LETTERS
Sepsis and trauma resuscitation have significant differences To the Editor: e read with interest the article by Frankel et al.,1 entitled, ‘‘Why is sepsis resuscitation not more like trauma resuscitation? Should it be?’’ We applaud the authors’ efforts to highlight the importance of source control for patients with surgical sources of sepsis and agree that surgical source control, when indicated, should be part of the early bundles of care for the management of sepsis. We would also agree with the message that overzealous fluid resuscitation can be detrimental. We are concerned, however, about downplaying the importance of rapid, preoperative hemodynamic stabilization of the septic patient. Although restoration of tissue perfusion is the ultimate goal in both types of shock, the means to this end must take into account the differences in pathophysiology. First, we agree with the authors that resuscitation of the bleeding patient must focus on rapid control of hemorrhage with immediate operative intervention because it is impossible to stabilize a bleeding patient until hemostasis has been achieved. In contrast, we would argue that rushing a septic patient to the operating room for source control before resuscitation could be detrimental. Expeditious administration of fluids and initiation of vasopressors in patients with septic shock can facilitate safer induction of anesthesia and may better enable the patient to tolerate physiologic changes associated with surgical interventions, for example, hemodynamic deterioration from bacteremia during manipulation of the septic source. As acute care surgeons and anesthesiologists are well aware, initiating interventions on grossly underresuscitated septic patients can be fraught with disastrous consequences. Exactly how much needs to be accomplished ‘‘in series’’ (preoperatively) versus ‘‘in parallel’’ (intraoperatively) needs further study, as current resuscitation end points are often inadequate and result in overresuscitation or underresuscitation. We agree with Frankel et al. that one should not ‘‘dawdle with goaldirected fluid resuscitation,’’ but that does not mean that resuscitation should be abandoned until source control has been achieved. Resuscitation must begin as soon as possible, then continue in parallel with source control in the operating room.
W
TO THE
EDITOR
Second, we are concerned about the suggestion by Frankel et al. that goal-directed therapy is not important.1 When Rivers et al.2 published their landmark article on early goaldirected therapy, standard care for patients with severe sepsis or septic shock in the emergency department was slow and unfocused. The only true ‘‘goal’’ was to transfer the patient out of the emergency department. Rivers et al. demonstrated that rapid resuscitation with fluids and vasopressors, with the goal of normalization of oxygen delivery to tissues, was beneficial. This approach quickly became the standard of care. The negative results of the three recent early goal-directed therapy trials should not instill a sense of nihilism regarding early resuscitation in septic patients, as some have suggested.3 Like all patients with shock, these patients experience critically inadequate oxygen delivery caused by complex pathophysiology that cannot be ignored. The recent trials essentially compared various protocols for rapid resuscitation. The control groups were more similar to the treatment group in the study by Rivers et al. than the control group.2 Current research and practice suggest a patient-centric resuscitation approach using macrocirculatory goals, resuscitation of the microcirculation, and optimization of individual organ system function. The degree to which these goals should be accomplished before anesthetic induction requires more study. Frankel et al. present a critical argument regarding the importance of early surgical consultation and source control when a surgical source of sepsis has been considered, but rapid hemodynamic resuscitation with fluids and vasopressors should proceed before and concurrent with intervention, with the goal of normalizing oxygen delivery to tissues as rapidly as possible. Although this goal may be the same for trauma and sepsis, directly using the trauma resuscitation paradigm for the septic surgical patient may not be the most efficacious approach.
Samuel A. Tisherman, MD Department of Surgery, Program in Trauma University of Maryland Baltimore, MD
Megan G. Anders, MD Department of Anesthesiology University of Maryland Baltimore, MD *The authors declare no conflicts of interest.
