Sepsis & Septic Shock- An Interview with Dr Lauren Black

In this episode, Sam Ashoo, MD interviews Lauren Black, MD about the August 2025 Emergency Medicine Practice article, Updates and Controversies in the Early Management of Sepsis and Septic Shock

00:00 Introduction and Welcome

01:09 Meet Dr. Lauren Page Black: Sepsis Expert

01:56 Sepsis Statistics and Impact

04:16 Understanding Sepsis Definitions

09:56 Screening Tools for Sepsis

13:57 Pre-Hospital Sepsis Recognition

19:33 Clinical Examination and Diagnostics

24:03 The Role of Lactate and Procalcitonin

27:40 Clinical Gestalt and Imaging in Diagnosis

29:21 CMS Bundle Requirements and Updates

34:02 Fluid Type Preferences in Sepsis

36:49 Antibiotic Timing and Selection

43:43 Vasopressors and Steroids in Sepsis Management

50:18 Special Populations and Future Directions

53:44 Conclusion and Resources

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Episode Transcript

lauren-p--black_1_08-12-2025_115919: I think this is one where everybody (00:00):
undefined

(00:01):
I work with knows how much Idislike this test in the ER.
I think it's now synonymous with me.

Sam (00:08):
Hi everyone, and welcome back to another episode of EMplify.
I'm your host, Sam Ashoo.
Before we jump into thismonth's episode, I wanna say
thank you for being a listener.
I want to encourage you to rate usin whatever app you're listening
in so that lots of other peoplecan also benefit from listening.
And I wanna remind you that EBmedicine.net is your one-stop shop
for all things emergency medicine,pediatric emergency medicine,

(00:32):
and evidence-based urgent care.
And if you happen to be going to thisyear's American College of Emergency
Physicians Scientific Assembly inSalt Lake City, I highly encourage
you to come by and say hello to us.
We will be at Booth 1 3, 7 7.
That's 1377 from September7th through September 10th.
Come by, say hello.

(00:53):
We'd love to see you face to face.
And now let's jump into thismonth's discussion on sepsis with
Dr. Lauren Page Black, whom I thinkyou will find to be just an amazing
resource for all things sepsis.

lauren-p--black_1_08-12-2025_115919: Hi, my name is Lauren Black. (01:09):
undefined
I'm an assistant professor ofemergency medicine at Northwestern
University Feinberg School ofMedicine where I am regular ER doctor.
I also teach residents and med students.
And I am also a sepsisresearcher funded by the NIH.

Sam (01:23):
Awesome.
And you are one of five authors forthe August 2025 emergency medicine
practice article on updates andcontroversies in the early management
of sepsis and septic shock.
So this is kind of a specialty niche foryou, something you're passionate about.

lauren-p--black_1_08-12-2025_115919: Yes, it was a big group. (01:40):
undefined
Big topic, big group.
And so thankful for all the co-authors.
Hope I represent them well.
It is myself and Dr. Faheem Guirgis,one of the other senior authors are
both NIH funded sepsis researchers.
So, it's pretty dear to my heart,so that's why I keep picking it.

Sam (01:55):
Good.
Good.
I'm always surprised by thesepsis statistics, honestly.
And when we talk about epidemiology,number of cases a year, mortality
rates those things always tendto jump off the page at me.
And so when I'm looking through thisarticle again, no surprise, but the
number of cases of sepsis in the nation.

(02:16):
You know, Here we're talking about850,000 cases in the US coming through
EDs that are related to sepsis.
And depending on how sick you are,severe sepsis to septic shock,
mortality can be as high as 40%.
That's really significant.

lauren-p--black_1_08-12-2025_115919: It is really significant. (02:31):
undefined
And, in addition to its human toll,with exactly like you said, at least
a 10% mortality for general sepsis,as you get to septic shock, four
out of every 10 patients will die.
It's also one of the most expensivereasons for hospitalization in the
United States and is unfortunatelythe ultimate common pathway for a lot
of people who die in the hospital.
Some estimates are, it's up to oneout of every three hospital deaths

(02:53):
ultimately are attributed to sepsis.

Sam (02:56):
And therefore the big effort from government agencies, hospital
associations, specialty organizations,to try and focus on things like tools
to help us detect sepsis early and earlygoal directed therapy, and all this effort
that we put into detecting it and treatingit as quickly and early as possible.
Right.

lauren-p--black_1_08-12-2025_115919: Yes, which has been met with a lot of (03:16):
undefined
challenges because sepsis is far moreof a syndrome than a discrete disease.
For many diseases, the patientsthemselves are different.
That's not unique to sepsis, butsepsis is far more of a syndrome,
and the fact that the infectiontypes are different, the patterns
of organ dysfunction are different.
And ultimately this leads to a lotof heterogeneity and a lot of really

(03:36):
different presentations, some subtleorgan dysfunction for some patients that
makes it really hard to screen for and,honestly, something a lot of the times
we can recognize it after the fact, butit is hard upfront sometimes to recognize
that the patient themselves is septic.
But certainly, especially forthe more severe patients with of
hypoperfusion or hypotension, timereally is important in recognizing

(03:58):
and treating sepsis in those patients.

Sam (04:01):
And then from the government standpoint and from the definition
standpoint, there's been a significantperiod of change, I'd say in the
last 10 or more years, where we kindof keep evolving the definitions.
Where are we now on that?

lauren-p--black_1_08-12-2025_115919: Yeah, that was one of my biggest goals in (04:16):
undefined
the paper we wrote that pairs with thispodcast is one of my goals was to really
reinforce and clarify the differencein consensus definitions and what the
most updated consensus definitionsare, as well as clarify where those are
similar and different than CMS sep-1,which is the government quality bundle
that hospitals are held accountable to.

(04:37):
So, first I'll take onconsensus definitions.
So, that has changed quite a bit.
Sepsis is a dysregulated host responseto an infection characterized by
organ dysfunction in the setting ofa suspected or confirmed infection.
So what the simple version of thatmeans is if somebody has an infection or
suspected infection and evidence of organdysfunction, they're considered septic.

