Start Peripheral Vasopressors Early in Shock!

It has been dogmatically believed that prolonged infusion of any vasopressor mandates placement of a central line.  However, available evidence doesn’t support this.

  1. Diluted solutions of all catecholamines are safe (except Vasopressin) to be administered peripherally via a well functioning 18-20G IV or larger in forearm (no hand/wrist/AC) .
  2. No old IVs (>72 hrs)
  3. Know how to treat extravasation
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Surviving Sepsis Guidelines 2021: Recommendations and Best Practice Statements

  • The recommendation for an initial fluid bolus of 30 mL/kg was downgraded from a strong recommendation to a weak recommendation, based on the low quality of evidence. However, resuscitation should start immediately.
  • Balanced crystalloid solution (e.g., lactated Ringer’s solution) should be used (rather than normal saline) for resuscitation.
  • Administration of vasopressors should be initiated via peripheral access, as opposed to waiting for placement of central venous access.
  • Patients with ongoing vasopressor requirements should receive intravenous corticosteroids (this recommendation was strengthened); however, administration of intravenous vitamin C is explicitly not recommended.

Neutropaenic fever in kids

 

  • Don’t be fooled. The patient with no immune system deserves significant respect and requires our vigilance.
  • Be thorough.Where is the source? Look at the mucous membranes and consider necrotizing fasciitis (i.e., look in the perineum)!
  • Be aggressive! If the child looks sick, throw all of the antibiotics at them. If the child looks well, monotherapy is recommended.
  • High Risk vs Low Risk… don’t decide alone. Your physical exam and lab results will help determine whether a patient is high risk or low risk, but that determination should be made concurrently with the patient’s oncologist.

 

Lactate in Sepsis: Pearls & Pitfalls…

Despite the ongoing controversy regarding the optimal endpoints of early sepsis resuscitation and the source of hyperlactemia, lactate remains the best non-invasive marker of illness severity. Given the current data, a ≥ 10% lactate clearance at 6 hours is an appropriate marker to follow when resuscitating a septic patient. However, recent research by Puskarich et al. showed that lactate normalization to < 2.0 mmol/L within the first 6 hours of resuscitation is superior to the rate of clearance.