REFERENCES 1. Frankel HL, Magee GA, Ivatury RR. Why is sepsis resuscitation not more like trauma
resuscitation? Should it be? J Trauma Acute Care Surg. 2015;79(4):669Y677. 2. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368Y1377. 3. Angus DC, Barnato AE, Bell D, et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS, and ProMISEe Investigators. Intensive Care Med. 2015;41:1549Y1560.
Re: Sepsis and trauma resuscitation have significant differences In Reply: n behalf of my coauthors of ‘‘Why is sepsis resuscitation not more like trauma resuscitation? Should it be?’’1 I thank Drs. Tisherman and Anders for their interest in our work and insightful comments. I would also like to commend Dr. Tisherman, in particular, for his leadership in the field of surgical critical care that is imperative if acute care surgeons wish to improve outcomes in sepsis caused by a surgical source. Foremost, my coauthors and I recognize the great strides that have been made globally in the care of the septic patient, which have resulted in dramatic improvements in survival. Still, the negative results of three well-executed prospective, randomized trials at high-volume centers on early goal-directed therapy,2 a central tenet of regulated sepsis care, should have surgical intensivists, especially, questioning how and when we properly resuscitate surgical patients with sepsis. In this season of great (and not so great) political discourse, my coauthors and I intentionally wrote this piece in a provocative manner to encourage acute care surgeons to step back to the table to engage in this dialogue. In real life, not hypothetical situations, I suspect that Drs. Tisherman and Anders, my coauthors, and I approach these patients very similarly. I agree that ‘‘expeditious administration of fluids and initiation of vasopressors to afford safer induction of anesthesia’’ is critical in the appropriate care of this cohort. I also agree that accomplishing resuscitation ‘‘in series’’ or ‘‘in parallel’’ is at the crux of the debate. I would argue, however, that the current interpretation of the ‘‘Surviving Sepsis’’ resuscitation paradigm with regulatory underpinnings has aggressively supported the ‘‘in series’’ model of resuscitation (and omitted the rapid diagnostic component) and that this potentially can be injurious to our patients.
O
J Trauma Acute Care Surg Volume 80, Number 4
677
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Sepsis and trauma resuscitation have significant differences To the Editor: e read with interest the article by Frankel et al.,1 entitled, ‘‘Why is sepsis resuscitation not more like trauma resuscitation? Should it be?’’ We applaud the authors’ efforts to highlight the importance of source control for patients with surgical sources of sepsis and agree that surgical source control, when indicated, should be part of the early bundles of care for the management of sepsis. We would also agree with the message that overzealous fluid resuscitation can be detrimental. We are concerned, however, about downplaying the importance of rapid, preoperative hemodynamic stabilization of the septic patient. Although restoration of tissue perfusion is the ultimate goal in both types of shock, the means to this end must take into account the differences in pathophysiology. First, we agree with the authors that resuscitation of the bleeding patient must focus on rapid control of hemorrhage with immediate operative intervention because it is impossible to stabilize a bleeding patient until hemostasis has been achieved. In contrast, we would argue that rushing a septic patient to the operating room for source control before resuscitation could be detrimental. Expeditious administration of fluids and initiation of vasopressors in patients with septic shock can facilitate safer induction of anesthesia and may better enable the patient to tolerate physiologic changes associated with surgical interventions, for example, hemodynamic deterioration from bacteremia during manipulation of the septic source. As acute care surgeons and anesthesiologists are well aware, initiating interventions on grossly underresuscitated septic patients can be fraught with disastrous consequences. Exactly how much needs to be accomplished ‘‘in series’’ (preoperatively) versus ‘‘in parallel’’ (intraoperatively) needs further study, as current resuscitation end points are often inadequate and result in overresuscitation or underresuscitation. We agree with Frankel et al. that one should not ‘‘dawdle with goaldirected fluid resuscitation,’’ but that does not mean that resuscitation should be abandoned until source control has been achieved. Resuscitation must begin as soon as possible, then continue in parallel with source control in the operating room.
