three, the comparison of the screening 919 00:46:58,746 --> 00:47:00,246 tools, if you've got the article. 920 00:47:00,246 --> 00:47:05,226 And so that's things like SOFA and qSOFA and MEWS and a multitude of 921 00:47:05,226 --> 00:47:08,316 others listed there along with their sensitivities and specificities, none 922 00:47:08,316 --> 00:47:10,776 of which are really all that great. 923 00:47:10,826 --> 00:47:15,266 And so qSOFA, we kind of held up as maybe something that really was going 924 00:47:15,266 --> 00:47:16,586 to have a lot of good potential. 925 00:47:16,806 --> 00:47:20,646 And it turns out that even that is not all that sensitive for the ED. 926 00:47:20,676 --> 00:47:21,126 Is that right? 927 00:47:21,596 --> 00:47:22,086 Lauren Page Black: Exactly. 928 00:47:22,311 --> 00:47:26,406 So I think where that came from is when they operationalize, and by they I mean 929 00:47:26,406 --> 00:47:29,826 the surviving sepsis campaign, when they operationalize the new sepsis, sepsis 930 00:47:29,826 --> 00:47:33,426 three definition, a dysfunctional host response to an infection, characterized 931 00:47:33,426 --> 00:47:37,656 by organ dysfunction in the setting of presumed infection, they clinically 932 00:47:37,656 --> 00:47:41,256 operationalize that as a SOFA score of two or more that was new in the 933 00:47:41,256 --> 00:47:42,906 setting of a presumed infection. 934 00:47:43,146 --> 00:47:46,503 I think what's hard is the SOFA score is hard to use in the ED. 935 00:47:46,533 --> 00:47:48,903 We don't always obtain all of those components, and I'm 936 00:47:48,903 --> 00:47:50,253 certainly not saying you should. 937 00:47:50,493 --> 00:47:55,063 So I think the desire behind qSOFA was to make something that was easier to 938 00:47:55,063 --> 00:47:58,843 operationalize in the ED if you weren't getting PDF ratios on people and it 939 00:47:58,843 --> 00:48:00,912 just didn't live up to that ability. 940 00:48:00,952 --> 00:48:01,512 Sam: It didn't do it. 941 00:48:01,672 --> 00:48:02,702 It did not do it. 942 00:48:03,032 --> 00:48:03,332 Okay. 943 00:48:03,422 --> 00:48:06,572 Well, so if we're working in the emergency department today and 944 00:48:06,572 --> 00:48:11,132 someone is insisting that we use one of these particular scoring methods, 945 00:48:11,372 --> 00:48:14,732 there's not really one that seems to stand out to me to be the best. 946 00:48:14,732 --> 00:48:18,482 So it's more like, use what you're being asked to use, but know that 947 00:48:18,482 --> 00:48:21,842 it's going to have limitations and maybe understand those limitations. 948 00:48:22,082 --> 00:48:25,622 Make it no better than your own judgment, maybe worse than your own judgment. 949 00:48:26,207 --> 00:48:28,487 Lauren Page Black: Hey, that's exactly what I would personally, yeah. 950 00:48:28,577 --> 00:48:29,237 Great summary. 951 00:48:29,732 --> 00:48:30,092 Sam: Okay. 952 00:48:30,612 --> 00:48:34,142 Alright, well then let's talk about the clinical side of sepsis then. 953 00:48:34,142 --> 00:48:38,132 So there are some people who listen to the podcast who are on the pre-hospital 954 00:48:38,132 --> 00:48:43,412 side of it, and that seems to be an important part in the handoff when 955 00:48:43,412 --> 00:48:44,792 they come to the emergency department. 956 00:48:44,882 --> 00:48:49,442 Are there things that can help them recognize sepsis in the pre-hospital 957 00:48:49,442 --> 00:48:53,332 setting so that they can help alert us to it when they arrive in the ED? 958 00:48:54,032 --> 00:48:54,572 Lauren Page Black: Sure. 959 00:48:54,692 --> 00:48:57,692 First of all, I admire our pre-hospital colleagues 'cause if sepsis is hard to 960 00:48:57,692 --> 00:49:02,436 screen for in the ED with all of our labs and et cetera it's exponentially 961 00:49:02,456 --> 00:49:03,536 in the pre-hospital setting. 962 00:49:03,816 --> 00:49:08,500 I would say things that are really helpful are histories if the patient 963 00:49:08,500 --> 00:49:12,102 is not acting right, they have some evidence of organ dysfunction that 964 00:49:12,372 --> 00:49:16,362 is obtained on history as well as vital signs in route being abnormal. 965 00:49:16,488 --> 00:49:19,218 And I'm certainly not saying that just because SIRS isn't sensitive enough 966 00:49:19,218 --> 00:49:22,158 doesn't mean we should be ignoring fevers or elevated heart rates. 967 00:49:22,158 --> 00:49:23,668 Those are super important. 968 00:49:23,668 --> 00:49:28,028 But, I would say parts of the history where mom and dad haven't been acting 969 00:49:28,028 --> 00:49:32,038 quite right for a few days, they haven't been going to the bathroom as 970 00:49:32,038 --> 00:49:34,712 often or something l ike that can be really helpful aspects of the history. 971 00:49:34,952 --> 00:49:36,542 But it's also just hard. 972 00:49:36,995 --> 00:49:39,635 If it's hard in the ED with our labs and I think it's super hard in 973 00:49:39,635 --> 00:49:40,985 the pre-hospital setting as well. 974 00:49:41,195 --> 00:49:43,715 The other things that can also help are whether or not they're taking meds 975 00:49:43,715 --> 00:49:46,155 that may mask of those SIRS criteria. 976 00:49:46,155 --> 00:49:49,065 So if there's that bag of meds sitting there, it's sometimes helpful to 977 00:49:49,065 --> 00:49:51,495 bring in, 'cause then you can find out if they're immunocompromised and 978 00:49:51,495 --> 00:49:54,315 we didn't know, or they were on a beta blocker or something like that. 979 00:49:54,435 --> 00:49:56,005 And those things can be really helpful 980 00:49:56,605 --> 00:49:59,875 Sam: Yeah, so that's a common theme for our pre-hospital personnel on this 981 00:49:59,875 --> 00:50:04,735 podcast is helping us obtain an accurate history from anyone who's on scene 982 00:50:04,910 --> 00:50:08,488 and then gathering medications just so we all have the same picture when 983 00:50:08,488 --> 00:50:09,568 you get to the emergency department. 984 00:50:09,618 --> 00:50:10,638 Those are excellent tips. 985 00:50:10,638 --> 00:50:15,288 There was a mention of local screening tools, but again, we don't even have 986 00:50:15,288 --> 00:50:16,878 great screening tools in the ED. 987 00:50:16,968 --> 00:50:19,248 Is there anything that's been proven to work pre-hospital? 988 00:50:19,598 --> 00:50:23,558 Lauren Page Black: To my knowledge, no, because those would also have to rely 989 00:50:23,558 --> 00:50:26,078 only on vital sign based arrangements. 990 00:50:26,078 --> 00:50:30,268 And I certainly think they can be helpful in identifying the sickest of the sick. 991 00:50:30,268 --> 00:50:33,970 I also think our prehospital colleagues have great clinical gestalt themselves 992 00:50:34,000 --> 00:50:37,150 and if somebody's hypotensive I think everybody knows they're sick. 993 00:50:37,150 --> 00:50:40,350 So I, again, am a little skeptical of the ability of these things to 994 00:50:40,350 --> 00:50:42,000 supplement Gestalt in some ways. 995 00:50:42,160 --> 00:50:43,960 People are certainly trying to look at those. 996 00:50:43,960 --> 00:50:48,030 I think it would be helpful if they could work in the pre-hospital setting as well. 997 00:50:48,180 --> 00:50:52,550 I think the linkage of the pre-hospital vital sign data would be ideal if 998 00:50:52,880 --> 00:50:55,740 that could happen in the emergency department especially like were 999 00:50:55,740 --> 00:50:57,000 they actually really hypotensive? 1000 00:50:57,000 --> 00:51:00,230 They got a later fluid and they were responsive and those type of history 1001 00:51:00,230 --> 00:51:03,320 things are important and it would be ideal I think, if we could link 1002 00:51:03,320 --> 00:51:04,730 those things to our environment. 1003 00:51:04,760 --> 00:51:07,550 'cause I think that provides a lot of rich information. 1004 00:51:07,800 --> 00:51:12,847 Especially if it wasn't then their first hypotensive ED vital sign is not really 1005 00:51:12,847 --> 00:51:14,947 their first hypotensive vital sign. 1006 00:51:14,947 --> 00:51:17,647 It was actually 30 minutes earlier when they got picked up. 1007 00:51:17,647 --> 00:51:19,347 And I think those things are super helpful. 1008 00:51:19,347 --> 00:51:22,357 But I certainly think if we're having challenges in the ED of 1009 00:51:22,357 --> 00:51:25,687 running screening tools, it's gonna also be pretty challenging 1010 00:51:25,687 --> 00:51:26,887 in the pre-hospital environment. 1011 00:51:27,067 --> 00:51:30,060 I think it's something where, honestly education about sepsis 1012 00:51:30,060 --> 00:51:34,350 and what populations really do need fluids or prompt antibiotics. 1013 00:51:34,350 --> 00:51:37,940 I think that probably is helpful as any screening tool could be. 1014 00:51:38,410 --> 00:51:40,990 Sam: All right, so one more loaded question. 1015 00:51:40,990 --> 00:51:46,650 I have some EMS agencies that, especially in the rural settings where there's 1016 00:51:46,650 --> 00:51:51,430 long transport times, talk about early administration of antibiotics en route 1017 00:51:51,430 --> 00:51:55,870 to the hospital before even ever getting to an ED for suspected sepsis cases. 1018 00:51:56,120 --> 00:52:00,377 Is there good evidence behind that kind of approach, or do you think, I mean, 1019 00:52:00,377 --> 00:52:04,627 your opinion's fine, do you think there's enough in the way of information at 1020 00:52:04,627 --> 00:52:08,937 your disposal in that kind of setting to go ahead and start antibiotics 1021 00:52:09,177 --> 00:52:11,277 in that kind of pre-hospital arena? 1022 00:52:11,967 --> 00:52:13,987 Lauren Page Black: I think perhaps in some populations. 