These trials may be most useful when they loosen a doctrine rather than create a new one. For years the danger was that sepsis resuscitation became morally attached to volume: giving more fluid felt like doing more resuscitation. ARISE-FLUIDS and CLOVERS make that reflex harder to defend, without handing clinicians a replacement reflex to apply blindly.
The useful residue may be proportionality. A liter has a different meaning in the patient who is volume-depleted than in the patient already carrying respiratory or cardio-renal vulnerability. The trial does not remove judgment; it makes the judgment harder to outsource to a rule.
That is why equivalence may be less boring than it sounds. When two strategies look broadly similar in the aggregate, the bedside question shifts from which strategy won to which patient has the least margin for the wrong excess. In sepsis, restraint and rescue are not opposite virtues. The work is knowing which one the physiology is asking for now.
Excellent analysis as usual. A teaching point used in the icu regularly is to hypothesis generate and then act but make sure you are right and fix if goes wrong. The benefits of dedicated teams and close monitoring allow that….and sure resus up but deresus when can … if they are dry they fly…the issue remains are floors good at the deresus? In this country where hospitalist quality is mixed that’s not so clear. Some know to do such and will do quick. Others panconsult hoping some diuretic friendly consulting physician will get there and do it when needed. (Have often felt that if a diuretic or no physician (only the one question to ask) simply rounded upon 15-20 pts by 9am we’d get fewer icu screens.) Would hope to state that in Australia and New Zealand less of that variability exists but am not sure for sure.
My daughter kept getting fluid overloaded in a hospital to the point she would be screaming her lungs are filling up with fluid and she is drowning and yet is on dry land. It happened so many times that I was carefully watching the fluids and then had to carefully watch the diuretics because then they would overdo those and she would be gasping for air from lack of blood! It was the most horrible torture I've ever seen or could imagine. She died in the hospital from another drowning event in from of my face with them claiming it was pneumonia - nobody with PNA complains their lungs are filling up with fluid. Then without consent they dropped her into a therapeutic paralysis with paralytics?!? Of course, she died paralyzed while drowning.... It took me years to figure out why the hospital was acting like that - then I ran into the Sepsis Protocol in the book "Mistreated" by Robert Pearl. In that book it directs doctors to not worry about the patient in front of them and to just trust that for every patient they kill with a drowning event like my daughter's, then 8 other patients they will never meet will have survived "sepsis" because they mindlessly fluid overloaded everyone like this for maybe having sepsis (no lab proof of infection is needed)....so I looked in my daughter's medical records to see if they ever "diagnosed" suspicion of sepsis in my daughter prior to these drowning events that no hospital staff ever seemed prepared to save her from. Yep, the day she died - a nurse had done a "sepsis" screen and charted that her hypotension pointed to sepsis.....but that nurse had just overdosed her with morphine and hour before so that would be the actual cause of hypotension. They never bothered with dialysis or even a drain to try and save her...no attempt at all to save her from the hospital's sepsis protocol induced drowning event. Can you guys group together and speak out against that book for promoting to not worry about killing the patient in the bed in front of the attending doctor in favor of following a strict protocol of drowning patients with fluid overload as a "treatment" for the maybe "sepsis" (no lab proof required) with NO concern for the patient to die by drowning? The nightmares never go away because I think this behavior continues - i want to know this has stopped. My daughter developed very LOW ALBUMIN in the hospital (could also be IV fluids induced) so the drownings should have been totally predictable....and she was not terminally ill and trying to stop the morphine which she claimed was making her worse. She should not be dead and, despite what that book says, it DOES MATTER! That book trivializes her life, and death, and almost makes the death sound like success. I bought that book in 2018, maybe a more recent edition has already corrected that wording - I sure hope so.
These trials may be most useful when they loosen a doctrine rather than create a new one. For years the danger was that sepsis resuscitation became morally attached to volume: giving more fluid felt like doing more resuscitation. ARISE-FLUIDS and CLOVERS make that reflex harder to defend, without handing clinicians a replacement reflex to apply blindly.