(05:00):
So prior to sepsis three, sepsiswas really defined by SIRS criteria
with a second category called severesepsis and a third septic shock.
In sepsis three, sepsis infection plusorgan dysfunction is really considered
sepsis now . Severe sepsis went away.
Septic shock maintains mostlyits similar definition.
It's a vasopressor requirementto maintain a MAP above 65 with

(05:21):
evidence of hypoperfusion usuallyconsidered a n elevated lactate.
As the sepsis three definitions changepartially because as we all know, SIRS
is not very sensitive or specific.
Old people don't necessarily mounta thermoid or leukemoid response
the same way young people do.
SIRS is, in a lot of ways,representative of a appropriate
host response to an infection.
If you or I got the flu,we'd have SIRS criteria.

(05:42):
It doesn't necessarily mean we haveorgan dysfunction, and it certainly
doesn't mean we have a dysregulatedhost response to an infection.
By the same token, the elderly patientor the immunocompromised patient
may not mount a white count, maynot have a fever, but they may have
pretty significant renal dysfunctionintermittent hypotension, et cetera.
That patient is clearly septic.

(06:03):
Those of us with the flu need someibuprofen and, you know, to move on.
And so the definitions changedlargely because of that nuance.
I think what makes it difficult isthe CMS sep one bundle has some slight
differences with the consensus guidelines.
And I think that adds a lotof confusion to the topic.
Though the CMS sep one bundlestechnically still rely on a SIRS
based definition, there's reallyonly two bundles you fall into.

(06:26):
So it's the severe sepsis bundle,which again, very closely mimic
sepsis three sepsis definition, aswell as the septic shock bundle.
One of the differences there though,is CMS sep one defines septic shock
as hypotension, even if they're not onvasopressors or a lactate greater than
four, even if they're not on vasopressor.
So that's what triggers the septicshock CMS bundle of the fluid

(06:48):
requirement component of the bundle.
But since those definitions are slightlydifferent, I think that does add some
confusion, which is one of the reasonswe tried to clear that up, in table
two a little bit, highlighting thesepsis three definitions, the fact
that severe sepsis is no longer acontemporary term, and compare it with
the CMS sep one core measure definitionsto hopefully add some clarity there.

Sam (07:11):
Yeah, so, the CMS world is where hospital core measures come from
and how hospitals are ranked andhow their performance is measured.
And still very important to us inthe emergency department because if a
hospital's being measured by it, we willbe measured by it as well as willing
participants in that relationship.
But then we also have the specialtysociety definitions, kind of like

(07:34):
the clinical side of medicine.
And that's more, I wanna saythat's more research based.
But is it more really just consensusopinions that have changed over
the last 10 years, or is there goodevidence that's driving that change?

lauren-p--black_1_08-12-2025_115919: I think that is a loaded question. (07:46):
undefined
I think both.
I think a lot of it is consensus based.
And then I do think there's some reallygood evidence that drives some of it,
but a lot of it certainly is consensusbased especially where the evidence just
doesn't completely answer our questions.
And they're both controversial intheir own regards and actually they
both had a lot of commentary byour emergency medicine societies

(08:09):
because they are a bit challenging.
I do think they mostly overlap in thepatient cohorts they're describing
in both, but I do think it is alittle bit confusing that they use
slightly different terminology.
I think that does make it hard.
But yes, I do think we are obligatedto be aware of both what the consensus
guidelines and the society groupsay as well as the core measures.

Sam (08:30):
Yeah so then when we're doing our charting and we're talking about hospital
core measures, and we want to clarifywith our hospital administrator colleagues
what we're talking about, we're usuallyreferring to CMS sep one or sep one
criteria, which haven't changed in over adecade and are still based on very early

(08:51):
consensus opinions of what sepsis is.
And then when we're talking with,say, our critical care colleagues and
we're talking about early detectionof sepsis, more clinical things, we're
using the sepsis three definition.
This is now as of 2021.
Is that the right year?

lauren-p--black_1_08-12-2025_115919 (09:08):
2016.
There have been some updates since then.
Though I do think SIRS is just hard toyou know, separate ourselves from this.
I think the ease of its use early on, Ithink makes it hard for people let it go

Sam (09:22):
Yeah that's right.

lauren-p--black_1_08-12-2025_115919: So I think we still see a lot (09:23):
undefined
of reticence to sort of let thatone have had its time in the sun

Sam (09:28):
Yeah.

lauren-p--black_1_08-12-2025_115919 (09:29):
But again, I do think, CMS only holds you to
a severe sepsis and a septic shock bundle.
And severe sepsis is essentiallythe sepsis three consensus
definition of sepsis.
So I think the confusion is mostlysemantic rather than actually describing
terribly different groups of people.

Sam (09:43):
Yeah, and I think you guys did a great job explaining that in the article.
So if you're listening and you haveaccess to this article I highly recommend
you go just read that one littlesection on definitions and terminology.
It's very well laid out.
Now in there, there's a discussionabout screening tools as well.
So today, in 2025, do we yet haveany good screening tools for sepsis?

lauren-p--black_1_08-12-2025_115919: No, I think they all have (10:06):
undefined
strengths and weaknesses.
We still don't have aperfect screening tool.
I'm sure all of us have a hospitalBPA that goes off all the time.
And think that's a hard sellto tell clinicians these things
aren't working perfectly.
They're not working perfectly.
It's one of the areas I do think willhopefully be addressed by advanced

(10:27):
analytic methods and machine learningand some EHR based predictive algorithms.
Though some of those are runningand currently available, their
performances have been largely mixed

Sam (10:38):
Mm-hmm.

lauren-p--black_1_08-12-2025_115919: And so I don't think any one of (10:39):
undefined
those is functioning perfectly.
I'm optimistic that willchange in a few years.
What I will say went away asa screening tool and the most
recent updates were qSOFA.
So if you read this paper or werehearing about that a little bit
ago, that has largely been retireddue to its suboptimal performance.
But I do think all of the screeningtools have some degree of something

(11:03):
left to be desired with regardto sensitivity and specificity.