1023 00:52:13,987 --> 00:52:18,497 So this I also think gets to a way where some of the literature has 1024 00:52:18,497 --> 00:52:22,107 kind of been propagated in a way that may not actually represent 1025 00:52:22,107 --> 00:52:23,517 what the literature actually says. 1026 00:52:23,727 --> 00:52:27,897 So the literature for time to antibiotics is fairly clear, although 1027 00:52:27,897 --> 00:52:30,597 I will say there's always a few papers that say something else. 1028 00:52:30,777 --> 00:52:34,617 But in general, broad strokes, time to antibiotics has really 1029 00:52:34,707 --> 00:52:39,057 reproducibly only shown to have a mortality benefit in patients who are 1030 00:52:39,057 --> 00:52:42,027 hypotensive or with hypoperfusion. 1031 00:52:42,027 --> 00:52:44,037 By that I mean like an elevated lactate. 1032 00:52:44,367 --> 00:52:48,677 The original Kumar study, which was fabulous, showed this profound 1033 00:52:48,677 --> 00:52:51,827 time to antibiotic benefit, but it wasn't from triage, it was 1034 00:52:51,827 --> 00:52:54,437 from time of onset of hypotension. 1035 00:52:54,767 --> 00:52:58,352 We're never gonna be able to redo that study again because it would be totally 1036 00:52:58,352 --> 00:53:02,402 unethical to hold you know, a largely safe intervention for most people. 1037 00:53:02,402 --> 00:53:06,152 But in general, it is in patients who are hypotensive or who 1038 00:53:06,152 --> 00:53:07,652 have evidence of hypoperfusion. 1039 00:53:07,832 --> 00:53:11,312 I'll also say in that Kumar study, the median time to antibiotics was 1040 00:53:11,312 --> 00:53:15,026 fairly long because this was in the two thousands, but we don't wait six, 1041 00:53:15,026 --> 00:53:18,279 12 hours anymore to give antibiotics to most septic people ideally. 1042 00:53:18,519 --> 00:53:23,802 So, I will say in the rural environment I do, particularly if somebody is 1043 00:53:23,802 --> 00:53:28,062 hypotensive, definitely think there could be a role for early antibiotics. 1044 00:53:28,062 --> 00:53:30,732 The evidence does not really support that. 1045 00:53:31,002 --> 00:53:34,272 Somebody who may just be like a little more confused from a urinary tract 1046 00:53:34,272 --> 00:53:38,742 infection or maybe a little dehydrated, the evidence is not largely supported. 1047 00:53:38,999 --> 00:53:43,409 The emergency, though still urgent nature of antibiotics in that subpopulation. 1048 00:53:43,589 --> 00:53:46,679 But I certainly think for somebody who is hypotensive it would be 1049 00:53:46,679 --> 00:53:50,229 very reasonable in the rural setting to start some antibiotics. 1050 00:53:50,229 --> 00:53:52,899 The hard thing is you wanna target those ideally to a 1051 00:53:52,899 --> 00:53:54,399 suspected source of infection. 1052 00:53:54,399 --> 00:53:57,537 So I, do think this stuff gets a little complicated. 1053 00:53:57,892 --> 00:54:00,532 Especially if they're that sick, it's hard to know some 1054 00:54:00,532 --> 00:54:01,942 allergies, et cetera, et cetera. 1055 00:54:02,122 --> 00:54:06,222 But I do think in some rural critical access areas, there probably is a 1056 00:54:06,222 --> 00:54:08,852 role for targeted early initiation. 1057 00:54:09,552 --> 00:54:10,242 Sam: That makes sense. 1058 00:54:10,722 --> 00:54:14,172 Alright, so let's talk about then when they finally get to the ED and we're 1059 00:54:14,287 --> 00:54:18,622 trying to get a history besides from our pre-hospital personnel who hopefully 1060 00:54:18,622 --> 00:54:22,548 have gathered as much information as they can, is there anything new in this arena 1061 00:54:22,548 --> 00:54:24,348 that we should be asking or looking for? 1062 00:54:25,048 --> 00:54:28,568 Lauren Page Black: I always just say, well, my mentor said, I'm gonna steal 1063 00:54:28,568 --> 00:54:32,041 Dr. Guergis' line myself, treat these people as a trauma, the sicker they are. 1064 00:54:32,041 --> 00:54:35,951 So the less they can tell you, the more we need to make sure we expose the 1065 00:54:35,951 --> 00:54:39,201 patient, make sure we roll them, make sure they don't have a sacral decub. 1066 00:54:39,221 --> 00:54:43,141 And I think not forgetting aspects of the history and physical, especially 1067 00:54:43,141 --> 00:54:44,431 when they could change management. 1068 00:54:44,671 --> 00:54:48,181 So we give pretty similar antibiotics to most of these people. 1069 00:54:48,181 --> 00:54:53,061 But, we wanna be thinking about things like endocarditis, prostate abscesses, 1070 00:54:53,721 --> 00:54:58,391 STIs, things that really might change management or things that might lead to a 1071 00:54:58,391 --> 00:55:03,874 source control procedure and targeting our history and physical exam to those things. 1072 00:55:04,574 --> 00:55:04,844 Sam: Good. 1073 00:55:04,994 --> 00:55:08,774 And so that goes for physical, like you just mentioned as well, obviously the 1074 00:55:08,774 --> 00:55:12,584 ideal scenario is you're not going to be examining them in triage, in a chair 1075 00:55:12,584 --> 00:55:17,794 fully clothed but hopefully, hopefully in a stretcher in a private area where 1076 00:55:17,794 --> 00:55:21,786 you can fully undress them and look for that source control and see if you can 1077 00:55:21,786 --> 00:55:25,391 find that open wound or that sacral decub or whatever it is that they might have. 1078 00:55:25,621 --> 00:55:27,501 So that part remains the same. 1079 00:55:27,501 --> 00:55:31,911 If you can, you should kinda strip them naked and actually get a look at their 1080 00:55:31,911 --> 00:55:34,501 skin and still go looking for the source. 1081 00:55:34,571 --> 00:55:38,406 And is that something that's commonly missed, you think when 1082 00:55:38,406 --> 00:55:39,486 we're talking about sepsis? 1083 00:55:39,486 --> 00:55:42,396 I mean, barring the fact that we're doing examinations and triage. 1084 00:55:43,169 --> 00:55:45,084 Lauren Page Black: I think the environment in which we're all practicing 1085 00:55:45,084 --> 00:55:47,544 emergency medicine is hard these days. 1086 00:55:47,544 --> 00:55:50,768 And so I, I do think it can be missed, and I'm not saying we need to do that 1087 00:55:50,768 --> 00:55:53,738 for absolutely every pick 'cause a lot of patients who are septic are 1088 00:55:53,738 --> 00:55:55,238 not that sick and can talk to us. 1089 00:55:55,288 --> 00:55:59,054 But I do think for the very sick patient, we should be doing everything we can 1090 00:55:59,054 --> 00:56:02,314 to roll and expose them, but we all know how hard it is to roll a bunch 1091 00:56:02,314 --> 00:56:04,954 of patients when you have a bunch of patients coming in and sometimes it's 1092 00:56:04,954 --> 00:56:08,074 logistically challenging if it's only you or one other person in the room. 1093 00:56:08,374 --> 00:56:12,536 Where I trained for residency we did a lot of rectal temps and I 1094 00:56:12,536 --> 00:56:16,450 would say probably the best part about that was it made us actually 1095 00:56:16,450 --> 00:56:17,330 Sam: Roll the patient, right? 1096 00:56:17,350 --> 00:56:18,940 Lauren Page Black: Roll every single patient. 1097 00:56:18,940 --> 00:56:21,494 I'm not saying we should be doing it as much as we used to when I 1098 00:56:21,494 --> 00:56:24,193 trained, but I do think one of the helpful parts about that was 1099 00:56:24,193 --> 00:56:25,688 just you got eyes on your patient. 1100 00:56:25,718 --> 00:56:29,078 Sam: Yeah, I will put in the plug for communication with nursing. 1101 00:56:29,078 --> 00:56:32,498 If you have an open line of communication with your nurses, you'll find out quickly 1102 00:56:32,498 --> 00:56:36,440 about infections from Foley catheter insertions or rectal temps all the time. 1103 00:56:36,440 --> 00:56:37,190 Lauren Page Black: Exactly. 1104 00:56:37,290 --> 00:56:39,990 I also think ultrasound can be kind of a useful adjunct to the 1105 00:56:39,990 --> 00:56:41,670 physical exam here in many cases. 1106 00:56:42,245 --> 00:56:42,535 Sam: Okay. 1107 00:56:42,840 --> 00:56:43,740 Tell me more about that. 1108 00:56:44,146 --> 00:56:44,686 Lauren Page Black: I think. 1109 00:56:45,386 --> 00:56:49,446 One, I think it can be super helpful to assess cardiac function 1110 00:56:49,446 --> 00:56:50,663 and see how their heart looks. 1111 00:56:50,663 --> 00:56:54,723 I also think we can use it to look for evidence of cellulitis in places where 1112 00:56:54,723 --> 00:56:56,163 clinically it may be harder to see. 1113 00:56:56,163 --> 00:57:00,135 So I think there's a lot of evidence that it can help kind of improve our gestalt. 1114 00:57:00,365 --> 00:57:00,765 Sam: Good. 1115 00:57:00,885 --> 00:57:01,155 Good. 1116 00:57:01,185 --> 00:57:04,382 All my fellow ultrasound colleagues will be very happy to hear that. 1117 00:57:04,382 --> 00:57:08,042 So more uses for the uh, the handy ultrasound you carry around your neck 1118 00:57:08,042 --> 00:57:09,752 instead of the stethoscope, for sure. 1119 00:57:10,452 --> 00:57:13,647 Okay, so if we get past history of physical, and now we're looking at 1120 00:57:13,647 --> 00:57:18,177 diagnostics and we're gonna get some labs, we're gonna have some sepsis 1121 00:57:18,177 --> 00:57:20,527 bundle we're gonna order in our EMR. 1122 00:57:20,687 --> 00:57:26,267 But of those numerous tests, what do we know is helpful? 1123 00:57:26,267 --> 00:57:29,477 Now, you've mentioned lactate level a few times as a surrogate 1124 00:57:29,477 --> 00:57:30,767 marker for organ dysfunction. 1125 00:57:30,767 --> 00:57:30,947 Right? 1126 00:57:31,697 --> 00:57:33,694 Lauren Page Black: Yeah, I think most of this is part of 1127 00:57:33,694 --> 00:57:35,284 our routine ordering stuff. 