2. Anything else? Glucose – tight control must be better NICE-SUGAR study investigators. Intensive versus conventional glucose control in critically ill patients. N. Engl. J. Med. 360, 1283– 1297 (2009) Normoglycemia in Intensive Care Evaluation– Survival Using Glucose Algorithm Regulation Aiming for sugar of <11 vs 4.4-6.1 was associated with a 42% reduction in mortality

3. FEAST trial Maitland, K et al Fluid Expansion as Supportive Therapy (FEAST) N Engl J Med. 2011;364:2483-2495 Trial of fluid bolus in sepsis in 3000 children in 6 African hospitals Fluid boluses increased mortality by 3% Most excess deaths due to cardiogenic shock, not fluid overload or respiratory failure.

4. Feast trial problems Africa – sick and dehydrated, walked for miles Kids Lots of malaria vs other sepsis

5. Why would fluid be bad? Why would it cause cardiovascular collapse, not fluid overload? The glycocalyx! Beyond the scope of this talk

6. Which fluid? Stop it! Crystalloids are fine Hydroxyethyl starches are worse for kidneys, provide no benefit Albumin – who knows, who cares. It is probably SAFE

7. How much fluid The hardest question in sepsis. Maybe in medicine. CVP – Probably no good Map/HR/Urine output/lactate/SVCO2 – fluid vs vasopressors? USS of IVC – as good as CVP IVC collapsibility change with leg raise - maybe

9. Beta blockers? Morelli A, Ertmer C, Westphal M, et al. Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock: A Randomized Clinical Trial. JAMA. 2013;310(16):1683-1691. Small study – 154 patients HR>95, high dose norad Esmolol to keep HR 80-94 Mortality 49% vs 80% ???