Sam (11:07):
And I see like a common problem with them is that some rely heavily on
data that we're not gathering in the ED.
And others that seem to parse thatout then become less sensitive or
less specific and just not as helpful.
And most of our EHR or AI relatedtools seem to just scrape for

(11:27):
SIRS criteria, which in and ofitself is not sufficient either.
So, there's no sweetspot yet that we have.

lauren-p--black_1_08-12-2025_115919: What I will say is I think (11:34):
undefined
clinicians are pretty good at it.
And I think part of the problem isnone of these have really outperformed
clinician gestalt, which we've seen forother diseases and syndromes as well.
And what I tell the residents whenI'm working with them is if you think
somebody has an infection, ask yourself,do they have new organ dysfunction?
And if they do, you should treat 'emas septic, and then if they've got new
organ dysfunction, ask yourself if youthink it's secondary to an infection.

(11:57):
And if they do, you should presumethey're septic or at least go on
a expedition for why they're not.
And clinicians seem tobe pretty good at that.
The tools have not performedbetter than our ability to do that.

Sam (12:09):
Yeah.
Yeah.
They're not making us better.
Not yet.

lauren-p--black_1_08-12-2025_115919: Not yet. (12:12):
undefined

Sam (12:13):
Okay.

lauren-p--black_1_08-12-2025_115919: In my opinion. (12:13):
undefined
Some people might have moreoptimistic outlooks, but it's
not one that I personally hold.

Sam (12:18):
Good.
All right.
Well that's table three, thecomparison of the screening
tools, if you've got the article.
And so that's things like SOFA andqSOFA and MEWS and a multitude of
others listed there along with theirsensitivities and specificities, none
of which are really all that great.
And so qSOFA, we kind of held up asmaybe something that really was going
to have a lot of good potential.

(12:39):
And it turns out that even that isnot all that sensitive for the ED.
Is that right?

lauren-p--black_1_08-12-2025_115919: Exactly. (12:44):
undefined
So I think where that came from is whenthey operationalize, and by they I mean
the surviving sepsis campaign, when theyoperationalize the new sepsis, sepsis
three definition, a dysfunctional hostresponse to an infection, characterized
by organ dysfunction in the settingof presumed infection, they clinically
operationalize that as a SOFA scoreof two or more that was new in the
setting of a presumed infection.

(13:06):
I think what's hard is the SOFAscore is hard to use in the ED.
We don't always obtain allof those components, and I'm
certainly not saying you should.
So I think the desire behind qSOFA wasto make something that was easier to
operationalize in the ED if you weren'tgetting PDF ratios on people and it
just didn't live up to that ability.

Sam (13:23):
It didn't do it.
It did not do it.
Okay.
Well, so if we're working in theemergency department today and
someone is insisting that we use oneof these particular scoring methods,
there's not really one that seemsto stand out to me to be the best.
So it's more like, use what you'rebeing asked to use, but know that
it's going to have limitations andmaybe understand those limitations.

(13:45):
Make it no better than your own judgment,maybe worse than your own judgment.

lauren-p--black_1_08-12-2025_115919: Hey, that's exactly what (13:49):
undefined
I would personally, yeah.
Great summary.

Sam (13:52):
Okay.
Alright, well then let's talk aboutthe clinical side of sepsis then.
So there are some people who listen tothe podcast who are on the pre-hospital
side of it, and that seems to be animportant part in the handoff when
they come to the emergency department.
Are there things that can help themrecognize sepsis in the pre-hospital
setting so that they can help alertus to it when they arrive in the ED?

lauren-p--black_1_08-12-2025_115919 (14:17):
Sure.
First of all, I admire our pre-hospitalcolleagues 'cause if sepsis is hard to
screen for in the ED with all of ourlabs and et cetera it's exponentially
in the pre-hospital setting.
I would say things that are reallyhelpful are histories if the patient
is not acting right, they have someevidence of organ dysfunction that
is obtained on history as well asvital signs in route being abnormal.

(14:39):
And I'm certainly not saying that justbecause SIRS isn't sensitive enough
doesn't mean we should be ignoringfevers or elevated heart rates.
Those are super important.
But, I would say parts of the historywhere mom and dad haven't been acting
quite right for a few days, theyhaven't been going to the bathroom as
often or something l ike that can bereally helpful aspects of the history.
But it's also just hard.

(14:59):
If it's hard in the ED with ourlabs and I think it's super hard in
the pre-hospital setting as well.
The other things that can also helpare whether or not they're taking meds
that may mask of those SIRS criteria.
So if there's that bag of meds sittingthere, it's sometimes helpful to
bring in, 'cause then you can findout if they're immunocompromised and
we didn't know, or they were on abeta blocker or something like that.
And those things can be really helpful

Sam (15:19):
Yeah, so that's a common theme for our pre-hospital personnel on this
podcast is helping us obtain an accuratehistory from anyone who's on scene
and then gathering medications justso we all have the same picture when
you get to the emergency department.
Those are excellent tips.
There was a mention of local screeningtools, but again, we don't even have
great screening tools in the ED.

(15:39):
Is there anything that's beenproven to work pre-hospital?

lauren-p--black_1_08-12-2025_115919: To my knowledge, no, because those (15:42):
undefined
would also have to rely only onvital sign based arrangements.
And I certainly think they can be helpfulin identifying the sickest of the sick.
I also think our prehospital colleagueshave great clinical gestalt themselves
and if somebody's hypotensive Ithink everybody knows they're sick.
So I, again, am a little skepticalof the ability of these things to

(16:03):
supplement Gestalt in some ways.
People are certainlytrying to look at those.
I think it would be helpful if they couldwork in the pre-hospital setting as well.
I think the linkage of the pre-hospitalvital sign data would be ideal if
that could happen in the emergencydepartment especially like were
they actually really hypotensive?
They got a later fluid and they wereresponsive and those type of history
things are important and it wouldbe ideal I think, if we could link

(16:26):
those things to our environment.
'cause I think that providesa lot of rich information.
Especially if it wasn't then their firsthypotensive ED vital sign is not really
their first hypotensive vital sign.
It was actually 30 minutesearlier when they got picked up.
And I think those thingsare super helpful.
But I certainly think if we'rehaving challenges in the ED of
running screening tools, it'sgonna also be pretty challenging

(16:48):
in the pre-hospital environment.
I think it's something where,honestly education about sepsis
and what populations really doneed fluids or prompt antibiotics.
I think that probably is helpfulas any screening tool could be.

