Thread by @JamesWilsonDO1

Where did the #sepsis 30mL/kg IVF rec come from?
After Rivers’ EGDT in 2001 until 2015, the literature was combed to find how much reasonable physicians gave to septic patients and their outcomes. That #? ~2-3L. Which is ABOUT 30mL/kg for the average sized adult.
Thought 🧵 1/6

I say “reasonable physicians” as the SSC guidelines admit this was decided upon from the average amount given in the pre randomization of PROCESS, ARISE, PROMISE trials. That amount being 2-3L.
#MedTwitter #pulmtwitter #FOAMed #MedEd #critcare #emergencymedicine
2/6

So. Should we NOT give it? Should we give it based on IDEAL or ACTUAL body weight (obese vs overly muscular have diff H2O reserves)? Should we give it only to those patients WITHOUT HFrEF/HFpEF or CKD4-5-ESRD or cirrhosis?

Should we *gasp* INDIVIDUALIZE it..?!
3/6

Smarter/more experienced resuscitationists weighed in before & continue to do so, as we have no consensus. But as #COVID19 showed us, most medical literature is study after study and metanalysis of those studies built upon sand-like foundations of scientific/medical knowledge
4/6

W antibiotic timing in sepsis (Dr Kumar et al @CritCareIDN #idcrit) 1 thing in the critically defined 1st 6h of #sepsis BUNDLE of care shows its importance, but not to an isolatable degree. No RCT would remove 1 element from bundle to find out which is MOST important.
5/6

Love to hear from ramparts of clinical practice about how u/ur institution practice
Mostly, I want discussion. Challenge each of us. That’s the medicine I fell in love.
@PulmCrit @RMavesMd @DrAndreKalil @KellyCawcuttMD @benabo @raj_karnatak @MBrigmon @IM_Crit_ @critconcepts
6/6

Paul Marik, a brilliant-ish PCCM asshole so assured of his “rightness” that he falsified data, wrote a scathing summation of the 30mL/kg scenario as a “hoax” in 2020, pre his professional demise. It’s a good read, if totally, yknow, biased & all.
ncbi.nlm.nih.gov/pmc/articles/P…

References

SSC2021 guidelines

sccm.org/Clinical-Resou…

Restrictive Vs Liberal IVF RESUSCnejm.org/doi/full/10.10…

Abx timing in sepsispubmed.ncbi.nlm.nih.gov/16625125/

PROCESS trial

nejm.org/doi/full/10.10…

ARISE trial
nejm.org/doi/full/10.10…

PROMISE trial

nejm.org/doi/full/10.10…