Welcome to the e-resources for my talk & subsequent panel discussion at the Northern New England Critical Care Conference 2017.

Slides from the talk are located here here.  Sorry they are black/white, it was the only way to reduce the file size enough to include it here.  Full-color pictures of important figures are in the blogs below.   More information about these topics is below, arranged in parallel to the structure of the talk:

• Early pressors
  • Early initiation of vasopressors
• Peripheral pressors
  • Peripheral vasopressors
  • Phenylephrine infusion is very similar to norepinephrine infusion
• Ignore CVP and mixed venous oxygen saturation
  • Mixed venous oxygen saturation: signal or noise?
  • CVP is useless (by Paul Marik)
• More to volume overload than pulmonary edema
  • Abdominal compartment syndrome & fluid overload
• Small IVC & hyperkinetic heart doesn't mean volume will help
  • Empty IVC & LV doesn't equal volume depletion
• Lactate isn't an indicator of perfusion or anaerobiasis
  • Understanding lactate
• Consider epinephrine as a 2nd line pressor
  • Take the epinephrine challenge
• Maybe vitamin C can help
  • Metabolic sepsis resuscitation

After the talk we had a panel discussion including Drs. William Charish (Surgery/CC) and Lyle Gerety (Anesthesia/CC).  It was a great discussion, with a few salient points as below:

• Peripheral pressors
  • Charish: Evidence consists of case reports, we may be over-reacting to the possible harm.
  • Gerety:  In the operating room we use peripheral phenylephrine like water.
  • Me:  For crashing patient, any peripheral catecholamine vasopressor is OK until stabilized (often with central line placement).  For patient remaining on peripheral pressors for longer periods of time (e.g. 6-48hr) I only use phenylephrine or epinephrine.
  • Gerety:  In addition to risk of extravasation, need to also consider risk of central line insertion.
• Resuscitation targets
  • Surprising amount of agreement about this, I thought, although there doesn't seem to be any magical resuscitation target.  Ultimately I think we're all similarly befuddled.
  • Important targets include urine output, MAP, skin perfusion, mental status, increasing/decreasing pressor requirement (back to the basics).
  • Lactate isn't a great resuscitation target but we will continue to trend this because it's required by CMS.
  • Rising lactate meaningless if patient is on epinephrine infusion (may be a harbinger of improvement rather than deterioration).
  • Rising lactate in patient not on epinephrine is sign of badness, not a blind trigger for fluid administration.  Evaluate patient globally: are we using wrong antibiotic?  Missing surgical source control?   Wrong diagnosis altogether?

Even more stuff:

• Alphabetized content  (sepsis listed under the infectious disease category)
• iSepsis (resource by Paul Marik on sepsis)