Sam (17:01):
All right, so one more loaded question.
I have some EMS agencies that, especiallyin the rural settings where there's
long transport times, talk about earlyadministration of antibiotics en route
to the hospital before even ever gettingto an ED for suspected sepsis cases.
Is there good evidence behind that kindof approach, or do you think, I mean,

(17:23):
your opinion's fine, do you think there'senough in the way of information at
your disposal in that kind of settingto go ahead and start antibiotics
in that kind of pre-hospital arena?

lauren-p--black_1_08-12-2025_115919: I think perhaps in some populations. (17:34):
undefined
So this I also think gets to a waywhere some of the literature has
kind of been propagated in a waythat may not actually represent
what the literature actually says.
So the literature for time toantibiotics is fairly clear, although
I will say there's always a fewpapers that say something else.
But in general, broad strokes,time to antibiotics has really

(17:57):
reproducibly only shown to have amortality benefit in patients who are
hypotensive or with hypoperfusion.
By that I mean like an elevated lactate.
The original Kumar study, whichwas fabulous, showed this profound
time to antibiotic benefit, butit wasn't from triage, it was
from time of onset of hypotension.

(18:17):
We're never gonna be able to redo thatstudy again because it would be totally
unethical to hold you know, a largelysafe intervention for most people.
But in general, it is in patientswho are hypotensive or who
have evidence of hypoperfusion.
I'll also say in that Kumar study,the median time to antibiotics was
fairly long because this was in thetwo thousands, but we don't wait six,

(18:38):
12 hours anymore to give antibioticsto most septic people ideally.
So, I will say in the rural environmentI do, particularly if somebody is
hypotensive, definitely think therecould be a role for early antibiotics.
The evidence does not really support that.
Somebody who may just be like a littlemore confused from a urinary tract
infection or maybe a little dehydrated,the evidence is not largely supported.

(19:01):
The emergency, though still urgent natureof antibiotics in that subpopulation.
But I certainly think for somebodywho is hypotensive it would be
very reasonable in the ruralsetting to start some antibiotics.
The hard thing is you wannatarget those ideally to a
suspected source of infection.
So I, do think this stuffgets a little complicated.
Especially if they're thatsick, it's hard to know some

(19:23):
allergies, et cetera, et cetera.
But I do think in some rural criticalaccess areas, there probably is a
role for targeted early initiation.

Sam (19:32):
That makes sense.
Alright, so let's talk about then whenthey finally get to the ED and we're
trying to get a history besides fromour pre-hospital personnel who hopefully
have gathered as much information as theycan, is there anything new in this arena
that we should be asking or looking for?

lauren-p--black_1_08-12-2025_115919: I always just say, well, my mentor (19:48):
undefined
said, I'm gonna steal Dr. Guergis'line myself, treat these people
as a trauma, the sicker they are.
So the less they can tell you, themore we need to make sure we expose the
patient, make sure we roll them, makesure they don't have a sacral decub.
And I think not forgetting aspects ofthe history and physical, especially
when they could change management.
So we give pretty similarantibiotics to most of these people.

(20:11):
But, we wanna be thinking about thingslike endocarditis, prostate abscesses,
STIs, things that really might changemanagement or things that might lead to a
source control procedure and targeting ourhistory and physical exam to those things.

Sam (20:27):
Good.
And so that goes for physical, like youjust mentioned as well, obviously the
ideal scenario is you're not going tobe examining them in triage, in a chair
fully clothed but hopefully, hopefullyin a stretcher in a private area where
you can fully undress them and look forthat source control and see if you can
find that open wound or that sacral decubor whatever it is that they might have.

(20:48):
So that part remains the same.
If you can, you should kinda strip themnaked and actually get a look at their
skin and still go looking for the source.
And is that something that'scommonly missed, you think when
we're talking about sepsis?
I mean, barring the fact that we'redoing examinations and triage.

lauren-p--black_1_08-12-2025_115919: I think the environment in which (21:06):
undefined
we're all practicing emergencymedicine is hard these days.
And so I, I do think it can be missed,and I'm not saying we need to do that
for absolutely every pick 'cause alot of patients who are septic are
not that sick and can talk to us.
But I do think for the very sick patient,we should be doing everything we can
to roll and expose them, but we allknow how hard it is to roll a bunch
of patients when you have a bunch ofpatients coming in and sometimes it's

(21:27):
logistically challenging if it's onlyyou or one other person in the room.
Where I trained for residency wedid a lot of rectal temps and I
would say probably the best partabout that was it made us actually

Sam (21:39):
Roll the patient, right?

lauren-p--black_1_08-12-2025_115919: Roll every single patient. (21:40):
undefined
I'm not saying we should be doingit as much as we used to when I
trained, but I do think one ofthe helpful parts about that was
just you got eyes on your patient.

Sam (21:48):
Yeah, I will put in the plug for communication with nursing.
If you have an open line of communicationwith your nurses, you'll find out quickly
about infections from Foley catheterinsertions or rectal temps all the time.

lauren-p--black_1_08-12-2025_115919: Exactly. (21:59):
undefined
I also think ultrasound can bekind of a useful adjunct to the
physical exam here in many cases.

Sam (22:05):
Okay.
Tell me more about that.

lauren-p--black_1_08-12-2025_115919: I think. (22:07):
undefined
One, I think it can be superhelpful to assess cardiac function
and see how their heart looks.
I also think we can use it to look forevidence of cellulitis in places where
clinically it may be harder to see.
So I think there's a lot of evidence thatit can help kind of improve our gestalt.

Sam (22:23):
Good.
Good.
All my fellow ultrasound colleagueswill be very happy to hear that.
So more uses for the uh, the handyultrasound you carry around your neck
instead of the stethoscope, for sure.
Okay, so if we get past history ofphysical, and now we're looking at
diagnostics and we're gonna get somelabs, we're gonna have some sepsis
bundle we're gonna order in our EMR.

