Wednesday Wrap-up 8/1/12

by jwillis • August 2, 2012 • 3 Comments

8AM- Manoach- Hemodynamic Monitoring

9AM- Wright- ACLS

10AM- Mallemat- The slowly crashing tamponade pt

Part 2- Who really needs a central line?

11AM- Walalce- Part 1- Emergency Medicine Health Services Research

Part 2- Regional Critical Care Supply and Demand

This week hit a lot of great critical care issues. In my opinion the most thought provoking and controversial lecture was Dr. Mallemat’s lecture on who really needs a central line. He included a lot of literature by the powerhouses of sepsis management.

The biggest controversy is what you use to monitor patient’s response to therapy, i.e. fluids, ScvO2 versus lactate. I think as a residency we are already sold on US for hemodynamic monitoring and we all know CVC is not the way to go for large amount of fluids. I think we are a little biased in the lactate department due to being a PROCESS center.

In the study shown by Dr. Mallemat in the JAMA commentary by Dr. Jones about lactate he discusses his RCT showing lactate to be non-inferior to ScvO2. The mortality was not significantly different and he says lactate is a more accurate picture of global tissue hypoxia. And of course it is easier to obtain with no central venous access needed. Article can be seen here:

http://journal.publications.chestnet.org/article.aspx?articleid=1148995

Dr. Rivers’ counterpoint to this discusses lactate as being a lot more complicated than Dr. Jones claims. That lactate clearance and levels are affected by too many factors such as liver failure. He also states lactate level does not address specific issues such as inotropy and oxygen carrying capacity the same way ScvO2 does. His final point about lactate precluding CVC access is that it may cause people to place lines too late in patients who really need them. This article can be found here:

http://journal.publications.chestnet.org/article.aspx?articleid=1148996

I would like to hear your guys opinions on this debate. I think a lot of people should have something to say. This is something we will see and deal with for the rest of careers. Let’s here some responses from all our future critical care docs!

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.