1128 00:57:35,284 --> 00:57:39,760 Just a CBC and a BMP, I would get on most of these patients really for 1129 00:57:39,760 --> 00:57:40,960 subtle signs of organ dysfunction. 1130 00:57:40,960 --> 00:57:44,050 So there's the floridly septic patient that walks in that you can 1131 00:57:44,050 --> 00:57:47,320 tell on vital signs alone, they're hypotensive, they look like garbage. 1132 00:57:47,620 --> 00:57:51,350 But then, there's a lot of patients where they have really more subtle 1133 00:57:51,350 --> 00:57:54,680 signs of organ dysfunction and they're septic, they have a creatinine of 1134 00:57:54,680 --> 00:57:58,550 three and it's usually 0.5 and they have other laboratory evidence of 1135 00:57:58,580 --> 00:58:00,110 kind of more subtle organ dysfunction. 1136 00:58:00,320 --> 00:58:03,550 And in those patients, it's fine to then initiate your sepsis protocol 1137 00:58:03,730 --> 00:58:07,630 at the time that the sepsis declares itself, which may be then at the 1138 00:58:07,630 --> 00:58:09,010 time some of their labs come back. 1139 00:58:09,010 --> 00:58:12,940 I do think a lactate is helpful if you're suspecting sepsis, but I also don't think 1140 00:58:12,940 --> 00:58:16,390 you should beat yourself up if you wait to order it until the BMP comes back. 1141 00:58:16,620 --> 00:58:19,520 'Cause I think it's okay for our differential to change over 1142 00:58:19,520 --> 00:58:21,134 the course of their ED course. 1143 00:58:21,164 --> 00:58:24,584 I do think lactate still can be helpful. 1144 00:58:24,584 --> 00:58:26,144 I don't think it is the holy grail. 1145 00:58:26,144 --> 00:58:28,604 We thought it was a handful of years ago. 1146 00:58:28,844 --> 00:58:31,094 Nonetheless, it can be helpful. 1147 00:58:31,664 --> 00:58:32,804 CMS wants you to do it. 1148 00:58:32,854 --> 00:58:35,509 And I do think although there are populations in whom it functions 1149 00:58:35,509 --> 00:58:39,299 less well, it can be a reasonable evidence of hypoperfusion. 1150 00:58:39,999 --> 00:58:40,159 Sam: Great. 1151 00:58:40,179 --> 00:58:44,306 And now tell me, you just mentioned this, but what kind of specific populations 1152 00:58:44,656 --> 00:58:46,906 does it tend to not be as helpful in. 1153 00:58:47,286 --> 00:58:49,596 Lauren Page Black: So patients with liver dysfunction may not 1154 00:58:49,596 --> 00:58:51,066 clear their lactate as well. 1155 00:58:51,066 --> 00:58:55,693 Patients who are on a bunch of albuterol may have or any beta agonism. 1156 00:58:55,693 --> 00:59:00,108 So certainly, if you end up on the third pressor and you start 'em 1157 00:59:00,108 --> 00:59:02,853 on epi or something, you can't really trend your lactate levels. 1158 00:59:02,853 --> 00:59:07,563 That said, the recent guidelines is less towards lactate clearance and 1159 00:59:07,563 --> 00:59:11,283 more towards lactate improvement in a more generalized setting. 1160 00:59:11,473 --> 00:59:16,063 Just because of the way the evidence about lactate normalization played 1161 00:59:16,063 --> 00:59:17,323 out over the past few years. 1162 00:59:17,593 --> 00:59:21,603 Sam: So if I happen to be in the unfortunate scenario of resuscitating 1163 00:59:21,603 --> 00:59:27,093 a patient with cirrhosis, then a simple improvement in that lactic acid may 1164 00:59:27,093 --> 00:59:30,933 still be what I'm looking for as opposed to complete resolution and clearance. 1165 00:59:31,338 --> 00:59:31,828 Lauren Page Black: Exactly. 1166 00:59:32,248 --> 00:59:35,948 What I will say is also the CMS bundle, you know, requires for all patients 1167 00:59:35,948 --> 00:59:39,258 with sepsis, and I'm using the modern definition for that, so the entity 1168 00:59:39,308 --> 00:59:43,328 formerly known as severe sepsis, get a lactate and they require it be 1169 00:59:43,328 --> 00:59:45,158 repeated if it's greater than two. 1170 00:59:45,158 --> 00:59:47,378 And we can talk about the bundle again in a little bit. 1171 00:59:47,588 --> 00:59:51,428 The exception to that though is if the second one is higher, they need a third. 1172 00:59:51,783 --> 00:59:51,863 Sam: Hmm. 1173 00:59:52,208 --> 00:59:53,888 Lauren Page Black: And we can talk about the bundle more, but you 1174 00:59:53,888 --> 00:59:57,258 know, if it goes from 4.1 to four you're technically done though that 1175 00:59:57,258 --> 00:59:59,508 patient is probably still really sick 1176 00:59:59,578 --> 00:59:59,788 Sam: Right. 1177 00:59:59,818 --> 01:00:02,878 Lauren Page Black: But technically if it goes from two to 2.1, you need a 1178 01:00:02,878 --> 01:00:07,058 third to be compliant with, you know, and I think we can put compliance and 1179 01:00:07,058 --> 01:00:10,888 sort of, what we think the patient needs in hopefully overlapping buckets. 1180 01:00:10,888 --> 01:00:14,158 But it's just worth knowing that any lactate above two requires clearance. 1181 01:00:14,158 --> 01:00:17,878 If it's less than two, you can stop and you don't need another repeat. 1182 01:00:18,208 --> 01:00:18,538 Sam: Okay. 1183 01:00:18,588 --> 01:00:21,558 Lauren Page Black: But I do think it still provides valuable information. 1184 01:00:21,558 --> 01:00:24,528 I just don't think it's a surrogate for all the information we need 1185 01:00:24,578 --> 01:00:25,118 Sam: Perfect. 1186 01:00:25,468 --> 01:00:25,768 All right. 1187 01:00:25,768 --> 01:00:29,908 And then one of my inpatient colleagues' favorite tests, the procalcitonin. 1188 01:00:30,008 --> 01:00:32,528 We should get all the time everywhere for everything. 1189 01:00:33,288 --> 01:00:33,888 Lauren Page Black: Exactly. 1190 01:00:33,888 --> 01:00:37,268 I think this is one where everybody I work with knows how much I 1191 01:00:37,328 --> 01:00:38,828 dislike this test in the ER. 1192 01:00:38,828 --> 01:00:40,908 I think it's now synonymous with me. 1193 01:00:41,178 --> 01:00:47,188 Um, But I think this is a perfect example of a great test in a different location. 1194 01:00:47,428 --> 01:00:50,548 I think procalcitonin can be really helpful, particularly to our 1195 01:00:50,548 --> 01:00:55,678 upstage colleagues for antibiotic deescalation and a few other scenarios. 1196 01:00:55,678 --> 01:00:56,548 However. 1197 01:00:57,248 --> 01:01:02,468 As a surrogate decision maker for antibiotic initiation, it 1198 01:01:02,468 --> 01:01:05,468 has never been shown to perform well in the emergency department. 1199 01:01:05,828 --> 01:01:09,068 The long answer is part of that's for a number of reasons. 1200 01:01:09,338 --> 01:01:13,398 They peak 12-48 hours after the onset of infection. 1201 01:01:13,618 --> 01:01:16,104 Granted, I don't know when onset of infection was. 1202 01:01:16,104 --> 01:01:19,974 Nobody really does in the ER, but the point is it may rise too late 1203 01:01:19,974 --> 01:01:21,774 for it to be helpful in the ER. 1204 01:01:22,014 --> 01:01:26,634 It also has really limited sensitivities in really important subgroups for us. 1205 01:01:26,634 --> 01:01:29,704 So like though, what's really good for lung infections, it's not really 1206 01:01:29,704 --> 01:01:32,764 great for atypical lung infections, and we know plenty of people 1207 01:01:32,764 --> 01:01:34,264 who have gotten sick from those. 1208 01:01:34,344 --> 01:01:39,341 It also doesn't perform as well for other infections, like skin soft 1209 01:01:39,341 --> 01:01:41,411 tissue and immunocompromised patients. 1210 01:01:41,951 --> 01:01:45,111 And several studies looked at this and looked at, how could it augment gestalt? 1211 01:01:45,131 --> 01:01:48,561 And it has never once been shown to outperform physician gestalt, 1212 01:01:48,641 --> 01:01:51,191 especially when studied in the emergency department environment. 1213 01:01:51,491 --> 01:01:53,861 I will put a caveat here that I'm talking about adults. 1214 01:01:53,891 --> 01:01:57,241 The pediatric world, that discussion is, very different. 1215 01:01:57,401 --> 01:02:00,641 But in adult patients, if you think they need antibiotics, like 1216 01:02:00,701 --> 01:02:02,031 you should order antibiotics. 1217 01:02:02,031 --> 01:02:05,301 And if you don't think they're septic, you can just document that. 1218 01:02:05,551 --> 01:02:08,304 If you think their vital sign abnormalities are 'cause they have a GI 1219 01:02:08,304 --> 01:02:11,934 bleed or tamponade or something else, and I don't think you need a procalcitonin. 1220 01:02:12,234 --> 01:02:16,194 In fact, I think that's a inappropriate use of a procalcitonin. 1221 01:02:16,414 --> 01:02:17,404 In that scenario. 1222 01:02:17,404 --> 01:02:20,584 I mean, just like outside of a few specific situations, you don't 1223 01:02:20,584 --> 01:02:25,768 really need a VBG on coding patients to tell you that their pH is bad. 1224 01:02:25,858 --> 01:02:28,831 Um, you know, I think this is one of the things where you just 1225 01:02:28,831 --> 01:02:32,728 have to anchor on your , clinical gestalt and it's okay to do that, 1226 01:02:32,858 --> 01:02:32,978 Sam: Good. 1227 01:02:32,978 --> 01:02:35,428 Lauren Page Black: And the evidence suggests that's the best in this scenario. 1228 01:02:35,833 --> 01:02:39,943 Sam: And then when it comes to imaging, this is all just guided by 1229 01:02:39,943 --> 01:02:45,013 your examination and your concern for occult infection areas where you might 1230 01:02:45,013 --> 01:02:48,163 not be able to see it as best as you can get from history and physical. 1231 01:02:48,718 --> 01:02:50,518 Lauren Page Black: Yeah, nothing has really changed about 1232 01:02:50,518 --> 01:02:52,043 this in the past few years. 