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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 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
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.
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. Reference Jones AE, et al; Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA : the journal of the American Medical Association. 2010, 303(8), 739-46. PMID: 20179283 |
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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. 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.