Almost no intensivist or emergency physician in the ...



MATERIAL FOR PUBLICATION ONLY IN THE ONLINE SUPPLEMENT

Supplement Table 1. Survey questions and possible answers. Questions were presented differently depending on previous answers. Respondents could not see the question headings (in bold).

Table 1a. Questions regarding clinical management

|1. Identifying sepsis severity |White cell count |

|A 65 year old 80kg previously well male presents with presumed |Arterial blood gas |

|pneumonia: HR 100, BP 125/50 (MAP 75), resp rate 22, SpO2 95% on |Lactate (arterial or venous) |

|room air, temp 38.7 degrees. The patient is awake and alert. |Procalcitonin |

|Which tests would you order to help determine illness severity? |C-reactive protein |

|(mark all that apply) |Erythrocyte sedimentation rate |

| |Chest X-ray |

| |I would not do any of these tests |

| |Other (please specify) |

|2. Meaning of lactate |No |

|Remember the vital signs: HR 100, BP125/50 (MAP 75), resp rate |Perhaps - it would depend on the rest of the |

|22, SpO2 95% on room air, temp 38.7 degrees. Let's say the |history/examination/tests |

|lactate is 4 mmol/L. (if you would not have ordered lactate, |Yes |

|assume another physician had) Does the lactate result influence | |

|your management plan? (mark only one answer) | |

|3. Initial treatment of hypotension in sepsis |No specific treatment for blood pressure; adequate treatment of |

|Now consider a different patient, again a 65 year old 80kg |the infection is sufficient. |

|previously healthy male with presumed pneumonia. This patient is|Commence vasopressor; do not give fluid |

|hypotensive. HR 120 BP 80/35 (MAP 50), resp rate 22, SpO2 95% on |Less than / equal to 500ml fluid bolus (and then reassess) |

|room air, temp 38.7 degrees. The patient is awake and alert. How|500ml - 1L (7-12ml/kg) fluid bolus (and then reassess) |

|would you first treat the low blood pressure? (mark only one |1L-1.5L (12-20ml/kg) fluid bolus (and then reassess) |

|answer) |1.5-2.5L (20-30 ml/kg) fluid bolus (and then reassess) |

| |>2.5L (>30 ml/kg) fluid bolus (and then reassess) |

|4. Procedures |I would not order any more monitoring (repeating the above vital |

|In the same patient, let's assume a 1.5L (=20ml/kg) fluid bolus |signs regularly is sufficient) |

|was given, and no vasopressors have yet been used. (If you would|Urinary catheter |

|not have done this, assume another physician had, and you have |Continuous pulse oximeter |

|now taken over care.) Vital signs are unchanged from those on |Arterial catheter |

|admission (HR 120, BP 80/35 (MAP 50), resp rate 22, SpO2 95%) |Central venous catheter |

|What monitoring devices would you employ at this point? (mark all|Pulmonary artery catheter |

|that apply) |Central venous catheter AND pulmonary artery catheter |

| |Another monitor of cardiac output (eg. PICCO, echocardiogram) |

| |Other (please specify) |

|5. Fluid or inotrope after initial bolus? |Give more IV fluid first (you will say how much in the next |

|Remember the vital signs: HR 120, BP 80/35 (MAP 50), resp rate |question). A vasopressor can be considered after more fluid. |

|22, SpO2 95% What would you order next to treat the low blood |Start a vasopressor now (before any more fluid is given)(fluid |

|pressure? If your answer might depend on the data from a |can continue at the same time and/or after this, if necessary) |

|monitoring device, what would you order now, while waiting for |No further treatment of the BP is required; adequate treatment of|

|the device to be inserted? (mark only one answer) |infection is sufficient |

|6. Vasopressor selection |Dopamine |

|Remember the vital signs: HR 120, BP 80/35 (MAP50), resp rate |Norepinephrine / noradrenaline |

|22, SpO2 95%. If despite optimal fluid management you need to |Epinephrine / adrenaline |

|use a vasopressor in this patient, which would you choose? (mark|Phenylephrine |

|only one answer) |Metaraminol |

| |Vasopressin |

|OR (depending on previous answer) |Other (please specify) |

| | |

|Remember the vital signs: HR 120, BP 80/35 (MAP50), resp rate | |

|22, SpO2 95%. Which vasopressor would you choose? (mark only | |

|one answer) | |

|7. Fluid goal |I would not give any more IV fluid |

|You chose to give more IV fluid first. How would you decide how|Titrate fluid to a goal CVP 8-12mmHg |

|much more fluid to give? (mark the most important factor) |OR Titrate fluid to a goal CVP 8-12mmHg, and only then start a |

| |vasopressor if BP remains low |

|OR (depending on previous answer) |Titrate fluid to a different goal CVP |

| |OR Titrate fluid to a different goal CVP, and only then start a |

| |vasopressor if BP remains low |

|While using a vasopressor you may wish to give more fluid. How |Titrate fluid to a specific change in CVP (ie. CVP trend is more |

|would you decide how much more fluid to give? (mark the most |important than absolute value) |

|important factor) |OR Titrate fluid to a specific change in CVP (ie. CVP trend is |

| |more important than absolute value), and only then start a |

| |vasopressor if BP remains low |

| |Titrate fluid to a monitoring endpoint other than CVP (eg. |

| |cardiac output) |

| |OR Titrate fluid to a monitoring endpoint other than CVP (eg. |

| |cardiac output), and only then start a vasopressor if BP remains |

| |low |

| |Give a SPECIFIC VOLUME of extra fluid (you have a feel for how |

| |much is enough) |

| |OR Give a SPECIFIC VOLUME of extra fluid (you have a feel for how|

| |much is enough), and only then start a vasopressor if BP remains |

| |low |

| |Titrate fluid to physical examination / urine output |

| |OR Titrate fluid to physical examination / urine output, and only|

| |then start a vasopressor if BP remains low. |

| |Give more IV fluid (to any end point); HOWEVER I would NEVER |

| |start a vasopressor |

|8. Central or mixed venous oxygen |No |

|You chose to insert a central venous catheter. Would you measure|Yes, via a continuous oximeter central venous catheter |