1233 01:02:52,143 --> 01:02:53,733 There was, I think a brief period of time people were 1234 01:02:53,733 --> 01:02:55,083 talking about medical pan scans. 1235 01:02:55,083 --> 01:02:57,673 I certainly don't think the evidence supports us doing that right now. 1236 01:02:57,673 --> 01:02:59,253 Who knows what I'll be saying in a handful of years. 1237 01:02:59,473 --> 01:03:02,943 What I will say is I do think judicious use of imaging can really 1238 01:03:02,943 --> 01:03:04,983 help us find sources of infection. 1239 01:03:05,193 --> 01:03:07,893 The particular population I do think we should have a pretty low 1240 01:03:07,893 --> 01:03:12,303 threshold for, in particular abdominal imaging, is the elderly patient. 1241 01:03:12,303 --> 01:03:13,953 And I think we all know that. 1242 01:03:14,213 --> 01:03:18,853 And I think if they have a pretty unremarkable UA and it's 1243 01:03:18,853 --> 01:03:20,893 like, eh, that could be a UTI. 1244 01:03:20,893 --> 01:03:23,439 But they look like absolutely terrible. 1245 01:03:23,539 --> 01:03:26,539 Those are the patients where I think anchoring on the UA may be inappropriate. 1246 01:03:26,539 --> 01:03:30,589 And it's probably best to at least consider abdominal imaging, especially 1247 01:03:30,589 --> 01:03:34,109 because, sicker elderly patients, immunocompromised patients may 1248 01:03:34,109 --> 01:03:35,789 not localize infections as well. 1249 01:03:35,789 --> 01:03:38,913 I mean, I think we all probably have several cases of this 1250 01:03:38,913 --> 01:03:40,096 we've seen over the years. 1251 01:03:40,196 --> 01:03:43,256 So I'd say I would have a low threshold, especially with the general ease in 1252 01:03:43,256 --> 01:03:47,816 most ERs of obtaining CT imaging, of considering abdominal imaging in elderly 1253 01:03:47,816 --> 01:03:49,316 and immunocompromised patients bellies. 1254 01:03:49,316 --> 01:03:52,736 Particularly 'cause often there's a source control procedure there that can change 1255 01:03:52,736 --> 01:03:56,626 management, or I won't say often, but enough of the time that it's relevant. 1256 01:03:56,626 --> 01:03:57,176 Sam: It's relevant. 1257 01:03:57,296 --> 01:03:57,686 Perfect. 1258 01:03:58,401 --> 01:04:01,341 Okay, then let's get into that CMS bundle for a second. 1259 01:04:01,371 --> 01:04:05,721 'cause now we're into that kinda initial management, that first few hours period. 1260 01:04:05,941 --> 01:04:09,121 Where are we in that requirement for the bundle? 1261 01:04:09,121 --> 01:04:10,856 Has that changed at all in the last few years? 1262 01:04:11,556 --> 01:04:14,589 Lauren Page Black: It has changed a little bit in the past few years. 1263 01:04:14,699 --> 01:04:19,079 What I first wanna say about the bundle is, not everybody with the bundle 1264 01:04:19,079 --> 01:04:24,029 requires 30 ccs per kilo by CMS, which I think sort of the way the bundles 1265 01:04:24,029 --> 01:04:25,169 are written, it can be confusing. 1266 01:04:25,169 --> 01:04:28,889 But essentially there's a severe sepsis bundle, which is what we now call sepsis. 1267 01:04:28,889 --> 01:04:31,559 So if you think somebody has organ dysfunction in the setting of an 1268 01:04:31,559 --> 01:04:35,339 infection, you need to order blood cultures prior to giving them antibiotics. 1269 01:04:35,669 --> 01:04:39,059 You need to order a lactate and you need to repeat it. 1270 01:04:39,059 --> 01:04:41,729 That's the six hour part of the bundle, if it's greater than two. 1271 01:04:42,029 --> 01:04:46,199 And you need to give antibiotics as reasonably early as possible. 1272 01:04:46,199 --> 01:04:48,096 It's really within the first three hours. 1273 01:04:48,156 --> 01:04:50,466 Though, they have this caveat, ideally within the first three 1274 01:04:50,466 --> 01:04:52,836 hours, what they hold you to is three hours, and I think that's 1275 01:04:52,836 --> 01:04:54,666 reasonable for that patient population. 1276 01:04:55,366 --> 01:04:59,516 Then, if they're hypotensive or if they have a lactate greater than 1277 01:04:59,516 --> 01:05:03,536 four, that's what triggers the 30 ccs per kilogram fluid bolus. 1278 01:05:03,596 --> 01:05:09,526 So if they have pneumonia and they have a new oxygen requirement and you know 1279 01:05:09,526 --> 01:05:12,106 that's technically sepsis, that's organ dysfunction, hypoxia in the setting 1280 01:05:12,106 --> 01:05:15,676 of an infection, that patient doesn't necessarily need 30 ccs per kilo. 1281 01:05:15,856 --> 01:05:18,706 Then if they become hypotensive or lower lactate comes back at four, that would 1282 01:05:18,706 --> 01:05:20,896 trigger the 30 cc per kilo fluid bolus. 1283 01:05:21,136 --> 01:05:25,096 In the past few years, CMS has pushed out some updates that give us some 1284 01:05:25,096 --> 01:05:27,076 ability to have some discretion there. 1285 01:05:27,286 --> 01:05:31,816 So resuscitation based on ideal body weight is acceptable for patients 1286 01:05:31,816 --> 01:05:35,536 whose BMIs are 31 or higher, so greater than 30, and you just have 1287 01:05:35,536 --> 01:05:39,616 to document resuscitation per ideal body weight given BMI greater than 30. 1288 01:05:39,916 --> 01:05:44,936 They also permit documentation of a lesser volume of fluid when 1289 01:05:44,936 --> 01:05:46,556 accompanied by clinical reasoning. 1290 01:05:46,736 --> 01:05:52,556 So for example, if somebody you know has an ICD because their EF is 10%, it is 1291 01:05:52,646 --> 01:05:57,686 reasonable and acceptable to document that, but it has to be pretty clear. 1292 01:05:57,686 --> 01:06:00,773 So you have to document the amount of fluid you're giving and why. 1293 01:06:00,773 --> 01:06:09,636 So 500 ccs of LR given instead of the 30 ccs per kilogram bolus due to concerns 1294 01:06:09,636 --> 01:06:14,766 for congestive heart failure, EF less than 10%, something along those lines or ESRD. 1295 01:06:14,766 --> 01:06:17,676 But in ESRD, fluid overload, congestive heart failure, they 1296 01:06:17,676 --> 01:06:19,206 give you some ability to document 1297 01:06:19,316 --> 01:06:19,606 Sam: Good. 1298 01:06:20,046 --> 01:06:22,416 Lauren Page Black: What I will say though is I also think this pendulum 1299 01:06:22,416 --> 01:06:24,846 has swung again with fluids in the past few years where I think people 1300 01:06:24,846 --> 01:06:28,306 are like terrified of fluids now and don't wanna give any at all. 1301 01:06:28,306 --> 01:06:31,976 And I think, you know, I think we'll hopefully see where we used to just 1302 01:06:32,396 --> 01:06:34,586 give a bajillion liters to everybody. 1303 01:06:34,586 --> 01:06:38,559 And I think we'll see the pendulum switch back a little bit, but that is what 1304 01:06:38,609 --> 01:06:40,499 from a CMS criteria, they hold you to. 1305 01:06:40,649 --> 01:06:44,519 Within the first six hours, they ask you to remeasure that lactate 1306 01:06:44,519 --> 01:06:45,839 if it was greater than two. 1307 01:06:46,059 --> 01:06:49,909 And if the patient still has a lactate greater than four, or they're 1308 01:06:49,909 --> 01:06:52,609 still hypotensive within the first six hours they ask that you start 1309 01:06:52,609 --> 01:06:56,199 vasopressors and reassess their volume status with like a clinical note. 1310 01:06:56,899 --> 01:07:01,129 That's pretty much the extent of the bundle, it hasn't changed dramatically. 1311 01:07:01,264 --> 01:07:06,034 Sam: So if you have someone whose say, initial lactate is high, let's say it's 1312 01:07:06,094 --> 01:07:10,774 five for the sake of this conversation, and then I repeat it, and now it's four 1313 01:07:10,774 --> 01:07:13,354 and a half, but they're not hypotensive. 1314 01:07:13,714 --> 01:07:17,314 In the CMS six hour bundle, it says you should be thinking about 1315 01:07:17,314 --> 01:07:21,884 vasopressors at this point, but this person is not clinically hypotensive. 1316 01:07:21,884 --> 01:07:23,804 It's not somebody I would normally start a pressor in. 1317 01:07:24,074 --> 01:07:26,774 Could I have to go write something in there saying this is why 1318 01:07:26,774 --> 01:07:28,139 I did not start vasopressors? 1319 01:07:28,709 --> 01:07:31,199 Lauren Page Black: No uh, the vasopressor part does say just 1320 01:07:31,259 --> 01:07:32,789 to maintain a MAP above 65. 1321 01:07:32,789 --> 01:07:35,579 So if they're maintaining that on their own, that's acceptable. 1322 01:07:35,789 --> 01:07:38,399 I also always think we should do the right thing for the patient 1323 01:07:38,399 --> 01:07:40,299 and, just fight it on the back end. 1324 01:07:40,299 --> 01:07:42,899 So if they don't need pressors, they don't need pressors. 1325 01:07:42,899 --> 01:07:47,139 And I think we should always have our first responsibility be to the patient 1326 01:07:47,219 --> 01:07:49,019 when those disagree with guidelines. 1327 01:07:49,019 --> 01:07:52,126 But no it's just vasopressors to maintain a map above 65. 1328 01:07:52,161 --> 01:07:52,451 Sam: Okay. 1329 01:07:52,646 --> 01:07:55,256 Lauren Page Black: It's not terribly different than what consensus guidelines 1330 01:07:55,256 --> 01:07:59,118 are, it's just that the lactate above four requires the fluid bolus 1331 01:07:59,118 --> 01:08:02,628 and they call that shock, even though we don't call that shock clinically. 1332 01:08:02,628 --> 01:08:04,700 And I do think that's the teeniest bit confusing. 1333 01:08:04,830 --> 01:08:06,949 I'd love to see some more clarity around that. 1334 01:08:07,099 --> 01:08:07,549 Sam: Yeah. 1335 01:08:08,249 --> 01:08:11,479 Lauren Page Black: But, you do not have to start vasopressors just for a lactate. 