Episode 55: Fluids in Sepsis, Post-intubation Analgesia and Sedation

Emergency Medicine Cases

Dr. Anton Helman

Education, Health & Fitness, Courses, Medicine, Science

4.7 • 602 Ratings

🗓️ 17 December 2014

⏱️ 52 minutes

🔗️ Recording | iTunes | RSS

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Summary

In this second part of the Weingart-Himmel Sessions on critical care pearls for the community ED on the EM Cases podcast, we discuss the many controversies and recent changes in fluid management in severe sepsis and septic shock. With the recently published ARISE trial, and some deviations from Early Goal Directed Therapy, we are changing the way we think about fluids in sepsis: the type of fluid, the volume of fluid, the rate of fluid administration, the timing of introducing vasopressors and the goals of fluid resuscitation. In the next section of the podcast we discuss the PAD mnemonic for post-intubation analgesia and sedation, the prevention of delirium, and medication choices to minimize time on the ventilator, and improve prognosis.

Transcript

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0:00.0	Welcome to the Emergency Medicine Cases podcast.
0:05.8	I'm your host, Dr. Anton Hellman, bringing you Canada's brightest minds in emergency medicine from EMC Studios in Toronto.
0:18.0	And here's part two of the Weingard Himmel sessions on fluid management and sepsis and post-intubation, sedation, and analgesia.
0:26.5	Oh my God, they're not breathing.
0:28.3	Does anyone know CPR?
0:30.1	We're going to get back to the same case that we outlined in the first part of this episode.
0:33.9	A 72-year-old man with a history of CHF diabetes and hypertension was wheeled into our
0:38.5	resuscitation room with a four-day history of worsening shortness of breath, cough
0:42.5	productive of green sputum, and a high fever. His wife called 911 as he was getting increasingly
0:47.9	confused and having a lot of difficulty breathing. On arrival, he appeared to be in moderate
0:52.2	to severe respiratory distress, setting 86% on a
0:55.4	non-re breather. His heart rate was 130, blood pressure 95 on 40, respiratory rate of 32, and a temp of 38.2.
1:04.3	Well, based on our last episode, we knew to do a delayed sequence intubation on this patient,
1:09.4	and we saved his life. But now we have to
1:12.3	decide about post-intubation analgesia and fluid resuscitation. We're going to start with fluid
1:17.7	resuscitation. There's been some controversy and some important trials published lately on fluid
1:23.1	management and sepsis, which have left a few questions in my mind that I'd like to put out here now.
1:29.1	The first one is, which fluid is the fluid of choice? Normal saline, ringers lactate, albumin,
1:35.1	does it even matter? Next, how much fluid should we be giving? Two liters in the first two hours,
1:41.6	six liters in the first 24 hours, 14 liters in the first 24 hours, 14 liters in the first 24
1:45.4	hours. How fast should we be running the fluids? Should it be as fast as possible? How do we get the
1:50.8	fluids in? What kind of venous access should we have? How many lines? What kind of lines? What should
	...

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