HIV/ID report at ZSFG was fascinating yesterday. We discussed a patient with VZV meningoencephalitis, transverse myelitis, vasculitis, and optic neuritis.
High yield ophthalmology exam maneuvers: detecting the Afferent pupillary defect (APD). Important to distinguish this from Associate Program Director Beth Harleman =).
A neuroanatomy refresher – Pupillary anatomy is complex! Consensual pupillary constriction is governed by a 4 nerve system that extends from the pupillary muscle to the brain stem (the Edinger Westphal nucleus). The pupillary muscles have afferent input from the midbrain, optic nerve, and retina (afferent input brain-> eyeball) and supply efferent signals to the same structures (efferent input eyeball->brain). In those with an intact consensual pupillary response 1) if you shine a light in the left eye, the right pupil constricts and 2) the pupils decide together how much to constrict based on input from both sides.
- Efferent nerve injury causes anisocoria. This means when you shine a light in the affected eye, it will not constrict.
- Afferent nerve injury causes the pupils to constrict to the same size, but the size varies depending on which eye you shine the light in, an APD. An APD is best detected through the swinging flashlight test. Enjoy this super useful diagram from up to date. I had to read the caption out loud three times before this made sense. Feel free to do the same!
Tiny bonus pearls: What causes eosinophilia in the CSF? Not a whole lot.
- theoretically a malignancy could do this
Pearls part 2: Seminal papers in managing septic shock.
Today we discussed a woman with septic shock due to gram negative rod bacteremia. The future critical care docs in the room (I see you, Katie Auriemma and Vincent Auyeung) guided us through a great conversation about some seminal papers in severe sepsis and septic shock.
The Rivers Trial AKA Early goal directed therapy
- published in 2001
- RCT of early goal directed therapy (EGDT) versus standard of care. Mortality was the primary outcome.
- What were the goals?! CVP, MAP and ScVO2. Check out the table below for the algorithm (pulled directly from the paper. People in Rivers received a lot of central lines, a lot of pressers, and a lot of blood.
- There was a 15% absolute risk reduction in mortality
- Transformed the way we treat sepsis. Caused EDs and ICUs to implement early fluids and antibiotics, use QI methods to track and improve their sepsis outcomes etc.
- While many implemented early fluids and antibiotics, few implemented the same goals (especially around central lines and ScVO2 monitoring) as Rivers.
- published in 2014
- RCT of 31 emergency departments in the US randomizing patients with septic shock to EGDT versus “protocol-based standard of care.” This is the early without the rigid goals that I referenced above. That protocol is below (pulled from the supplementary appendix of ProCESS).
- There as no difference in outcomes with respect to mortality or organ failure.
What does it mean?!?!
- The physiologic goals set by EGDT are probably not necessary for high quality septic shock care
- QI interventions and thinking have lead to huge improvements in sepsis mortality.
- Ask your favorite critical care doctor for their take on the best goals, protocol and approach to managing septic shock.
What about the SOFA?!?!
- More that soon. Gotta keep you coming back somehow =)
.Rivers E1, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. N Engl J Med. 2001 Nov 8;345(19):1368-77. Early goal-directed therapy in the treatment of severe sepsis and septic shock
ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F, Terndrup T, Wang HE, Hou PC, LoVecchio F, Filbin MR, Shapiro NI, Angus DC. A randomized trial of protocol-based care in early septic shock. N Engl J Med. 2014 May 1;370(18):1683-93. doi: 10.1056/NEJMoa1401602. Epub 2014 Mar 18.