1336 01:08:11,749 --> 01:08:11,929 Sam: Yeah. 1337 01:08:11,929 --> 01:08:15,349 And when you say they call that shock, you mean CMS in their definition? 1338 01:08:15,349 --> 01:08:15,979 Calls them? 1339 01:08:15,979 --> 01:08:18,349 Calls anybody with a lactate greater than four, that's persisting 1340 01:08:18,349 --> 01:08:21,429 to be in shock when that's clinically not the case for us. 1341 01:08:22,129 --> 01:08:22,669 Lauren Page Black: Exactly. 1342 01:08:22,739 --> 01:08:25,559 And it's really just that they use it to trigger the septic shock 1343 01:08:25,559 --> 01:08:28,589 bundle, which is really the fluids and then the, if they're persistently 1344 01:08:28,589 --> 01:08:30,569 hypotensive, vasopressor requirement. 1345 01:08:30,809 --> 01:08:33,839 But yes, that would trigger their septic shock bundle, and those 1346 01:08:33,989 --> 01:08:37,709 people would be captured by the septic shock abstraction methods 1347 01:08:37,784 --> 01:08:38,204 Sam: Gotcha. 1348 01:08:38,904 --> 01:08:39,174 Okay. 1349 01:08:39,174 --> 01:08:41,244 Let's talk about fluid type. 1350 01:08:41,334 --> 01:08:43,764 One conversation that people love to have. 1351 01:08:43,764 --> 01:08:47,554 So we're talking about some kind of fluid. 1352 01:08:47,554 --> 01:08:51,904 Most of us are using either normal saline or some kind of lactated ringer. 1353 01:08:52,204 --> 01:08:56,764 Is there actually a preference for one over the other or evidence that might 1354 01:08:56,764 --> 01:08:58,559 swing us in one way versus the other? 1355 01:08:59,259 --> 01:09:01,059 Lauren Page Black: So this is still quite controversial. 1356 01:09:01,219 --> 01:09:04,519 I will say, the last time we wrote this, SALT-ED and SMART had come out 1357 01:09:04,719 --> 01:09:08,949 and those two studies were pragmatic, randomized, controlled trials where they 1358 01:09:08,949 --> 01:09:14,099 switched out the fluids every month and looked at mortality and then MAKE 1359 01:09:14,099 --> 01:09:18,389 30 and did see a slight difference in MAKE 30, which was a composite outcome 1360 01:09:18,842 --> 01:09:20,562 in favor of balanced crystalloids. 1361 01:09:20,999 --> 01:09:24,389 However, and since I think the last version of this paper was published, they 1362 01:09:24,389 --> 01:09:28,079 then did a subgroup analysis of patients with sepsis that I think was well done. 1363 01:09:28,079 --> 01:09:31,079 It was pre-planned, it was clearly pre-planned in their protocol, and 1364 01:09:31,079 --> 01:09:34,299 they found a mortality difference in favor of balanced crystalloids 1365 01:09:34,319 --> 01:09:35,639 rather than normal saline. 1366 01:09:35,819 --> 01:09:38,846 So that's pretty compelling to me, even though it wasn't a randomized 1367 01:09:38,846 --> 01:09:43,816 study in that group in particular, it's a well-planned secondary analysis 1368 01:09:43,996 --> 01:09:47,086 of a population that makes sense to look at this in, and there's a 1369 01:09:47,086 --> 01:09:49,246 mortality benefit in favor of LR. 1370 01:09:49,246 --> 01:09:54,599 So I think, in general I think LR does outperform normal saline based on the 1371 01:09:54,599 --> 01:09:56,189 best quality of the evidence we have. 1372 01:09:56,189 --> 01:09:57,989 I think it makes sense physiologically. 1373 01:09:58,199 --> 01:10:01,254 It's no longer has a huge difference in cost. 1374 01:10:01,254 --> 01:10:03,557 So , in my personal practice I lean on LR. 1375 01:10:03,557 --> 01:10:06,747 I'm also married to a surgeon and there's nothing they hate more than normal saline. 1376 01:10:06,747 --> 01:10:10,504 So maybe maybe it's partially that, but for sepsis, I feel far more 1377 01:10:10,504 --> 01:10:13,264 strongly I think this is a case where we should be using balanced 1378 01:10:13,264 --> 01:10:15,004 crystalloids instead of normal saline. 1379 01:10:15,339 --> 01:10:18,334 Sam: And that subgroup analysis you talked about in sepsis patients, 1380 01:10:18,339 --> 01:10:21,334 was that those with septic shock or just all comers sepsis. 1381 01:10:21,764 --> 01:10:23,294 Lauren Page Black: It was their ICU cohort arm. 1382 01:10:23,294 --> 01:10:24,554 So they were the sicker patients. 1383 01:10:24,554 --> 01:10:28,767 So whether or not they were intubated , in the ICU or in septic shock, it 1384 01:10:28,767 --> 01:10:32,547 was the sicker patients that they did show that mortality benefit in. 1385 01:10:32,787 --> 01:10:37,114 But mortality benefits are hard to see in sepsis, just because of the 1386 01:10:37,114 --> 01:10:38,524 number of patients you have to enroll. 1387 01:10:38,524 --> 01:10:41,064 And so I feel like it's a pretty compelling result, however, 1388 01:10:41,064 --> 01:10:42,474 it is in the sickest patients 1389 01:10:42,524 --> 01:10:42,814 Sam: Okay. 1390 01:10:43,179 --> 01:10:43,509 All right. 1391 01:10:43,509 --> 01:10:45,249 So lactated ringers it is. 1392 01:10:45,309 --> 01:10:49,329 And then there is a part of the bundle that requires a repeat assessment. 1393 01:10:49,329 --> 01:10:53,739 So what does that have to look like for CMS to be satisfied? 1394 01:10:53,739 --> 01:10:55,779 And then what should it look like for us clinically? 1395 01:10:56,479 --> 01:11:00,719 Lauren Page Black: For CMS it is a documentation of intravascular 1396 01:11:00,719 --> 01:11:02,669 volume status and tissue perfusion. 1397 01:11:02,819 --> 01:11:06,059 I think for us clinically, I think it's just going to the bedside and 1398 01:11:06,059 --> 01:11:09,199 reassessing the patient, not the computer, and make sure they actually 1399 01:11:09,199 --> 01:11:10,279 look better or don't look worse. 1400 01:11:10,279 --> 01:11:13,949 Which I think, sometimes you go in and, maybe none of the fluids are going 1401 01:11:13,949 --> 01:11:16,792 in, maybe it's in their AC and they've got it kinked up and the fluids are 1402 01:11:16,872 --> 01:11:18,672 largely still in the bag or something. 1403 01:11:18,752 --> 01:11:21,602 So I always think it's wise to go back in a few times and check on these 1404 01:11:21,602 --> 01:11:25,447 patients that are a bit tenuous and have a high probability of decompensating. 1405 01:11:26,097 --> 01:11:26,367 Sam: All right. 1406 01:11:26,367 --> 01:11:28,317 And then let's talk about antibiotics. 1407 01:11:28,317 --> 01:11:32,437 So, timing of antibiotic administration, you mentioned earlier, but there 1408 01:11:32,437 --> 01:11:37,747 is a requirement in the CMS bundle, at least some requirement for time. 1409 01:11:37,897 --> 01:11:42,337 And then clinically, do we have good evidence that even for a subset of 1410 01:11:42,337 --> 01:11:45,487 populations, it might be best to just give 'em as soon as we can? 1411 01:11:46,187 --> 01:11:46,457 Lauren Page Black: Yeah. 1412 01:11:46,457 --> 01:11:47,627 So I think that's a great question. 1413 01:11:47,627 --> 01:11:49,217 CMS will hold you to three hours. 1414 01:11:49,247 --> 01:11:51,597 That's still what the guidelines hold you to. 1415 01:11:51,597 --> 01:11:54,597 I think that gives us a fair amount of time to get some 1416 01:11:54,597 --> 01:11:56,217 idea of a source of infection. 1417 01:11:56,217 --> 01:11:58,077 So I actually think that's pretty reasonable. 1418 01:11:58,347 --> 01:11:59,727 Sam: Can I clarify there for one second? 1419 01:11:59,727 --> 01:12:03,357 Is that three hours from when they arrive, or three hours from when 1420 01:12:03,392 --> 01:12:05,472 you recognize them to have sepsis 1421 01:12:05,822 --> 01:12:07,072 Lauren Page Black: Three hours from sepsis recognition 1422 01:12:07,247 --> 01:12:07,937 Sam: recognition? 1423 01:12:08,007 --> 01:12:08,297 Okay. 1424 01:12:08,822 --> 01:12:11,102 Lauren Page Black: And there are some nuances here, just like on the 1425 01:12:11,102 --> 01:12:13,172 backend with what that's called. 1426 01:12:13,362 --> 01:12:16,542 So you know, sometimes if a BPA goes off and you click like sepsis 1427 01:12:16,542 --> 01:12:20,612 suspected, I think that can start your timer actually in some scenarios. 1428 01:12:20,972 --> 01:12:23,732 But it's the time of sepsis recognition in general. 1429 01:12:23,732 --> 01:12:26,319 So you have three hours from that to order antibiotics. 1430 01:12:26,559 --> 01:12:30,729 I will say the time to antibiotics mortality difference is in the patients 1431 01:12:30,729 --> 01:12:33,189 with hypoperfusion or hypotension. 1432 01:12:33,309 --> 01:12:37,059 So in those patients, I would go ahead and start them early on because 1433 01:12:37,059 --> 01:12:39,069 they have a clear mortality benefit. 1434 01:12:39,349 --> 01:12:43,019 And so if they're very sick, I would either start broad spectrum 1435 01:12:43,019 --> 01:12:46,529 antibiotics or target to what your best idea is clinically. 1436 01:12:46,719 --> 01:12:50,519 But those patients, I think we should be pushing whether that means, physicians 1437 01:12:50,519 --> 01:12:54,269 are doing lines themselves, et cetera, in order to get them antibiotics early on. 1438 01:12:54,509 --> 01:12:57,999 But for the rest of the patients, you have some time to determine 1439 01:12:57,999 --> 01:12:59,963 the most appropriate antibiotic. 1440 01:13:00,259 --> 01:13:06,146 I will say there is some change as the surviving sepsis campaign also 1441 01:13:06,246 --> 01:13:11,386 re-put out our one bundle, which is confusing again because it's 1442 01:13:11,416 --> 01:13:17,249 nomenclature is fairly similar to the CMS bundle where I think the goal was 1443 01:13:17,249 --> 01:13:22,653 to administer antibiotics earlier on if the patient has evidence of shock. 1444 01:13:22,653 --> 01:13:24,213 And I do think that's important. 1445 01:13:24,393 --> 01:13:26,643 I think the nomenclature around that is a little confusing. 