|central venous oxygen? (mark only one answer) |Yes, via intermittent blood gas analysis from the central venous |

|OR |catheter |

|You chose to insert a pulmonary artery catheter. Would you |Yes, via a continuous oximeter pulmonary artery catheter |

|measure mixed venous oxygen? (mark only one answer) |Yes, via intermittent blood gas analysis from the pulmonary |

|OR |artery catheter |

|You chose to insert both a central venous catheter and a | |

|pulmonary artery catheter. Would you measure central or mixed | |

|venous oxygen? (mark only one answer) | |

|9. Transfusion threshold |Do nothing else. These numbers are acceptable. |

|Let's say the patient has been given an adequate volume of fluid,|Transfuse PRBCs until the Hb is > 10 g/dl |

|and now has a BP of 125/50 (MAP 75), HR 100 on a moderate rate |Increase the rate of the norepinephrine/noradrenaline; there is |

|(0.1mcg/kg/min) norepinephrine/noradrenaline infusion. The Hb is|no immediate need to assess cardiac output |

|8.5 g/dl. The ScVO2 is 50%. There is not yet a monitor of |Add/substitute an inotrope (eg. epinephrine/adrenaline, |

|cardiac output in place. (again, if you would have placed |dobutamine, dopexamine, dopamine); there is no immediate need to |

|different monitors or managed the patient differently, assume |assess cardiac output |

|you have taken over care from another physician). Which ONE of |Place a cardiac output monitor, and only add an inotrope/alter |

|the following would you do next? (mark only one answer) |vasopressor rate/transfuse based on the measured CO |

| |Perform a clinical examination of cardiac output (skin colour, |

| |urine output). Add an inotrope/alter vasopressor rate/transfuse |

| |if indicated. |

|10. Need for inotropes |No. Septic patients usually have a high cardiac output. Inotropes|

|Let's say the Hb is 10.5 g/dl, BP 125/50 (MAP 75) after fluid + |cause significant complications. |

|moderate rate (0.1mcg/kg/min) norepinephrine/noradrenaline, and |Only if indicated by a monitor of cardiac output. |

|the ScVO2 is 50%. Would you start an inotrope (eg. |Only if clinical examination (hypoperfusion, low urine output, |

|epinephrine/adrenaline, dobutamine, dopexamine, dopamine)? (mark|etc.) suggested this was necessary (there is no need for a |

|only one answer) |cardiac output monitor) |

| |Yes, because the ScVO2 is or=95/50(MAP>or=65), ScVO2>or=70%) |

| |I believe as good/better results are achieved using care tailored|

| |to the patient, rather than protocol based care. |

| |Other (please specify) |

Table 1b. Demographic questions. Adult or pediatric practice was identified at the start of the survey; all other questions were asked at the end.

|Adult or pediatric |Adult patients only |

|What type of patients do you care for? |Adult and paediatric patients |

| |Paediatric patients only |

|Country |Australia or New Zealand |

|What is your region of practice? (mark only one answer) |United Kingdom |

| |United States |

| |Other |

|Specialty |Intensive or Critical Care Medicine |

|What is your main specialty? (if you practice more than one |Emergency Medicine |

|specialty, what is the majority of your practice?) |Internal Medicine |

| |Surgery |

| |Anaesthesia |

| |Other (please specify) |

|Experience |25 years |

|Qualification A |Yes |

|Do you hold a postgraduate clinical specialist qualification |No |

|obtained on the completion of training in this specialty? i.e. | |

|Board certification (US), Fellowship of the specialty college | |

|(Australia, NZ, Canada), CCT or CCST(UK), Specialist diploma | |

|(Europe) | |

|Qualification B |Yes |

|(For UK and Ireland respondents only): Do you hold the Membership|No |

|or Fellowship of your relevant Royal College (FRCA, MRCP, MRCS, | |

|MFAEM, etc.)? | |

|Hospital type |Large metropolitan university hospital |

|What best describes the hospital where you work? |Smaller metropolitan non-university hospital (or District General|

| |Hospital for UK respondents) |

| |Rural hospital |

| |Other (please specify) |

Supplement Table 2. Demographic characteristics of respondents included in the primary analysis

| |Number of included responses |Hospital type: % academic (vs. |Years of experience: %≤10 years |

| | |smaller metropolitan |(vs. >10 years) |

| | |non-university or rural) | |

|ANZ total |408 |65.4 |38.2 |

| ANZ EM | 259 | 56.4 | 41.7 |

| ANZ ICU | 149 | 81.2 | 32.2 |

|US total |779 |53.5 |43.1 |

| US EM | 169 | 27.2 | 39.1 |

| US ICU | 610 | 60.8 | 44.3 |

|UK total |505 |43.6 |46.5 |

| UK EM | 118 | 53.4 | 58.5 |

| UK ICU | 286 | 41.3 | 36.0 |

| UK Acute Medicine | 101 | 38.6 | 62.4 |

|EM total |546 |46.7 |44.5 |

|ICU total |1045 |58.4 |40.3 |

|Acute Medicine total |101 |38.6 |62.4 |

|Overall total |1692 |53.4 |46.6 |

SUPPLEMENT FIGURE LEGENDS

Supplement Figure 1.

Which tests would you order to help determine illness severity?

* Significant effect (compared with US ICU) on selecting this response in logistic regression model, p ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download