Starting soon, Sepsis: Most Recent Advances

#CHESTCritCare is going to be Tweeting hightlights live by @crit_caring_MD

Up first, Dr. Matthew Churpek discussing machine learning and big data.

Trade off between high sensitivity and high specificity depending on if you use SIRS vs. qSOFA.

NEWS and MEWS much more acute tools for predicting mortality.

Big data may be the answer to identify and determine why patients deteriorate, even better than MEWS, SIRS, or qSOFA.

Identifying which patients are infected is key! 🔑
➡️Clinicians do a poor job at identifying infections in patients.
➡️Objective vital signs / labs are slightly better but have their own issues.

Machine learning (gradient boosted machines) were the most accurate at identifying infected patient.

What about on infection admission? Machine learning was also better.

But does it matter you ask?? What about outcomes??

Implementing real time alerts decreased mortality!
Up next, @sqsimp talking about Pre-symptomatic Diagnosis of Sepsis

Little evidence on pre-symptomatic sepsis (area for research!)

Is sepsis dichotomous?? 🤔
Where do you draw the line? Should there be a line at all?

Nice connection back to Dr. Churpek's talk, ? when the diagnosis of sepsis or infection.

Talking here about the time before the infection is detected (far left of the sepsis time continuum).

Challenges in pre-symptomatic diagnosis:

➡️detecting/predicting infection or organ dysfunction
➡️heterogeneity of sepsis
➡️# at risk is much much higher than those who progress to organ dysfunction or shock

The Rapid Analysis of Threat Exposure (RATE) owned by the Department of Defense, claims to predict infection 48hr before clinical suspicion better than 85% accuracy....
no public papers/data

Up next: Dr. Jonathan Sevransky talking about hydrocortisone, vitamin C and thiamine.

Initial study by Dr. Fowler showing in a dose dependent manner a lowering of SOFA score with IV high dose vitamin C.

Then Dr. Marik published is ground breaking triple therapy trial.

Three triple therapy studies:

➡️CITRIS-ALI no difference in SOFA score or biomarkers (primary outcomes), secondary analysis of mortality was significant (?? meaningful)
➡️VITAMINS with no difference in mortality
➡️ACT reduced SOFA score
ViCTAS trial currently under peer review!!! Looking forward to those results. Hope that this will guide further treatment decisions regarding triple therapy of vitamin C, steroids, and thiamine.

Up last is Dr. Ivor Douglas, early vs. late fluids.

Important questions in sepsis:

What volume/rate of fluid?
What amount of fluid prior to pressors?

The exact balance is what we want to achieve.

Don't forget about the microcirculation.

Ultimately, it comes down to liberal vs. conservative fluids.

SEP-1 has embedded in us the early delivery of fluid in sepsis. Prospective studies brings this into question.

Bundles, work, but it was ABX driven. Raises into question if early fluid is a priority (fluid is still important!)

PETALS CLOVER Trial ongoing
(Crystalloid Liberal Or Vasopressors Early in Resuscitation in Sepsis)
aims to enroll >2300 patients
primary outcome 90 day inpatient mortality

What about an individual patient approach for fluid management??

FRESH trial (Fluid Responsiveness Evaluation in Sepsis-associated Hypotension)


• • •

Missing some Tweet in this thread? You can try to force a refresh

Keep Current with CHEST Critical Care NetWork

CHEST Critical Care NetWork Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!


Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @CHESTCritCare

21 Oct
Coagulopathy on COVID-19 is about to start! @accpchest #CHEST2020 #CHESTCritCare
Comparison of VTE in other diseases in the ICU #CHEST2020 #CHESTCritCare Image
And comparison of COVID-19 VTE and historical ICU co-horts. Thrombosis in COVID higher in well matched ARDS patients and also higher than in patients with flu. @accpchest #CHEST2020 #CHESTCritCare Image
Read 11 tweets
20 Oct
@GallodeMoraesMD will be live tweeting the #PICS talk @ACCP #CHESTCritCare
@crit_caring_MD @GioraNetzer @itsradu @ICU_Recovery are talking about #PICS now!
At 12 months only 44% of ICU survivors are PICS-free, being cognitive a significative part of the post-ICU impairment. With more ICU survivors, we will likely be seeing more PICS. #CHEST2020 #CHESTCritCare
The lack of visitors in the COVID-19 era, will likely contribute to higher number of survivors with PICS #CHEST2020 #CHESTCritCare
Read 11 tweets
19 Oct
First up: Props to #CHEST2020 learning partners for that amazing wait music. Ne'er been a fan of wait music. But this is ... well .. peppy. Am in the mood to learn about #AirwayManagement!

Speakers: @Chaeface @J_Mendelson_MD @KDoerschug

Coverage: @virenkaul

.@J_Mendelson_MD: HFNC and proning in severe hypoxic resp failure:

- Can reduce dead space ventilation, assist with WOB, improved resp mechanics
- Pre-COVID data: Can be successful in potentially preventing invasive ventilation vs NIV and low flow O2

#CHEST2020 #CHESTCritCare Image
.@Chaeface: Pre-oxygenation modifications to reduce aerosolization

Use V-E technique vs C-E technique for rescue BMV. Improved efficacy for ventilation and better seal. (Lower picture):

#CHEST2020 #COVID19 Image
Read 9 tweets
18 Oct
Vitamins in Critical Illness starting now!

Discussing: Vitamin C, Vitamin B12, Vitamin D

#CHEST2020 Image
Vitamin B12 up first by Dr. Jayshil Patel.
#CHEST2020 Image
There are elevated hydrogen sulfide (H2S) in early sepsis.
Read 22 tweets
18 Oct
Covering pardon the interruption with @davidschulman moderating!!!!!

Power-packed speaker list covering a gamut of critical care topics at #CHEST2020

@SMHollenberg @ammo_uw @KristinBurkart3 and Dr. Bowton

And punches are already being thrown. D'oh! Image
Here are the competitors:
Dr. Bowton: The Real Deal Tarheel
@KristinBurkart3: The Beat of the Northeast
@SMHollenberg: The Heartless Cardiologist
@ammo_uw: Dr. "Who Can Ask for Anything" Morris

Here are the ground rules!

New rules this year!!

#CHEST2020 Image
Role of glucocorticoids in CAP:
Dr. Bowton: No mortality benefit
@SMHollenberg: Loses points 4 trying to get points. "It's a toss-up"
@ammo_uw: "Depends": How do you define severe" They help for severe!
@KristinBurkart3: Do the "boys" never find indication? ... burn!

#CHEST2020 Image
Read 36 tweets
18 Oct
Amazing discussion going on at the #CHEST2020 opening session by @sqsimp @CHESTPrez @RMavesMd @mnarasimhan Image
@mnarasimhan highlights that as we know more about the natural course of COVID-19 we have seen that #PPE works! Also, that we should try non-invasive ventilation in COVID-19 patients as long as we have appropriate PPE #CHEST2020 #CHESTCritCare
@RMavesMd highlighted that several countries in the South Hemisphere didn't have as much flu this season as in previous years, and hopefully we will see the same phenomenon in the US now that flu season is coming #CHEST2020 #CHESTCritCare
Read 4 tweets

Did Thread Reader help you today?

Support us! We are indie developers!

This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!

Follow Us on Twitter!