1446 01:13:26,643 --> 01:13:30,663 I also think it perhaps misjudges the complexity of the emergency department 1447 01:13:30,813 --> 01:13:33,036 where one hour is pretty hard. 1448 01:13:33,276 --> 01:13:38,069 I think that may be easier to do in environments where people 1449 01:13:38,069 --> 01:13:39,329 already have lines, et cetera. 1450 01:13:39,329 --> 01:13:42,634 But if you think they're septic from the time they walk in, an 1451 01:13:42,634 --> 01:13:45,824 hour is still sometimes a little hard to get all this stuff going. 1452 01:13:45,984 --> 01:13:50,884 But there is some more discussion from consensus guidelines, but again, not the 1453 01:13:50,884 --> 01:13:54,824 CMS metrics, that are pushing for an hour. 1454 01:13:54,824 --> 01:13:59,624 If sepsis is definite or probable, I would personally just keep doing what 1455 01:13:59,624 --> 01:14:01,184 we all think is best for the patient. 1456 01:14:01,374 --> 01:14:04,944 But I think that nomenclature is a bit confusing because it so closely mimics CMS 1457 01:14:04,944 --> 01:14:09,504 step one, but CMS step one has not changed their guidelines off of three hours. 1458 01:14:09,569 --> 01:14:13,079 Sam: Okay, and that's three hours regardless of whether they're in shock 1459 01:14:13,079 --> 01:14:16,314 or whether they're just have plain old sepsis and they're stable as can be. 1460 01:14:17,014 --> 01:14:17,504 Lauren Page Black: Exactly. 1461 01:14:17,799 --> 01:14:19,989 I mean, it does say like within one hour if possible. 1462 01:14:19,989 --> 01:14:23,169 And I think some of that is because in those sicker patients we should be pushing 1463 01:14:23,169 --> 01:14:24,793 for earlier initiation of antibiotics. 1464 01:14:24,793 --> 01:14:28,271 But even if you're pretty sure they're septic, if they don't have 1465 01:14:28,271 --> 01:14:31,881 shock or hypoperfusion, you really do have time . The evidence suggests 1466 01:14:31,881 --> 01:14:35,511 you have some time to figure out the appropriate antibiotic choice. 1467 01:14:35,721 --> 01:14:37,971 And I think that's also beneficial to the patient. 1468 01:14:37,971 --> 01:14:40,525 'cause we all know the patient who's gotten like four different 1469 01:14:40,525 --> 01:14:43,337 antibiotics what we initially thought and then it changes. 1470 01:14:43,337 --> 01:14:46,917 And so I think there does have to be some sort of judicious balance 1471 01:14:46,917 --> 01:14:51,111 between antibiotic stewardship in the right patients and prompt 1472 01:14:51,111 --> 01:14:52,461 antibiotic administration. 1473 01:14:52,461 --> 01:14:55,011 And I think those things are intention sometimes, and I think that's 1474 01:14:55,011 --> 01:14:56,811 where some of the controversy is. 1475 01:14:56,811 --> 01:15:00,727 And I think the benefit of early antibiotics clearly outweighs the risk 1476 01:15:00,727 --> 01:15:04,747 in the sicker patients who have low blood pressures, who even if they're not 1477 01:15:04,747 --> 01:15:08,487 requiring vasopressors, but if they're intermittently hypotensive or they 1478 01:15:08,487 --> 01:15:10,244 have evidence of severe hypoperfusion. 1479 01:15:10,244 --> 01:15:13,061 I do think we should promptly give those people antibiotics, but I think we 1480 01:15:13,061 --> 01:15:15,781 should consider antibiotic stewardship in some of the other populations. 1481 01:15:15,781 --> 01:15:18,847 And we can wait two hours for the x-ray to actually come back. 1482 01:15:19,102 --> 01:15:19,672 Sam: Perfect. 1483 01:15:19,856 --> 01:15:20,066 Okay. 1484 01:15:20,066 --> 01:15:22,856 And then when it comes to picking the correct antibiotic, 1485 01:15:22,856 --> 01:15:24,686 there's a great table. 1486 01:15:24,686 --> 01:15:29,916 It's a very large table, but table five in the article talks about the infection 1487 01:15:29,916 --> 01:15:32,466 by type and then recommended antibiotics. 1488 01:15:32,466 --> 01:15:36,246 And if they're penicillin allergic, or anaphylactic, really , then 1489 01:15:36,246 --> 01:15:37,356 some alternate choices. 1490 01:15:37,356 --> 01:15:38,976 So it's all laid out there for you. 1491 01:15:39,286 --> 01:15:41,596 Everybody likes to give rocephin just off the bat. 1492 01:15:41,596 --> 01:15:44,416 It stops the clock and it's what we have in the Pyxis machine and 1493 01:15:44,416 --> 01:15:45,646 it's very easy to administer. 1494 01:15:45,916 --> 01:15:49,096 But there are times where you might consider giving something else. 1495 01:15:49,286 --> 01:15:52,256 And so having at least one or two other medications in 1496 01:15:52,256 --> 01:15:54,476 your armamentarium is helpful. 1497 01:15:54,576 --> 01:15:59,706 And I think this table does a good job laying that out by source if 1498 01:15:59,706 --> 01:16:03,006 you happen to know the source or at least suspect something specific. 1499 01:16:03,796 --> 01:16:04,206 Lauren Page Black: Thank you. 1500 01:16:04,426 --> 01:16:05,436 We hope it's helpful. 1501 01:16:05,491 --> 01:16:06,841 We spent a fair amount of time on it. 1502 01:16:07,081 --> 01:16:10,831 Let's say the only big changes there in the past few years are, HCAP has 1503 01:16:10,831 --> 01:16:15,751 kind of gone away in favor of still largely giving cap coverage to severe 1504 01:16:15,751 --> 01:16:20,744 community acquired pneumonia, unless they have prior MRS A respiratory 1505 01:16:20,744 --> 01:16:24,511 isolates or hospitalization and, you know, some of the other risk factors. 1506 01:16:24,591 --> 01:16:26,867 I don't really know clinically that our clinical practice has 1507 01:16:26,867 --> 01:16:29,332 changed a whole lot because of that. 1508 01:16:29,332 --> 01:16:33,222 But it's worth knowing that there has been some changes to those definitions 1509 01:16:33,472 --> 01:16:35,459 and those blanket recommendations. 1510 01:16:35,459 --> 01:16:38,526 I would also say the big thing that I do think clinically has changed is 1511 01:16:38,526 --> 01:16:42,696 there is a whole lot more ESBL, like community acquired extended spectrum 1512 01:16:42,696 --> 01:16:46,389 beta lactamase UTIs than there were, I feel like even five years ago. 1513 01:16:46,419 --> 01:16:50,586 And so if you think this suspected source is a uti, it's still so clunky 1514 01:16:50,586 --> 01:16:54,546 to look at old cultures, I think in most EMRs, but that is one place 1515 01:16:54,546 --> 01:16:57,626 where I really do think looking at old cultures is particularly important. 1516 01:16:57,786 --> 01:17:02,231 Because if they had an ESBL infection, I would not give them a beta-lactam. 1517 01:17:02,231 --> 01:17:04,191 I wouldn't give them rocephin or cefepime. 1518 01:17:04,211 --> 01:17:08,651 I would try to target one of the antibiotics to which they had 1519 01:17:08,651 --> 01:17:10,061 shown to be sensitive in the past. 1520 01:17:10,466 --> 01:17:13,886 Sam: Yeah, I will say I think that adds kind of two extra 1521 01:17:13,886 --> 01:17:15,476 steps to your decision making. 1522 01:17:15,476 --> 01:17:19,076 Like one, can you access an old culture of any sort? 1523 01:17:19,296 --> 01:17:22,866 It seems like when I am consulting my infectious disease colleagues, that's 1524 01:17:22,866 --> 01:17:25,936 always just, the most significant thing they're doing is going and just 1525 01:17:25,936 --> 01:17:29,386 looking at a prior culture data and then basing their best guess on that. 1526 01:17:29,686 --> 01:17:33,196 And second, what it is you're allowed to give in the emergency department. 1527 01:17:33,196 --> 01:17:38,406 A lot of us have the broadest spectrum drugs under lock and key by pharmacy. 1528 01:17:38,646 --> 01:17:42,336 And so sometimes it requires a little call to your ID colleague and say, 1529 01:17:42,336 --> 01:17:45,836 Hey, their last culture showed this and I really want to give ertapenem 1530 01:17:45,836 --> 01:17:48,856 or whatever it is, or meropenem and I need your blessing to do it. 1531 01:17:49,016 --> 01:17:52,076 And it seems silly, but you know, in the days of antibiotic 1532 01:17:52,076 --> 01:17:54,716 stewardship, it's just kind of another hoop you have to jump through. 1533 01:17:54,716 --> 01:17:57,296 So if you have that data, that's great. 1534 01:17:57,486 --> 01:17:58,566 And by all means use it. 1535 01:17:58,566 --> 01:18:02,376 'cause yes, the resistance , is getting ridiculous and it's only 1536 01:18:02,376 --> 01:18:04,026 getting worse as time goes on. 1537 01:18:04,106 --> 01:18:05,756 Lauren Page Black: The only other thing I wanted to say about the table to be 1538 01:18:05,756 --> 01:18:07,526 clear is it's for patients who are septic. 1539 01:18:07,526 --> 01:18:11,266 I'm not saying that these should be our first line antibiotics for patients 1540 01:18:11,266 --> 01:18:14,186 who don't have organ dysfunction, and maybe they just have a few SIRS 1541 01:18:14,206 --> 01:18:15,376 criteria and they're going home. 1542 01:18:15,596 --> 01:18:18,206 But it is for patients who are being admitted for sepsis. 1543 01:18:18,436 --> 01:18:19,756 Sam: good great clarifying point. 1544 01:18:20,426 --> 01:18:21,986 Okay, let's talk about vasopressors. 1545 01:18:21,986 --> 01:18:22,446 So the. 1546 01:18:22,791 --> 01:18:28,581 article mentions norepinephrine, dopamine, vasopressin, epinephrine 1547 01:18:28,831 --> 01:18:31,681 what is your favorite starting agent? 1548 01:18:31,681 --> 01:18:32,521 Do you have one? 1549 01:18:32,521 --> 01:18:33,151 And tell me why. 1550 01:18:33,271 --> 01:18:33,991 Convince me why. 1551 01:18:34,556 --> 01:18:36,866 Lauren Page Black: Norepinephrine should be everybody's first line 1552 01:18:36,896 --> 01:18:38,306 vasopressor for septic shock. 