(22:43):
But of those numerous tests,what do we know is helpful?
Now, you've mentioned lactatelevel a few times as a surrogate
marker for organ dysfunction.
Right?

lauren-p--black_1_08-12-2025_115919: Yeah, I think most of this is part (22:54):
undefined
of our routine ordering stuff.
Just a CBC and a BMP, I would geton most of these patients really for
subtle signs of organ dysfunction.
So there's the floridly septicpatient that walks in that you can
tell on vital signs alone, they'rehypotensive, they look like garbage.
But then, there's a lot of patientswhere they have really more subtle
signs of organ dysfunction and they'reseptic, they have a creatinine of

(23:17):
three and it's usually 0.5 and theyhave other laboratory evidence of
kind of more subtle organ dysfunction.
And in those patients, it's fine tothen initiate your sepsis protocol
at the time that the sepsis declaresitself, which may be then at the
time some of their labs come back.
I do think a lactate is helpful if you'resuspecting sepsis, but I also don't think
you should beat yourself up if you waitto order it until the BMP comes back.

(23:39):
'Cause I think it's okay forour differential to change over
the course of their ED course.
I do think lactate still can be helpful.
I don't think it is the holy grail.
We thought it was a handful of years ago.
Nonetheless, it can be helpful.
CMS wants you to do it.
And I do think although there arepopulations in whom it functions
less well, it can be a reasonableevidence of hypoperfusion.

Sam (24:02):
Great.
And now tell me, you just mentioned this,but what kind of specific populations
does it tend to not be as helpful in.

lauren-p--black_1_08-12-2025_115919: So patients with liver dysfunction (24:10):
undefined
may not clear their lactate as well.
Patients who are on a bunch ofalbuterol may have or any beta agonism.
So certainly, if you end up on thethird pressor and you start 'em
on epi or something, you can'treally trend your lactate levels.
That said, the recent guidelines isless towards lactate clearance and

(24:30):
more towards lactate improvementin a more generalized setting.
Just because of the way the evidenceabout lactate normalization played
out over the past few years.

Sam (24:40):
So if I happen to be in the unfortunate scenario of resuscitating
a patient with cirrhosis, then a simpleimprovement in that lactic acid may
still be what I'm looking for as opposedto complete resolution and clearance.

lauren-p--black_1_08-12-2025_115919: Exactly. (24:54):
undefined
What I will say is also the CMS bundle,you know, requires for all patients
with sepsis, and I'm using the moderndefinition for that, so the entity
formerly known as severe sepsis,get a lactate and they require it be
repeated if it's greater than two.
And we can talk about thebundle again in a little bit.
The exception to that though is if thesecond one is higher, they need a third.

Sam (25:14):
Hmm.

lauren-p--black_1_08-12-2025_115919: And we can talk about the bundle more, (25:15):
undefined
but you know, if it goes from 4.1 tofour you're technically done though that
patient is probably still really sick

Sam (25:22):
Right.

lauren-p--black_1_08-12-2025_115919 (25:22):
But technically if it goes from two to 2.1,
you need a third to be compliant with, youknow, and I think we can put compliance
and sort of, what we think the patientneeds in hopefully overlapping buckets.
But it's just worth knowing that anylactate above two requires clearance.
If it's less than two, you can stopand you don't need another repeat.

Sam (25:41):
Okay.

lauren-p--black_1_08-12-2025_115919: But I do think it still (25:41):
undefined
provides valuable information.
I just don't think it's a surrogatefor all the information we need

Sam (25:47):
Perfect.
All right.
And then one of my inpatient colleagues'favorite tests, the procalcitonin.
We should get all the timeeverywhere for everything.

lauren-p--black_1_08-12-2025_115919: Exactly. (25:56):
undefined
I think this is one where everybodyI work with knows how much I
dislike this test in the ER.
I think it's now synonymous with me.
Um, But I think this is a perfect exampleof a great test in a different location.
I think procalcitonin can bereally helpful, particularly to our
upstage colleagues for antibioticdeescalation and a few other scenarios.

(26:18):
However.
As a surrogate decision makerfor antibiotic initiation, it
has never been shown to performwell in the emergency department.
The long answer is part ofthat's for a number of reasons.
They peak 12-48 hours afterthe onset of infection.
Granted, I don't know whenonset of infection was.

(26:39):
Nobody really does in the ER, butthe point is it may rise too late
for it to be helpful in the ER.
It also has really limited sensitivitiesin really important subgroups for us.
So like though, what's really goodfor lung infections, it's not really
great for atypical lung infections,and we know plenty of people
who have gotten sick from those.
It also doesn't perform as well forother infections, like skin soft

(27:02):
tissue and immunocompromised patients.
And several studies looked at this andlooked at, how could it augment gestalt?
And it has never once been shownto outperform physician gestalt,
especially when studied in theemergency department environment.
I will put a caveat here thatI'm talking about adults.
The pediatric world, thatdiscussion is, very different.
But in adult patients, if youthink they need antibiotics, like

(27:23):
you should order antibiotics.
And if you don't think they'reseptic, you can just document that.
If you think their vital signabnormalities are 'cause they have a GI
bleed or tamponade or something else, andI don't think you need a procalcitonin.
In fact, I think that's ainappropriate use of a procalcitonin.
In that scenario.
I mean, just like outside of afew specific situations, you don't
really need a VBG on coding patientsto tell you that their pH is bad.

(27:48):
Um, you know, I think this isone of the things where you just
have to anchor on your , clinicalgestalt and it's okay to do that,

Sam (27:55):
Good.

lauren-p--black_1_08-12-2025_115919: And the evidence suggests that's (27:55):
undefined
the best in this scenario.

Sam (27:58):
And then when it comes to imaging, this is all just guided by
your examination and your concern foroccult infection areas where you might
not be able to see it as best as youcan get from history and physical.

lauren-p--black_1_08-12-2025_115919: Yeah, nothing has really changed (28:11):
undefined
about this in the past few years.
There was, I think a briefperiod of time people were
talking about medical pan scans.
I certainly don't think the evidencesupports us doing that right now.
Who knows what I'll besaying in a handful of years.
What I will say is I do thinkjudicious use of imaging can really
help us find sources of infection.
The particular population I dothink we should have a pretty low
threshold for, in particular abdominalimaging, is the elderly patient.

