I’ve never even seen one before.
Many emergency physicians are getting around not having the specialized equipment issue by obtaining intermittent venous blood gas measurements off of a central venous line.
But what if you had a 30 y/o woman with early pyelonephritis/urosepsis who has severe sepsis by definition? She’s got 10 peripheral lines (I’m exaggerating, of course), a normalized blood pressure with early IV fluids, and appears non-toxic. Her lactate, however, is 9! Do you really need a central line? My gut says no, but the EGDT protocol says yes — for the purpose of CVP and ScvO2 measurements.
Trick of the Trade
Use a less-invasive approach where bedside ultrasound and serial venous lactate levels replace central venous lines and ScvO2 measurements, respectively.
Last year, JAMA published a landmark study 1 showing that lactate clearance of ≥10% over the first 2 hours is “not a worse measurement” than ScvO2≥70%. This double-negative statistical speak came about because it was a non-inferiority study.
So how does this affect the original Rivers protocol? To review, here’s the original protocol, which I posted about earlier:
In the less invasive model:
- Fluid resuscitate through peripheral IV access instead of a central line.
- Follow volume status either with a bedside ultrasound or urine output.
- Follow venous lactate levels at time 0 and 2 hours. If the lactate clearance is ≥10% over these 2 hours, you should follow the algorithm as if the ScvO2≥70%. That means no need for immediate transfusion or vasopressor agents.
How do you know when you have adequately volume-resuscitated a patient using bedside ultrasound? Measure the IVC diameter about 1-2 cm from the right atrium junction.
- If the IVC diameter ≤1.5 cm and has ≥50% collapse with inspiration, the patient has a very low CVP.
- If the IVC diameter is at least 1.5 cm and has minimal collapse with inspiration, the patient is euvolemic. Move to the next step — assessing the MAP.
This doesn’t mean that all EGDT patient should have ONLY peripheral lines. Persistent hypotension, a non-clearing lactate level, and/or clinical toxicity warrant more invasive monitoring and management.
Scott Weingart has an in-depth, 21-minute podcast about the JAMA article and noninvasive approach to sepsis: Podcast link. Scott also briefly interviews Dr. Alan Jones (Carolinas Medical Center), the first author of the study, in the podcast.