1553 01:18:38,526 --> 01:18:43,056 I think the evidence is very strong that it is superior certainly to 1554 01:18:43,056 --> 01:18:49,053 dopamine for septic shock and has not performed worse than vasopressin 1555 01:18:49,053 --> 01:18:50,283 in any of the other studies. 1556 01:18:50,493 --> 01:18:53,553 So I think norepinephrine really should be our first line agent, and I think 1557 01:18:53,553 --> 01:18:57,186 that's about the easiest part of septic shock and there's certainly some nuances 1558 01:18:57,186 --> 01:19:01,736 in the research world, but as far as the overwhelming conglomeration of 1559 01:19:01,736 --> 01:19:03,799 the evidence, the answer is levophed. 1560 01:19:04,049 --> 01:19:06,850 And then vasopressin should be your second additional agent. 1561 01:19:06,909 --> 01:19:07,199 Sam: Okay. 1562 01:19:07,804 --> 01:19:11,524 Then if you are debating whether or not you could give this through a peripheral 1563 01:19:11,524 --> 01:19:14,494 line because you haven't placed a central line yet and your nursing 1564 01:19:14,494 --> 01:19:18,364 colleagues have this tenuous line, is it okay to just go ahead and start it? 1565 01:19:18,979 --> 01:19:20,524 Lauren Page Black: It is absolutely okay to give it 1566 01:19:20,524 --> 01:19:22,610 peripherally and I think we should. 1567 01:19:22,864 --> 01:19:24,994 When we had to start a central line for everybody I think that 1568 01:19:24,994 --> 01:19:28,204 also actually delayed some people's more appropriate shock treatment. 1569 01:19:28,204 --> 01:19:33,554 But evidence is very clear that through a large, fairly proximal peripheral IV, it 1570 01:19:33,554 --> 01:19:36,644 is very reasonable to give vasopressors. 1571 01:19:36,744 --> 01:19:40,894 And so I personally do routinely start them peripherally. 1572 01:19:41,164 --> 01:19:45,334 My personal practices is, if they're on pretty high doses I still put in the 1573 01:19:45,334 --> 01:19:48,454 central line, and this changes person to person in place to place, but if they're 1574 01:19:48,454 --> 01:19:52,220 just requiring five of   levophed I think it's actually perfectly fine to just send 1575 01:19:52,220 --> 01:19:54,140 them upstairs with peripheral pressors. 1576 01:19:54,140 --> 01:19:55,490 And I think the evidence supports that. 1577 01:19:55,770 --> 01:19:58,020 And I think we are seeing that slowly be more and more common. 1578 01:19:58,020 --> 01:20:01,530 And I think it's lovely that I think that's taken one of the cognitive hoops 1579 01:20:01,585 --> 01:20:03,795 of the decision to start vasopressors. 1580 01:20:03,875 --> 01:20:06,575 I think it's perfectly fine to start  levophed peripherally and 1581 01:20:06,575 --> 01:20:07,985 the evidence largely supports that. 1582 01:20:08,429 --> 01:20:12,329 Sam: And if you've only got the 22 gauge in the top of the hand. 1583 01:20:12,975 --> 01:20:13,695 Lauren Page Black: I would put something 1584 01:20:13,905 --> 01:20:15,825 Sam: Alright, just gonna push you outta that one. 1585 01:20:15,825 --> 01:20:16,305 That's okay. 1586 01:20:16,340 --> 01:20:17,595 Lauren Page Black: It's not that magical. 1587 01:20:18,549 --> 01:20:22,869 If you've got a reasonable 18 in the AC or something, that's fine. 1588 01:20:22,869 --> 01:20:25,415 But yeah, if you've got a 22 in the hand, you gotta get more. 1589 01:20:26,230 --> 01:20:29,850 In that case too, what I tell people too is it's our nursing colleagues 1590 01:20:29,850 --> 01:20:32,500 and upstairs colleagues, if that's all we've got they need more access 1591 01:20:32,500 --> 01:20:34,360 than that for a variety of reasons. 1592 01:20:34,360 --> 01:20:37,240 So, I still certainly think there's a role for a central line. 1593 01:20:37,240 --> 01:20:39,932 I just don't think we need to do it as often as we used to. 1594 01:20:40,632 --> 01:20:40,932 Sam: All right. 1595 01:20:40,932 --> 01:20:42,552 Let's talk about steroids. 1596 01:20:42,582 --> 01:20:46,112 So this pendulum has swung several times as well. 1597 01:20:46,112 --> 01:20:49,532 Where are we now days with steroids, and what kinds of 1598 01:20:49,532 --> 01:20:50,822 steroids are we talking about? 1599 01:20:51,512 --> 01:20:52,802 Lauren Page Black: So I think this is one of the biggest 1600 01:20:52,802 --> 01:20:54,362 changes in the past few years. 1601 01:20:54,362 --> 01:20:57,332 I do feel like this has gone back and forth a whole lot. 1602 01:20:57,552 --> 01:21:02,042 Current consensus guidelines now do recommend hydrocortisone either a 50 1603 01:21:02,042 --> 01:21:06,782 milligram bolus every six hours or continuous infusion at 200 milligrams 1604 01:21:07,082 --> 01:21:08,402 for patients in septic shock. 1605 01:21:09,102 --> 01:21:12,672 I will say as a caveat to that, in the fine print, you know, it says 1606 01:21:12,672 --> 01:21:15,799 like if they're still requiring vasopressors after four hours 1607 01:21:15,829 --> 01:21:17,629 and there is some nuance to that. 1608 01:21:17,629 --> 01:21:23,050 So I'm not saying the second you start five of  levophed, they need to be chased 1609 01:21:23,050 --> 01:21:25,585 with like 50 milligrams of hydrocortisone. 1610 01:21:25,809 --> 01:21:28,435 But I do think we all know what boarding is like now. 1611 01:21:28,435 --> 01:21:30,445 You know, I do think if they're downstairs for a few hours, then 1612 01:21:30,445 --> 01:21:33,645 they're still requiring  levophed, I would definitely give that to them. 1613 01:21:33,945 --> 01:21:37,905 The evidence for that was not based on any mortality benefit. 1614 01:21:38,175 --> 01:21:41,355 What it was based on was, in the meta-analysis, it showed 1615 01:21:41,625 --> 01:21:43,965 improved time to shock resolution. 1616 01:21:44,370 --> 01:21:49,010 Essentially in patients who received steroids, and the consensus guidelines 1617 01:21:49,010 --> 01:21:54,200 felt that since it's a fairly low cost, low risk intervention, the benefits 1618 01:21:54,200 --> 01:21:55,910 of steroids outweighed the risk. 1619 01:21:55,940 --> 01:21:58,130 But it did not have a mortality benefit. 1620 01:21:58,430 --> 01:22:02,710 I will say, as a caveat to a second population, though, a pretty compelling 1621 01:22:02,710 --> 01:22:06,280 meta-analysis of steroids in patients with severe community-acquired 1622 01:22:06,280 --> 01:22:10,570 pneumonia did show reduced mortality and mechanical ventilation. 1623 01:22:10,570 --> 01:22:13,800 So in those patients, even if they're not requiring pressors if you're 1624 01:22:13,830 --> 01:22:17,760 intubating somebody for pneumonia and sending them to the ICU, or even 1625 01:22:17,760 --> 01:22:20,550 if you have them on high flow for pneumonia and they're not requiring 1626 01:22:20,580 --> 01:22:24,530 vasopressors, I would still give that person some hydrocortisone as well due 1627 01:22:24,530 --> 01:22:26,630 to the current best state and evidence. 1628 01:22:26,660 --> 01:22:28,680 But again this one has changed quite a few times. 1629 01:22:28,980 --> 01:22:32,944 As sort of a cutting edge, I think we'll see some more studies about 1630 01:22:32,944 --> 01:22:35,704 adding fludrocortisone so adding some additional mineral corticoid 1631 01:22:35,954 --> 01:22:37,544 coverage in addition to hydrocortisone. 1632 01:22:37,544 --> 01:22:41,474 But that's very much in the research world right now and not standard of care. 1633 01:22:41,474 --> 01:22:46,134 But for patients with persistent shock requiring levophed in the ED 1634 01:22:46,134 --> 01:22:50,870 or patients intubated intubated high flow, et cetera, for pneumonia, I would 1635 01:22:50,870 --> 01:22:52,070 give those patients steroids as well. 1636 01:22:52,440 --> 01:22:57,750 Sam: Now I'm curious, in your practice, are you doing that as just a protocol 1637 01:22:57,750 --> 01:23:02,160 event or are you only applying that to say the ones who you know well, 1638 01:23:02,160 --> 01:23:05,520 they're gonna be down here for a while, there's no ICU beds, I'm just gonna do 1639 01:23:05,520 --> 01:23:07,440 this as the kind of the final thought? 1640 01:23:07,530 --> 01:23:10,440 Or is it just in your protocol like, we're gonna give this and if they happen 1641 01:23:10,440 --> 01:23:11,610 to be down here, they're getting it. 1642 01:23:11,760 --> 01:23:14,220 If they've already gone to the ICU, then they'll just get it there. 1643 01:23:14,940 --> 01:23:17,464 Lauren Page Black: My personal protocol is, I give it, but I'm a 1644 01:23:17,464 --> 01:23:20,734 sepsis researcher, and I'm mostly focused on shock, so I care a lot. 1645 01:23:21,014 --> 01:23:26,004 I think so much is lost in handoffs regardless of best intentions. 1646 01:23:26,037 --> 01:23:28,657 I think it can be hard to tell what happened downstairs 1647 01:23:28,657 --> 01:23:29,977 and what was or wasn't done. 1648 01:23:30,227 --> 01:23:33,554 So I personally usually do it unless there's a reason I 1649 01:23:33,554 --> 01:23:34,604 don't think it's necessary. 1650 01:23:34,604 --> 01:23:38,354 Sometimes I start pressers a little bit earlier than necessary if I think 1651 01:23:38,354 --> 01:23:39,644 they need it for a certain reason. 1652 01:23:39,674 --> 01:23:43,059 And in that patient who, I think they just need some, and this is like personal 1653 01:23:43,059 --> 01:23:46,599 practice, not necessarily evidence based, but if I'm starting some  levophed to 1654 01:23:46,599 --> 01:23:50,259 just get them through their fluid boluses, 'cause they're persistently hypertensive 1655 01:23:50,259 --> 01:23:53,252 and I think they can get off of it once they're more fluid resuscitated, 1656 01:23:53,252 --> 01:23:54,542 I don't give it to that patient. 