Thread by @CHESTCritCare

Starting soon, Sepsis: Most Recent Advances

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

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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.

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NEWS and MEWS much more acute tools for predicting mortality.

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

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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.

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

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

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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

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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?

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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).

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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

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DATA!!
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

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

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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.

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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.

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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.

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Don't forget about the microcirculation.

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

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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!)

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

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What about an individual patient approach for fluid management??

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

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