Processing ProCESS: what does it mean for the small ED?
Gday. Welcome back. It has been a slow month on the blog as I recover from the wonderful exertions of the SMACC GOLD conference. After last week’s post on knowledge translation into the bush – this week I am jumping right in and aiming to translate some of the latest into your practice!
This is also the first podcast in a new series I have decided to call “Broome Pearls” – these are solo podcasts from myself on small topics, papers and stuff I find interesting – hope you do too! There will still be a mix of interviews and guests, a few “Lessons Hard Learned” and some video sessions. However, I think the solo stuff is easier for the short, micro-topics I get to thinking about most weeks.
This podcast is all about the ProCESS trial – NEJM, March 18 2014. This trial is big news: the biggest study into early sepsis management in a while – specifically looking at the efficacy of 3 different “bundles” or algorithms of care. This included a redo of the original Rivers EGDT trial from 2001.
Now this may seem a bit high-tech for the average small, rural ED – but you know the line from Dr Tim Leeuwenburg: “Critical Illness does not respect geography!” And this paper has some great lessons for us working in the bush. I think this paper brings world-class care to within our reach.
Have a listen here:
The references I mention are:
Seth Trueger’s take on ProCESS
Simon Carley’s historical perspective on how we have improved outcomes in the last dozen years.
Scott Weingart has interviewed Dr Angus (lead author) of ProCESS on Emcrit – you will have to wait for the SMACC podcast to hear his talk from a few weeks ago.
And here is a proposed fluid algorithm – that is not too far off the “standard therapy” protocol – I carry this one in my head. Love to hear your thoughts
OK – let me know what you think about the format, the content and the vibe.
The use of ultrasound as a non-invasive way of evaluating haemodynamics and volume status is promising and worthy of investigating. It certainly has relevance in settings where PAC, PICCO and SvcO2 are not readily available.
1) Why not check volume status of IVC first before any fluid? You could also do limited echo looking at stroke volume change with passive leg raise or respiratory changes with arterial waveform
2) Give fluid not according to formula but titrate to IVC and SV
3) Once IVC shows hypovolaemia is corrected reevaluate all parameters e.g. cap refill, mentation, MAP, Urine output, lactate
4) If still poor perfusion, carefully give more fluid until IVC full or B lines on lung U/S or start pressor e.g. norad and titrate up
5) If high pressor requirements then recheck LV function and consider an inotrope e.g. dobutamine
Thanka a million casey
Now this what we want. Excellent algorithm , I will keep it also in my head & smart phone.
Thanks again casey
Keep up .