Maneuvers to Assess Fluid Responsiveness in Septic Shock or Vasodilatory Shock

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Cardiovascular diseases, Central line, Emergency Procedures, Featured, Infections, Mechanical Ventilation, medical procedures
More Tags – Arterial Line, CVP, end-expiratory occlusion test, featured, passive leg raise, pulse pressure variability, sepsis, septic shock, shock, stroke volume variability, vasodilatory shock
Aggressive fluid administration is a hallmark of septic shock management and has been espoused by the Surviving Sepsis Campaign and is a part of the CMS SEP-1 sepsis bundle. The sepsis bundle includes administration of 30 ml/kg crystalloid bolus (LR…
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How to Prevent and Manage Malpositioned Central Lines

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Events, Featured, Infections, Medical General, medical procedures
More Tags – central line, central line complications, Central line insertion, central line malpositioning, featured, femoral lines, HPC updates, IJ lines, Simulation Based Training; Central Line Training, subclavian lines
Malpositioned central venous catheters occurs in about 7% of central line placements. A malpositioned central line is any central venous catheter where the tip is located anywhere other than the superior vena cava (SVC) for internal jugular lines or subclavian…
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Management of Pleural Infections

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Chest Tube, Featured, Infections, King Tube, medical procedures, Respiratory diseases, Thoracentesis
More Tags – chest tube, empyema, featured, HPC updates, parapneumonic effusion, pleural effusion, thoracentesis, tube thoracostomy
Complicated parapneumonic effusions frequently represent pleural space infections. Approximately 1 in 7 cases of pneumonia have an associated parapneumonic effusion (PPE) on chest x-ray. Most of these effusions are small and usually resolve spontaneously with prompt antibiotic administration. However, moderate-to-large…
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The subclavian vein may be the preferred location over IJ and Femoral Locations for Central Line Placement

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Chest Tube, Featured Procedure, Infections
More Tags – central line complications, central line placement, central lines, featured procedure, HPC updates
Where to place a central venous catheter is a decision driven mainly by individual preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause…
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Summary of AASLD Practice Guidelines on Cirrhotic Ascites – Paracentesis Indicated for all Hospitalized Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured Procedure, Infections, Medical General, medical procedures, Paracentesis
More Tags – Cirrhotic ascites, featured procedure, Guidlelines, HPC updates, paracentesis, SBP, spontaneous bacterial peritonitis
According to AASLD Practice Guidelines, all patients with cirrhotic ascites admitted to the hospital should have a diagnostic paracentesis to rule out spontaneous bacterial peritonitis (SBP). Treatment of SBP requires cefotaxime plus albumin 1.5 gm/kg on the first day and…
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Summary of EASL Guidelines on Ascites, SBP and HRS Management in Cirrhosis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Gastrointestinal diseases, Infections, medical procedures, Paracentesis
More Tags – ascites, featured, HPC updates, paracentesis, spontaneous bacterial peritonitis
This blog summarizes the recent European Association for the Study of the Liver (EASL) guidelines on the management of ascites, spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS) in patients with cirrhosis. Cirrhotic ascites occurs as a consequence of portal…
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Blood Cultures are Not Recommended for Most Non-Severe Cases of UTI, Cellulitis, or Pneumonia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Dermatology, Emergency Procedures, Infections, medical procedures, Nephrology, Respiratory diseases
More Tags – bacteremia, cellulitis, community-acquired pneumonia, HPC updates, pneumonia, UTI
In many hospitals, blood cultures have become a reflexive habit for patients presenting to the ER with any suspected infection.  This was, in part, due to the inappropriate addition of routine blood cultures as a core measure in 2001 by…
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Septic Cancer Patients May Have A Decreased Mortality Using a Liberal Versus a Restrictive Transfusion Threshold

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Infections, Oncology
More Tags – cancer, HPC updates, sepsis, transfusion
There is now very convincing evidence to support a restrictive transfusion threshold — hemoglobin, <7 g/dL — for most critically ill patients that is supported by guidelines from the American Association of Blood Banks and the TRICC and FOCUS trials. …
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The subclavian vein may be the preferred location over IJ and Femoral Locations for Central Line Placement

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Infections, medical procedures
More Tags – central line complications, central line placement, central lines, HPC updates
Where to place a central venous catheter is a decision driven mainly by individual preference. The limited evidence available has not established any site as superior; the subclavian position has been reported as being less infection-prone, but more likely to cause…
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Antipyretics Do Not Change Mortality in Septic Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Hospital Procedures, Infections, medical procedures
More Tags – HPC updates, nosocomial infections, sepsis
Fever is universally treated in the setting of infection in virtually all hospitals, but does treatment of fever improve outcomes in patients with sepsis? This meta-analysis of eight randomized trials (1507 patients) and six observational studies (2058 patients) that compared…
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Antimicrobial Stewardship Recommends Shorter Duration of Antibiotics for Community-Acquired Pneumonia and Healthcare-Associated Pneumonia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Infections, medical procedures, Respiratory diseases
More Tags – antibiotic stewardship, antimicrobial stewardship, CAP, community-acquired pneumonia, HCAP, healthcare-associate pneumonia, HPC updates, pneumonia
The Infectious Diseases Society of America (IDSA) guidelines remain the gold standard guidelines for infectious disease problems.  The IDSA recommends treating patients with community-acquired pneumonia (CAP) for 5 days and it recommends treating those with healthcare-associated pneumonia (HCAP) for 7-8…
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Continuous Infusion of Beta-Lactam Antibiotics is Superior to Intermittent Dosing for Sepsis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Hospital Procedures, Infections, medical procedures
More Tags – antibiotics, beta-lactam antibiotics, HPC updates, sepsis, septic shock
The bactericidal activity of antibiotics depends on the class of antibiotic used. Some antibiotics like vancomycin, aminoglycosides and fluoroquinolones are dose-dependent for their bactericidal activity. Other antibiotics like beta-lactam antibiotics are time-dependent antibiotics.  Time-dependent antibiotics have increased bactericidal activity the…
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Misdiagnosed Cellulitis Increases Unnecessary Hospital Admissions and Antibiotic Use

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Dermatology, Emergency Procedures, Gastrointestinal diseases, Hematology, Infections, medical procedures
More Tags – cellulitis, contact dermatitis, gout or pseudogout, HPC updates, skin infection, venous stasis dermatitis, venous thrombosis
There are multiple noninfectious medical disorders that mimic cellulits.  In this retrospective study, researchers focused on misdiagnosis of cellulitis in 259 patients hospitalized with presumed diagnoses of lower extremity cellulitis at a Boston teaching hospital. Patients with complicating factors (e.g.,…
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Summary of Sepsis and Septic Shock Treatment in 2017

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Cardiovascular diseases, Central line, Hematology, Infections, Mechanical Ventilation, medical procedures, Respiratory diseases
More Tags – ARDS, Arterial lines, central lines, hemodynamic monitoring, HPC updates, mechanical ventilation, sepsis, septic shock, vasopressors
Definitions Presumed source with SIRS criteria = infection Infection with life-threatening organ dysfunction = sepsis Sepsis refractory to intravenous fluid challenge = septic shock Treatment of sepsis or septic shock Draw blood cultures x 2 Analyze any fluid that may…
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