(28:35):
And I think we all know that.
And I think if they have apretty unremarkable UA and it's
like, eh, that could be a UTI.
But they look like absolutely terrible.
Those are the patients where I thinkanchoring on the UA may be inappropriate.
And it's probably best to at leastconsider abdominal imaging, especially
because, sicker elderly patients,immunocompromised patients may

(28:57):
not localize infections as well.
I mean, I think we all probablyhave several cases of this
we've seen over the years.
So I'd say I would have a low threshold,especially with the general ease in
most ERs of obtaining CT imaging, ofconsidering abdominal imaging in elderly
and immunocompromised patients bellies.
Particularly 'cause often there's a sourcecontrol procedure there that can change
management, or I won't say often, butenough of the time that it's relevant.

Sam (29:19):
It's relevant.
Perfect.
Okay, then let's get intothat CMS bundle for a second.
'cause now we're into that kinda initialmanagement, that first few hours period.
Where are we in thatrequirement for the bundle?
Has that changed at allin the last few years?

lauren-p--black_1_08-12-2025_115919: It has changed a little (29:34):
undefined
bit in the past few years.
What I first wanna say about the bundleis, not everybody with the bundle
requires 30 ccs per kilo by CMS, whichI think sort of the way the bundles
are written, it can be confusing.
But essentially there's a severe sepsisbundle, which is what we now call sepsis.
So if you think somebody has organdysfunction in the setting of an

(29:54):
infection, you need to order bloodcultures prior to giving them antibiotics.
You need to order a lactateand you need to repeat it.
That's the six hour part of thebundle, if it's greater than two.
And you need to give antibioticsas reasonably early as possible.
It's really within the first three hours.
Though, they have this caveat,ideally within the first three
hours, what they hold you to isthree hours, and I think that's

(30:15):
reasonable for that patient population.
Then, if they're hypotensive or ifthey have a lactate greater than
four, that's what triggers the30 ccs per kilogram fluid bolus.
So if they have pneumonia and they havea new oxygen requirement and you know
that's technically sepsis, that's organdysfunction, hypoxia in the setting
of an infection, that patient doesn'tnecessarily need 30 ccs per kilo.

(30:38):
Then if they become hypotensive or lowerlactate comes back at four, that would
trigger the 30 cc per kilo fluid bolus.
In the past few years, CMS has pushedout some updates that give us some
ability to have some discretion there.
So resuscitation based on ideal bodyweight is acceptable for patients
whose BMIs are 31 or higher, sogreater than 30, and you just have
to document resuscitation per idealbody weight given BMI greater than 30.

(31:02):
They also permit documentationof a lesser volume of fluid when
accompanied by clinical reasoning.
So for example, if somebody you know hasan ICD because their EF is 10%, it is
reasonable and acceptable to documentthat, but it has to be pretty clear.
So you have to document the amountof fluid you're giving and why.

(31:23):
So 500 ccs of LR given instead of the 30ccs per kilogram bolus due to concerns
for congestive heart failure, EF less than10%, something along those lines or ESRD.
But in ESRD, fluid overload,congestive heart failure, they
give you some ability to document

Sam (31:42):
Good.

lauren-p--black_1_08-12-2025_115919: What I will say though is I also think (31:43):
undefined
this pendulum has swung again with fluidsin the past few years where I think
people are like terrified of fluidsnow and don't wanna give any at all.
And I think, you know, I think we'llhopefully see where we used to just
give a bajillion liters to everybody.
And I think we'll see the pendulum switchback a little bit, but that is what
from a CMS criteria, they hold you to.

(32:03):
Within the first six hours, theyask you to remeasure that lactate
if it was greater than two.
And if the patient still has alactate greater than four, or they're
still hypotensive within the firstsix hours they ask that you start
vasopressors and reassess their volumestatus with like a clinical note.
That's pretty much the extent of thebundle, it hasn't changed dramatically.

Sam (32:24):
So if you have someone whose say, initial lactate is high, let's say it's
five for the sake of this conversation,and then I repeat it, and now it's four
and a half, but they're not hypotensive.
In the CMS six hour bundle, itsays you should be thinking about
vasopressors at this point, but thisperson is not clinically hypotensive.

(32:44):
It's not somebody I wouldnormally start a pressor in.
Could I have to go write somethingin there saying this is why
I did not start vasopressors?

lauren-p--black_1_08-12-2025_115919: No uh, the vasopressor part does (32:51):
undefined
say just to maintain a MAP above 65.
So if they're maintaining thaton their own, that's acceptable.
I also always think we should dothe right thing for the patient
and, just fight it on the back end.
So if they don't need pressors,they don't need pressors.
And I think we should always have ourfirst responsibility be to the patient
when those disagree with guidelines.

(33:11):
But no it's just vasopressorsto maintain a map above 65.

Sam (33:15):
Okay.

lauren-p--black_1_08-12-2025_115919: It's not terribly different than (33:15):
undefined
what consensus guidelines are, it'sjust that the lactate above four
requires the fluid bolus and theycall that shock, even though we
don't call that shock clinically.
And I do think that's theteeniest bit confusing.
I'd love to see somemore clarity around that.

Sam (33:30):
Yeah.

lauren-p--black_1_08-12-2025_115919: But, you do not have to start (33:31):
undefined
vasopressors just for a lactate.

Sam (33:34):
Yeah.
And when you say they call that shock,you mean CMS in their definition?
Calls them?
Calls anybody with a lactategreater than four, that's persisting
to be in shock when that'sclinically not the case for us.

lauren-p--black_1_08-12-2025_115919: Exactly. (33:45):
undefined
And it's really just that theyuse it to trigger the septic shock
bundle, which is really the fluidsand then the, if they're persistently
hypotensive, vasopressor requirement.
But yes, that would trigger theirseptic shock bundle, and those
people would be captured by theseptic shock abstraction methods

Sam (34:00):
Gotcha.
Okay.
Let's talk about fluid type.
One conversation that people love to have.
So we're talking about some kind of fluid.
Most of us are using either normalsaline or some kind of lactated ringer.
Is there actually a preference for oneover the other or evidence that might
swing us in one way versus the other?

lauren-p--black_1_08-12-2025_115919: So this is still quite controversial. (34:22):
undefined
I will say, the last time we wrotethis, SALT-ED and SMART had come out
and those two studies were pragmatic,randomized, controlled trials where they
switched out the fluids every monthand looked at mortality and then MAKE
30 and did see a slight difference inMAKE 30, which was a composite outcome
in favor of balanced crystalloids.

