So managed to pin another really bright guy down today and get his thoughts. Of course we digress some, but I think in all the topics that are truly important to sepsis resuscitation.
So I think all the resuscitationists I have spoken to tend to hover around the same common points:
- lactate is a marker of severity of insult/injury/inflammation but NOT something to specifically treat with an automatic fluid “chaser.”
- getting a global assessment of the patient’s perfusion – including things such as CRT is important.
- a strategy that seeks to exterminate fluid responsiveness is non-sensical and pathological.
The nice thing for our southern neighbours is that this study may give you a solid excuse to shake off that lactate mandate.
And I think that Korbin’s ending remarks are important, and it is something I try to teach residents, that there is little value in rapidly normalizing hemodynamic values – which treats the medical team very well – if there is an aftermath that is not beneficial for the patient. Kathryn Maitland’s FEAST study is the real groundbreaker for that concept. So probably a coordinated and careful ground assault is better than dropping the nuke.
For more discussion on this trial check out Rory Spiegel’s breakdown at https://emcrit.org/emnerd/em-nerd-the-case-of-the-deceitful-lantern/ and our discussion at https://thinkingcriticalcare.com/2019/02/19/the-andromeda-shock-study-a-physiological-breakdown-with-rory-spiegel-emnerd-foamed-foamcc-foamer/
cheers!
a couple points:
First, much thanks to Scott Weingart whose technical pointers are improving my audio quality! Still a ways to go but on the path!
Second, if you’re not registered for H&R2019, there’s only about 20 spots left. And only a handful for the much-anticipated Resuscitative TEE course. Don’t miss out. If you enjoy these discussions, there will be plenty of that, especially in the protected meet-the-faculty times.
And finally, though he doesn’t yet have a blog, you can now follow Korbin on twitter @khaycock2!
Philippe
thinking critical care 
I find it strange that as a rationale for tissue hypoxia (as some feel that lactate is) many will quote the DO2 equation. There is much focus on preload because of this focus and optimizing O2 delivery. Strangely 4-5 minutes later, the same very intelligent folks will say that one cannot utilize the O2 in sepsis. It seems incongruent then to maximize this through massive amounts of fluid when the condition won’t allow you to utilize it. So much focus on convective O2 delivery creates real problems with diffusion limited O2 delivery later on.
Yup, agree! Thanks for listening!