W
TO THE
EDITOR
Second, we are concerned about the suggestion by Frankel et al. that goal-directed therapy is not important.1 When Rivers et al.2 published their landmark article on early goaldirected therapy, standard care for patients with severe sepsis or septic shock in the emergency department was slow and unfocused. The only true ‘‘goal’’ was to transfer the patient out of the emergency department. Rivers et al. demonstrated that rapid resuscitation with fluids and vasopressors, with the goal of normalization of oxygen delivery to tissues, was beneficial. This approach quickly became the standard of care. The negative results of the three recent early goal-directed therapy trials should not instill a sense of nihilism regarding early resuscitation in septic patients, as some have suggested.3 Like all patients with shock, these patients experience critically inadequate oxygen delivery caused by complex pathophysiology that cannot be ignored. The recent trials essentially compared various protocols for rapid resuscitation. The control groups were more similar to the treatment group in the study by Rivers et al. than the control group.2 Current research and practice suggest a patient-centric resuscitation approach using macrocirculatory goals, resuscitation of the microcirculation, and optimization of individual organ system function. The degree to which these goals should be accomplished before anesthetic induction requires more study. Frankel et al. present a critical argument regarding the importance of early surgical consultation and source control when a surgical source of sepsis has been considered, but rapid hemodynamic resuscitation with fluids and vasopressors should proceed before and concurrent with intervention, with the goal of normalizing oxygen delivery to tissues as rapidly as possible. Although this goal may be the same for trauma and sepsis, directly using the trauma resuscitation paradigm for the septic surgical patient may not be the most efficacious approach.
Samuel A. Tisherman, MD Department of Surgery, Program in Trauma University of Maryland Baltimore, MD
Megan G. Anders, MD Department of Anesthesiology University of Maryland Baltimore, MD *The authors declare no conflicts of interest.
REFERENCES 1. Frankel HL, Magee GA, Ivatury RR. Why is sepsis resuscitation not more like trauma
resuscitation? Should it be? J Trauma Acute Care Surg. 2015;79(4):669Y677. 2. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368Y1377. 3. Angus DC, Barnato AE, Bell D, et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS, and ProMISEe Investigators. Intensive Care Med. 2015;41:1549Y1560.
Re: Sepsis and trauma resuscitation have significant differences In Reply: n behalf of my coauthors of ‘‘Why is sepsis resuscitation not more like trauma resuscitation? Should it be?’’1 I thank Drs. Tisherman and Anders for their interest in our work and insightful comments. I would also like to commend Dr. Tisherman, in particular, for his leadership in the field of surgical critical care that is imperative if acute care surgeons wish to improve outcomes in sepsis caused by a surgical source. Foremost, my coauthors and I recognize the great strides that have been made globally in the care of the septic patient, which have resulted in dramatic improvements in survival. Still, the negative results of three well-executed prospective, randomized trials at high-volume centers on early goal-directed therapy,2 a central tenet of regulated sepsis care, should have surgical intensivists, especially, questioning how and when we properly resuscitate surgical patients with sepsis. In this season of great (and not so great) political discourse, my coauthors and I intentionally wrote this piece in a provocative manner to encourage acute care surgeons to step back to the table to engage in this dialogue. In real life, not hypothetical situations, I suspect that Drs. Tisherman and Anders, my coauthors, and I approach these patients very similarly. I agree that ‘‘expeditious administration of fluids and initiation of vasopressors to afford safer induction of anesthesia’’ is critical in the appropriate care of this cohort. I also agree that accomplishing resuscitation ‘‘in series’’ or ‘‘in parallel’’ is at the crux of the debate. I would argue, however, that the current interpretation of the ‘‘Surviving Sepsis’’ resuscitation paradigm with regulatory underpinnings has aggressively supported the ‘‘in series’’ model of resuscitation (and omitted the rapid diagnostic component) and that this potentially can be injurious to our patients.
O
J Trauma Acute Care Surg Volume 80, Number 4
677
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