(34:43):
However, and since I think the lastversion of this paper was published, they
then did a subgroup analysis of patientswith sepsis that I think was well done.
It was pre-planned, it was clearlypre-planned in their protocol, and
they found a mortality differencein favor of balanced crystalloids
rather than normal saline.
So that's pretty compelling to me,even though it wasn't a randomized
study in that group in particular,it's a well-planned secondary analysis

(35:06):
of a population that makes senseto look at this in, and there's a
mortality benefit in favor of LR.
So I think, in general I think LR doesoutperform normal saline based on the
best quality of the evidence we have.
I think it makes sense physiologically.
It's no longer has ahuge difference in cost.
So , in my personal practice I lean on LR.
I'm also married to a surgeon and there'snothing they hate more than normal saline.

(35:29):
So maybe maybe it's partially that,but for sepsis, I feel far more
strongly I think this is a casewhere we should be using balanced
crystalloids instead of normal saline.

Sam (35:38):
And that subgroup analysis you talked about in sepsis patients,
was that those with septicshock or just all comers sepsis.

lauren-p--black_1_08-12-2025_115919: It was their ICU cohort arm. (35:44):
undefined
So they were the sicker patients.
So whether or not they were intubated, in the ICU or in septic shock, it
was the sicker patients that theydid show that mortality benefit in.
But mortality benefits are hard tosee in sepsis, just because of the
number of patients you have to enroll.
And so I feel like it's a prettycompelling result, however,
it is in the sickest patients

Sam (36:05):
Okay.
All right.
So lactated ringers it is.
And then there is a part of the bundlethat requires a repeat assessment.
So what does that have to looklike for CMS to be satisfied?
And then what should itlook like for us clinically?

lauren-p--black_1_08-12-2025_115919 (36:19):
For CMS it is a documentation of intravascular
volume status and tissue perfusion.
I think for us clinically, I thinkit's just going to the bedside and
reassessing the patient, not thecomputer, and make sure they actually
look better or don't look worse.
Which I think, sometimes you go inand, maybe none of the fluids are going
in, maybe it's in their AC and they'vegot it kinked up and the fluids are

(36:39):
largely still in the bag or something.
So I always think it's wise to goback in a few times and check on these
patients that are a bit tenuous and havea high probability of decompensating.

Sam (36:49):
All right.
And then let's talk about antibiotics.
So, timing of antibiotic administration,you mentioned earlier, but there
is a requirement in the CMS bundle,at least some requirement for time.
And then clinically, do we have goodevidence that even for a subset of
populations, it might be best tojust give 'em as soon as we can?

lauren-p--black_1_08-12-2025_115919 (37:09):
Yeah.
So I think that's a great question.
CMS will hold you to three hours.
That's still what theguidelines hold you to.
I think that gives us a fairamount of time to get some
idea of a source of infection.
So I actually thinkthat's pretty reasonable.

Sam (37:21):
Can I clarify there for one second?
Is that three hours from when theyarrive, or three hours from when
you recognize them to have sepsis

lauren-p--black_1_08-12-2025_115919: Three hours from sepsis recognition (37:28):
undefined

Sam (37:30):
recognition?
Okay.

lauren-p--black_1_08-12-2025_115919 (37:31):
And there are some nuances here, just like
on the backend with what that's called.
So you know, sometimes if a BPAgoes off and you click like sepsis
suspected, I think that can startyour timer actually in some scenarios.
But it's the time of sepsisrecognition in general.
So you have three hours fromthat to order antibiotics.
I will say the time to antibioticsmortality difference is in the patients

(37:53):
with hypoperfusion or hypotension.
So in those patients, I would goahead and start them early on because
they have a clear mortality benefit.
And so if they're very sick, Iwould either start broad spectrum
antibiotics or target to whatyour best idea is clinically.
But those patients, I think we should bepushing whether that means, physicians
are doing lines themselves, et cetera, inorder to get them antibiotics early on.

(38:17):
But for the rest of the patients,you have some time to determine
the most appropriate antibiotic.
I will say there is some change asthe surviving sepsis campaign also
re-put out our one bundle, whichis confusing again because it's
nomenclature is fairly similar to theCMS bundle where I think the goal was

(38:40):
to administer antibiotics earlier onif the patient has evidence of shock.
And I do think that's important.
I think the nomenclature aroundthat is a little confusing.
I also think it perhaps misjudges thecomplexity of the emergency department
where one hour is pretty hard.
I think that may be easier todo in environments where people

(39:01):
already have lines, et cetera.
But if you think they're septicfrom the time they walk in, an
hour is still sometimes a littlehard to get all this stuff going.
But there is some more discussion fromconsensus guidelines, but again, not the
CMS metrics, that are pushing for an hour.
If sepsis is definite or probable, Iwould personally just keep doing what

(39:22):
we all think is best for the patient.
But I think that nomenclature is a bitconfusing because it so closely mimics CMS
step one, but CMS step one has not changedtheir guidelines off of three hours.

Sam (39:32):
Okay, and that's three hours regardless of whether they're in shock
or whether they're just have plain oldsepsis and they're stable as can be.

lauren-p--black_1_08-12-2025_115919: Exactly. (39:39):
undefined
I mean, it does say likewithin one hour if possible.
And I think some of that is because inthose sicker patients we should be pushing
for earlier initiation of antibiotics.
But even if you're pretty surethey're septic, if they don't have
shock or hypoperfusion, you reallydo have time . The evidence suggests
you have some time to figure outthe appropriate antibiotic choice.
And I think that's alsobeneficial to the patient.

(40:00):
'cause we all know the patientwho's gotten like four different
antibiotics what we initiallythought and then it changes.
And so I think there does have tobe some sort of judicious balance
between antibiotic stewardshipin the right patients and prompt
antibiotic administration.
And I think those things are intentionsometimes, and I think that's
where some of the controversy is.
And I think the benefit of earlyantibiotics clearly outweighs the risk

(40:23):
in the sicker patients who have lowblood pressures, who even if they're not
requiring vasopressors, but if they'reintermittently hypotensive or they
have evidence of severe hypoperfusion.
I do think we should promptly givethose people antibiotics, but I think we
should consider antibiotic stewardshipin some of the other populations.
And we can wait two hours forthe x-ray to actually come back.