1657 01:23:54,542 --> 01:23:58,675 But if I think the patient's gonna stay on pressers, I usually go ahead and give it. 1658 01:23:58,975 --> 01:24:03,192 But again, the guideline was pretty clear that, they put some four hour line on it, 1659 01:24:03,192 --> 01:24:07,912 but this is all very consensus based and I think I agree with them the evidence, 1660 01:24:08,102 --> 01:24:13,172 does favor shock resolution and patients who received hydrocortisone, I think 1661 01:24:13,172 --> 01:24:16,862 there's probably people who respond really well and people who aren't responders. 1662 01:24:16,862 --> 01:24:19,019 And that's why we sort of see this mixed response. 1663 01:24:19,019 --> 01:24:20,669 And I think that's probably some of the challenge of the 1664 01:24:20,669 --> 01:24:22,289 heterogeneity of sepsis in general. 1665 01:24:22,989 --> 01:24:23,379 Sam: Okay. 1666 01:24:23,469 --> 01:24:26,199 And then let's just lastly touch on blood transfusions. 1667 01:24:26,199 --> 01:24:30,329 So, within the last decade we've changed to a pretty conservative, 1668 01:24:30,329 --> 01:24:34,629 like restrictive blood transfusion policies in most hospitals where, 1669 01:24:34,659 --> 01:24:37,359 if your hemoglobin is not less than seven, I'm not even thinking about it. 1670 01:24:37,539 --> 01:24:39,459 Is that the same for my septic patients? 1671 01:24:39,459 --> 01:24:40,989 Or do I need to have a higher threshold for that? 1672 01:24:41,339 --> 01:24:41,789 Lauren Page Black: No. 1673 01:24:41,849 --> 01:24:45,529 So the old like caring capacity days, those have also been retired. 1674 01:24:45,579 --> 01:24:50,019 If they don't have some obvious sign, like obvious blood loss 1675 01:24:50,129 --> 01:24:51,149 I wouldn't give them blood 1676 01:24:51,374 --> 01:24:51,704 Sam: Perfect. 1677 01:24:52,159 --> 01:24:52,499 All right. 1678 01:24:52,569 --> 01:24:53,819 Lauren Page Black: Unless their hemoglobin is less than seven, 1679 01:24:53,819 --> 01:24:55,319 like the regular indications. 1680 01:24:55,419 --> 01:24:55,499 Sam: Excellent. 1681 01:24:56,199 --> 01:24:59,409 And then there are some special populations that were discussed 1682 01:24:59,409 --> 01:25:02,919 in the paper, like the elderly, we touched on the one with cirrhosis 1683 01:25:02,919 --> 01:25:04,089 and end stage renal disease. 1684 01:25:04,389 --> 01:25:09,099 Other than the fact that those with cirrhosis may have that persistent lactic 1685 01:25:09,099 --> 01:25:14,149 acidosis and that they're risk because they're relatively immunocompromised. 1686 01:25:14,149 --> 01:25:16,609 What else do we need to know about our cirrhotic patients? 1687 01:25:16,959 --> 01:25:19,619 Lauren Page Black: I think it's, still maintaining a high index of suspicion 1688 01:25:19,619 --> 01:25:22,349 because I think sometimes some of their vital signed arrangements in a lot of 1689 01:25:22,349 --> 01:25:26,859 those more complicated populations can be attributed to their disease state, 1690 01:25:27,029 --> 01:25:29,769 but may actually not be normal for them. 1691 01:25:29,829 --> 01:25:30,279 Sam: Hmm. 1692 01:25:30,339 --> 01:25:33,909 Lauren Page Black: And I think recognizing that some of our complicated patient 1693 01:25:33,909 --> 01:25:36,839 populations may have more subtle signs of organ dysfunction and still 1694 01:25:36,839 --> 01:25:38,752 having a high index of suspicion. 1695 01:25:39,452 --> 01:25:45,002 Sam: Yes, I can recall several cirrhotic patients who like live at a systolic 1696 01:25:45,002 --> 01:25:51,662 blood pressure of 91 and then have like zero capacity for any kind of infection, 1697 01:25:51,662 --> 01:25:53,462 and then will syncopize immediately. 1698 01:25:53,462 --> 01:25:56,402 So I'm always worried about my cirrhotic with syncope and 1699 01:25:56,402 --> 01:25:58,052 going, well, you live at 91. 1700 01:25:58,052 --> 01:26:00,422 I mean, there's really not a whole lot of pressure left. 1701 01:26:00,992 --> 01:26:03,302 Lauren Page Black: And I think, remembering the unique infections 1702 01:26:03,302 --> 01:26:04,982 that can happen in those populations. 1703 01:26:04,982 --> 01:26:09,902 So I think, making sure you look for SBP in the right patients, considering in ESRD 1704 01:26:09,902 --> 01:26:13,362 patients who are on peritoneal dialysis considering, whether or not they have 1705 01:26:13,632 --> 01:26:18,189 SBP or, related to PD I think looking at lines for patients who have indwelling 1706 01:26:18,189 --> 01:26:23,289 lines for dialysis and just keeping a high index of suspicion for unique sources that 1707 01:26:23,289 --> 01:26:24,999 impact some of these patient populations. 1708 01:26:25,309 --> 01:26:29,599 Sam: Okay, so we're at the end of our time and we spent a lot of 1709 01:26:29,599 --> 01:26:32,179 time talking about CMS sep one. 1710 01:26:32,489 --> 01:26:38,579 Where in the future are there some areas maybe for advancement or improvement 1711 01:26:38,639 --> 01:26:43,529 in SEP one as we look towards better applying it to populations in sepsis? 1712 01:26:43,879 --> 01:26:47,989 Lauren Page Black: I would say I think we should at least have some acknowledgement 1713 01:26:47,989 --> 01:26:51,429 that CMS sep one has some challenges. 1714 01:26:51,459 --> 01:26:55,415 And I think as we see it slated to become a pay for performance 1715 01:26:55,415 --> 01:26:56,945 measure, it's pretty complicated. 1716 01:26:56,945 --> 01:26:59,565 And I think there are some things that are intention. 1717 01:26:59,565 --> 01:27:03,945 I think we're increasingly seeing this, like one size fits all approach 1718 01:27:03,945 --> 01:27:07,875 to sepsis being questioned, I think rightly so in the research community. 1719 01:27:08,055 --> 01:27:10,275 I think honestly, some of these clinical trials failed not because 1720 01:27:10,275 --> 01:27:13,455 the interventions, I'm not the only person who thinks this, not because the 1721 01:27:13,455 --> 01:27:16,275 interventions themselves didn't work, but we just don't know who to use them in. 1722 01:27:16,455 --> 01:27:19,095 There's probably some patients who respond better to some of these 1723 01:27:19,095 --> 01:27:20,355 things and some patients who don't. 1724 01:27:20,355 --> 01:27:23,032 And when we study them as a whole, the effect washes out. 1725 01:27:23,182 --> 01:27:26,332 But there probably are people who may have some benefits to some of these things. 1726 01:27:26,332 --> 01:27:28,972 Same with clovers and restrictive versus liberal fluids. 1727 01:27:29,242 --> 01:27:33,095 There might be some patients who really do need a restrictive fluid approach. 1728 01:27:33,095 --> 01:27:35,285 We just don't know exactly who those are right now. 1729 01:27:35,285 --> 01:27:38,942 So I think that CMS sep one still retains this one size fits all 1730 01:27:38,942 --> 01:27:42,292 approach, I think is challenging in light of the current evidence. 1731 01:27:42,372 --> 01:27:46,152 I think the lack of nuance regarding fluids, though I think most 1732 01:27:46,152 --> 01:27:47,572 patients can handle some fluids. 1733 01:27:47,572 --> 01:27:51,219 But the lack of nuance to that definition, the tension with antibiotic 1734 01:27:51,219 --> 01:27:54,999 administration, especially as we see some pushes from consensus guidelines to move 1735 01:27:54,999 --> 01:27:59,335 it earlier, I think doesn't represent the individual nature of patients that well. 1736 01:27:59,335 --> 01:28:03,349 And I think emergency medicine providers are smart enough that we can, you 1737 01:28:03,349 --> 01:28:05,749 know, have some individualization to our approach to the patient. 1738 01:28:05,749 --> 01:28:07,039 And I think there is some tension there. 1739 01:28:07,039 --> 01:28:11,585 And you've seen our EM societies make some statements, questioning 1740 01:28:11,585 --> 01:28:13,815 whether or not some of these things need to be updated. 1741 01:28:14,035 --> 01:28:17,245 And I think it's at least worth having some of that discussion about 1742 01:28:17,275 --> 01:28:21,400 what is the best thing for patients in light of what we know in 2025. 1743 01:28:21,750 --> 01:28:25,780 Sam: Thank you so much for coming on the podcast, sharing your wisdom 1744 01:28:25,780 --> 01:28:28,090 with us, and also for being an author. 1745 01:28:28,270 --> 01:28:33,040 This is a fantastic article, so thank you and your other co-authors 1746 01:28:33,220 --> 01:28:34,600 for taking the time to write it. 1747 01:28:34,600 --> 01:28:38,740 I think it does a tremendous job summarizing where we are in sepsis 1748 01:28:38,740 --> 01:28:43,450 today in 2025, and I really look forward to hearing more from all of you. 1749 01:28:43,700 --> 01:28:46,040 And I hope you'll come back on the podcast and share your wisdom 1750 01:28:46,040 --> 01:28:47,120 with us again in the future. 1751 01:28:47,810 --> 01:28:49,135 Lauren Page Black: Thank you so much for your time. 1752 01:28:49,135 --> 01:28:49,720 It was fun. 1753 01:28:50,070 --> 01:28:51,890 Sam: And that's a wrap for this month's episode. 1754 01:28:51,930 --> 01:28:54,510 I hope you found it educational and informative. 1755 01:28:54,710 --> 01:28:59,570 Don't forget to go to ebmedicine.net to read the article and claim your CME. 1756 01:28:59,740 --> 01:29:02,930 And of course, check out all three of the journals and the multitude of 1757 01:29:02,930 --> 01:29:07,290 resources available to you, both for emergency medicine, pediatric emergency 1758 01:29:07,290 --> 01:29:09,560 medicine, and evidence based urgent care. 1759 01:29:09,870 --> 01:29:11,840 Until next time, everyone be safe.