This the recap of the 2nd of our 2 "Sepsis Smackdown" cases. Several weeks back, we presented to you the case of Lucy, a 79 yo female resident of a nursing facility presenting to your busy community ED with reported altered mental status. She's unable to provide you with a meaningful history but you piece together she's been acting abnormally at the nursing facility over the course of the past several days at the nursing facility and is now febrile, tachycardic, and hypotensive. In your testing, you find her to have a UTI, begin her resuscitation and admit her to the hospitalist and MICU. While waiting for a bed, she continues to be poorly responsive to your resuscitation...
Q1 - Do you think it is the responsibility of the ED physician to reassess volume status on this patient or is that the responsibility of the admitting physician at this point? If so, what method would you choose and why?
There probably is no right or wrong answer for this question, though depending on the scenario, one response may be more appropriate than another. The majority of residents responding to this question felt that it was the responsibility of the ED physician to assess the volume status of this patient. Generally people felt that if the patient was still physically in the emergency department, further acute care fell under the purview of the ED, even though she is admitted to the hospital. This seems to stem from her continued need for intervention. However, many also felt that as long as the patient gets what she needs, and receives adequate care (whether from the ED or from the inpatient team), then it didn’t matter as much who provided that care. Those who expressed this sentiment did suggest that in either event, care decisions should be discussed with the admitting provider. It is important that we remember that when there is a patient in need and when we are in a position to act, we should. However, we should also take into consideration the patient care plans set in place by our inpatient colleagues.
When reassessing volume status, there were no clear winners in terms of how to reassess the patient. Most seemed to favor a multimodal approach including overall gestalt from physical exam, UOP, and ultrasound of the IVC.
Q2 - In addition to administering fluids, at what point do you consider adding on a vasopressor, which do you choose, what MAP do you target, and why?
The residents responding to this question felt that targeting a MAP of 60-65 was appropriate for this patient. Target MAPs in this range tend to be adequate to allow for cerebral and vital organ perfusion, though it should also be remembered to take the patient’s exam and presentation into context. Most felt that without significant improvement after two liters or 20-30 cc/kg of fluid, that a vasopressor would be indicated. Highlighted by most respondents was our responsibility to evaluate the effectiveness of our interventions for these patients, and the need to reassess pump function or signs of fluid overload. According to the new sepsis guidelines, a reassessment of patients in severe sepsis or septic shock should occur within six hours of initial presentation (a goal we should all already be meeting).
Overwhelmingly people felt that the most appropriate initial vasopressor would be norepinephrine. The reasoning was that in septic shock, hypotension is due to vasodilation from inflammatory mediators or toxins, and that the alpha-1 activity of norepinephrine would increase vasoconstriction and BP. The additional effects of beta-1 activity would bolster cardiac function and increase cardiac output, which can also be impaired in sepsis. Epinephrine, dobutamine, and vasopressin were considered second line agents in sepsis. According to the surviving sepsis guidelines, most patients should receive epinephrine as the next agent after norepinephrine. Vasopressin also makes for a good adjunct, and often works synergistically with norepinephrine, often allowing that drip to be scaled back. While not mentioned by respondents to the question, phenylephrine may be used in septic shock, though the surviving sepsis guidelines discourage it until there are at least two other vasoactive substances on board, and there is still evidence of hypotension or hypoperfusion. In septic patients without severe/refractory bradycardia, and at low risk for dysrhythmia, dobutamine may be considered.
Q3 - If it is required, do you think it is appropriate and safe to start a low dose vasopressor through a large bore IV peripherally to increase venous return and admit the patient to the ICU or is this “poor form”/bad medicine?
This question provided a fair amount of evidence-based discussion. Most involved felt that starting a vasopressor through a reasonable peripheral IV (PIV) was appropriate and safe if done for a limited time only, though not a preferred option if central access could be obtained. The must, at some point, be a plan for placement of central access if the patient is going to continue to need pressors and fluid resuscitation. However, in a busy ED, especially one with other critical patients and few providers, using a PIV initially is appropriate, though this should invariably be communicated to the inpatient team.
One strong argument for time-limited use of PIVs for pressor support came from a literature review (fueled by the EMCrit podcast on the same topic, citing “Central or Peripheral Catheters for Initial Venous Access of ICU Patients: A Randomized Controlled Trial by Ricard JD, et al”) which found that short term pressors are safe and that adverse events are rare, though can be severe. The largest culprit for causing major local tissue injury is norepinephrine, and this causes more problems in IVs placed distal to the antecubital or popliteal fossas. In one study, it was 55 hours on average after infusion that damage was noted. Extravasation injuries were more quickly seen (average 24 hours after infusion), but 80% of these had no long-term sequalae. Nevertheless, prompt treatment (phentolamine, elevation, surgical consultation, etc) is warranted should these injuries occur.
Q4 - What is your threshold for placing a central line and in this case do you feel that it is the responsibility of the ED physician to place that line or should it be placed by the admitting physician in this case? How about an arterial line?
Again, there is no necessarily right or wrong answer to this question. People generally felt that this patient would require central access at some point. Most felt that the ED physician should obtain this access if there is reasonable time to do so. However, we should be reminded that our inpatient ICU colleagues are oftentimes just as busy, and sometimes busier than we are, so relying on their time to complete a needed procedure may not be appropriate or best care for the patient. Ultimately, it is our responsibility to ensure that there is a plan in place for central access, and if this plan cannot be ensured, that getting a central line in falls to us, no matter how busy we are.
Opinions on placing an arterial line were quite on the other side of the spectrum. Most commentators did not feel any significant urgency to place an A line in this patient, especially if there were no reason to believe the cuff to be inaccurate. The vast majority of residents feel just as comfortable following pressures off of the cuff as they do from the numbers provided by an arterial line. Opinion swayed only slightly towards A line placement if the patient were more critically ill, the department were not busy, or if they would need frequent ABGs while in the ED. However, most preferred to just avoid it in general, as they felt it would not affect their immediate treatment or care. It is unlikely that an A line will be urgently required for most patients while in the ED, though placement of this type of line should still be part of any emergency physician’s armamentarium.
Author: Nathanial Mann, MD, PGY-4 UC EM Residency
Edited: Jeffery Hill, MD MEd