The useful residue may be proportionality. A liter has a different meaning in the patient who is volume-depleted than in the patient already carrying respiratory or cardio-renal vulnerability. The trial does not remove judgment; it makes the judgment harder to outsource to a rule.
That is why equivalence may be less boring than it sounds. When two strategies look broadly similar in the aggregate, the bedside question shifts from which strategy won to which patient has the least margin for the wrong excess. In sepsis, restraint and rescue are not opposite virtues. The work is knowing which one the physiology is asking for now.
They just can’t let go of this religious belief, despite multiple randomized trials showing that liberal fluid strategy is not harmful.
I was waiting for your input before I will podcast about this. Thanks so much for the excellent analysis as usual.
Once again, Dr. Hassabolus has been vindicated. And now there was a trend towards higher death from restriction of fluids. Bolus away!!!!
Excellent analysis as usual. A teaching point used in the icu regularly is to hypothesis generate and then act but make sure you are right and fix if goes wrong. The benefits of dedicated teams and close monitoring allow that….and sure resus up but deresus when can … if they are dry they fly…the issue remains are floors good at the deresus? In this country where hospitalist quality is mixed that’s not so clear. Some know to do such and will do quick. Others panconsult hoping some diuretic friendly consulting physician will get there and do it when needed. (Have often felt that if a diuretic or no physician (only the one question to ask) simply rounded upon 15-20 pts by 9am we’d get fewer icu screens.) Would hope to state that in Australia and New Zealand less of that variability exists but am not sure for sure.
You need a study for that?
My daughter kept getting fluid overloaded in a hospital to the point she would be screaming her lungs are filling up with fluid and she is drowning and yet is on dry land. It happened so many times that I was carefully watching the fluids and then had to carefully watch the diuretics because then they would overdo those and she would be gasping for air from lack of blood! It was the most horrible torture I've ever seen or could imagine. She died in the hospital from another drowning event in from of my face with them claiming it was pneumonia - nobody with PNA complains their lungs are filling up with fluid. Then without consent they dropped her into a therapeutic paralysis with paralytics?!? Of course, she died paralyzed while drowning.... It took me years to figure out why the hospital was acting like that - then I ran into the Sepsis Protocol in the book "Mistreated" by Robert Pearl. In that book it directs doctors to not worry about the patient in front of them and to just trust that for every patient they kill with a drowning event like my daughter's, then 8 other patients they will never meet will have survived "sepsis" because they mindlessly fluid overloaded everyone like this for maybe having sepsis (no lab proof of infection is needed)....so I looked in my daughter's medical records to see if they ever "diagnosed" suspicion of sepsis in my daughter prior to these drowning events that no hospital staff ever seemed prepared to save her from. Yep, the day she died - a nurse had done a "sepsis" screen and charted that her hypotension pointed to sepsis.....but that nurse had just overdosed her with morphine and hour before so that would be the actual cause of hypotension. They never bothered with dialysis or even a drain to try and save her...no attempt at all to save her from the hospital's sepsis protocol induced drowning event. Can you guys group together and speak out against that book for promoting to not worry about killing the patient in the bed in front of the attending doctor in favor of following a strict protocol of drowning patients with fluid overload as a "treatment" for the maybe "sepsis" (no lab proof required) with NO concern for the patient to die by drowning? The nightmares never go away because I think this behavior continues - i want to know this has stopped. My daughter developed very LOW ALBUMIN in the hospital (could also be IV fluids induced) so the drownings should have been totally predictable....and she was not terminally ill and trying to stop the morphine which she claimed was making her worse. She should not be dead and, despite what that book says, it DOES MATTER! That book trivializes her life, and death, and almost makes the death sound like success. I bought that book in 2018, maybe a more recent edition has already corrected that wording - I sure hope so.