Q1 - Do you think it is the responsibility of the ED physician to reassess volume status on this patient or is that the responsibility of the admitting physician at this point? If so, what method would you choose and why?

There probably is no right or wrong answer for this question, though depending on the scenario, one response may be more appropriate than another. The majority of residents responding to this question felt that it was the responsibility of the ED physician to assess the volume status of this patient. Generally people felt that if the patient was still physically in the emergency department, further acute care fell under the purview of the ED, even though she is admitted to the hospital. This seems to stem from her continued need for intervention. However, many also felt that as long as the patient gets what she needs, and receives adequate care (whether from the ED or from the inpatient team), then it didn’t matter as much who provided that care. Those who expressed this sentiment did suggest that in either event, care decisions should be discussed with the admitting provider. It is important that we remember that when there is a patient in need and when we are in a position to act, we should. However, we should also take into consideration the patient care plans set in place by our inpatient colleagues.

When reassessing volume status, there were no clear winners in terms of how to reassess the patient. Most seemed to favor a multimodal approach including overall gestalt from physical exam, UOP, and ultrasound of the IVC.

Q2 - In addition to administering fluids, at what point do you consider adding on a vasopressor, which do you choose, what MAP do you target, and why?

The residents responding to this question felt that targeting a MAP of 60-65 was appropriate for this patient. Target MAPs in this range tend to be adequate to allow for cerebral and vital organ perfusion, though it should also be remembered to take the patient’s exam and presentation into context. Most felt that without significant improvement after two liters or 20-30 cc/kg of fluid, that a vasopressor would be indicated. Highlighted by most respondents was our responsibility to evaluate the effectiveness of our interventions for these patients, and the need to reassess pump function or signs of fluid overload. According to the new sepsis guidelines, a reassessment of patients in severe sepsis or septic shock should occur within six hours of initial presentation (a goal we should all already be meeting).

Overwhelmingly people felt that the most appropriate initial vasopressor would be norepinephrine. The reasoning was that in septic shock, hypotension is due to vasodilation from inflammatory mediators or toxins, and that the alpha-1 activity of norepinephrine would increase vasoconstriction and BP. The additional effects of beta-1 activity would bolster cardiac function and increase cardiac output, which can also be impaired in sepsis. Epinephrine, dobutamine, and vasopressin were considered second line agents in sepsis. According to the surviving sepsis guidelines, most patients should receive epinephrine as the next agent after norepinephrine. Vasopressin also makes for a good adjunct, and often works synergistically with norepinephrine, often allowing that drip to be scaled back. While not mentioned by respondents to the question, phenylephrine may be used in septic shock, though the surviving sepsis guidelines discourage it until there are at least two other vasoactive substances on board, and there is still evidence of hypotension or hypoperfusion. In septic patients without severe/refractory bradycardia, and at low risk for dysrhythmia, dobutamine may be considered.

Q3 - If it is required, do you think it is appropriate and safe to start a low dose vasopressor through a large bore IV peripherally to increase venous return and admit the patient to the ICU or is this “poor form”/bad medicine?