Sam (40:42):
Perfect.
Okay.
And then when it comes topicking the correct antibiotic,
there's a great table.
It's a very large table, but table fivein the article talks about the infection
by type and then recommended antibiotics.
And if they're penicillin allergic,or anaphylactic, really , then
some alternate choices.
So it's all laid out there for you.

(41:02):
Everybody likes to giverocephin just off the bat.
It stops the clock and it's whatwe have in the Pyxis machine and
it's very easy to administer.
But there are times where you mightconsider giving something else.
And so having at least oneor two other medications in
your armamentarium is helpful.
And I think this table does a goodjob laying that out by source if

(41:22):
you happen to know the source or atleast suspect something specific.

lauren-p--black_1_08-12-2025_115919: Thank you. (41:26):
undefined
We hope it's helpful.
We spent a fair amount of time on it.
Let's say the only big changes therein the past few years are, HCAP has
kind of gone away in favor of stilllargely giving cap coverage to severe
community acquired pneumonia, unlessthey have prior MRS A respiratory
isolates or hospitalization and, youknow, some of the other risk factors.

(41:47):
I don't really know clinicallythat our clinical practice has
changed a whole lot because of that.
But it's worth knowing that there hasbeen some changes to those definitions
and those blanket recommendations.
I would also say the big thing thatI do think clinically has changed is
there is a whole lot more ESBL, likecommunity acquired extended spectrum
beta lactamase UTIs than there were,I feel like even five years ago.

(42:09):
And so if you think this suspectedsource is a uti, it's still so clunky
to look at old cultures, I thinkin most EMRs, but that is one place
where I really do think looking at oldcultures is particularly important.
Because if they had an ESBL infection,I would not give them a beta-lactam.
I wouldn't give them rocephin or cefepime.
I would try to target one of theantibiotics to which they had

(42:31):
shown to be sensitive in the past.

Sam (42:33):
Yeah, I will say I think that adds kind of two extra
steps to your decision making.
Like one, can you accessan old culture of any sort?
It seems like when I am consulting myinfectious disease colleagues, that's
always just, the most significantthing they're doing is going and just
looking at a prior culture data andthen basing their best guess on that.
And second, what it is you're allowedto give in the emergency department.

(42:56):
A lot of us have the broadest spectrumdrugs under lock and key by pharmacy.
And so sometimes it requires a littlecall to your ID colleague and say,
Hey, their last culture showed thisand I really want to give ertapenem
or whatever it is, or meropenemand I need your blessing to do it.
And it seems silly, but youknow, in the days of antibiotic
stewardship, it's just kind ofanother hoop you have to jump through.

(43:17):
So if you have that data, that's great.
And by all means use it.
'cause yes, the resistance , isgetting ridiculous and it's only
getting worse as time goes on.

lauren-p--black_1_08-12-2025_115919: The only other thing I wanted to (43:27):
undefined
say about the table to be clear isit's for patients who are septic.
I'm not saying that these should beour first line antibiotics for patients
who don't have organ dysfunction,and maybe they just have a few SIRS
criteria and they're going home.
But it is for patients whoare being admitted for sepsis.

Sam (43:41):
good great clarifying point.
Okay, let's talk about vasopressors.
So the.
article mentions norepinephrine,dopamine, vasopressin, epinephrine
what is your favorite starting agent?
Do you have one?
And tell me why.
Convince me why.

lauren-p--black_1_08-12-2025_115919: Norepinephrine should be everybody's (43:57):
undefined
first line vasopressor for septic shock.
I think the evidence is very strongthat it is superior certainly to
dopamine for septic shock and hasnot performed worse than vasopressin
in any of the other studies.
So I think norepinephrine really shouldbe our first line agent, and I think
that's about the easiest part of septicshock and there's certainly some nuances

(44:20):
in the research world, but as far asthe overwhelming conglomeration of
the evidence, the answer is levophed.
And then vasopressin should beyour second additional agent.

Sam (44:29):
Okay.
Then if you are debating whether or notyou could give this through a peripheral
line because you haven't placed acentral line yet and your nursing
colleagues have this tenuous line, isit okay to just go ahead and start it?

lauren-p--black_1_08-12-2025_115919: It is absolutely okay to give it (44:41):
undefined
peripherally and I think we should.
When we had to start a centralline for everybody I think that
also actually delayed some people'smore appropriate shock treatment.
But evidence is very clear that through alarge, fairly proximal peripheral IV, it
is very reasonable to give vasopressors.
And so I personally do routinelystart them peripherally.

(45:04):
My personal practices is, if they'reon pretty high doses I still put in the
central line, and this changes person toperson in place to place, but if they're
just requiring five of   levophed I thinkit's actually perfectly fine to just send
them upstairs with peripheral pressors.
And I think the evidence supports that.
And I think we are seeing thatslowly be more and more common.
And I think it's lovely that I thinkthat's taken one of the cognitive hoops

(45:24):
of the decision to start vasopressors.
I think it's perfectly fine tostart  levophed peripherally and
the evidence largely supports that.

Sam (45:31):
And if you've only got the 22 gauge in the top of the hand.

lauren-p--black_1_08-12-2025_115919: I would put something (45:35):
undefined

Sam (45:36):
Alright, just gonna push you outta that one.
That's okay.

lauren-p--black_1_08-12-2025_115919: It's not that magical. (45:39):
undefined
If you've got a reasonable 18 inthe AC or something, that's fine.
But yeah, if you've got a 22 inthe hand, you gotta get more.
In that case too, what I tell peopletoo is it's our nursing colleagues
and upstairs colleagues, if that'sall we've got they need more access
than that for a variety of reasons.
So, I still certainly thinkthere's a role for a central line.

(46:00):
I just don't think we need todo it as often as we used to.

Sam (46:03):
All right.
Let's talk about steroids.
So this pendulum has swungseveral times as well.
Where are we now days withsteroids, and what kinds of
steroids are we talking about?

lauren-p--black_1_08-12-2025_115919: So I think this is one of the biggest (46:14):
undefined
changes in the past few years.
I do feel like this has goneback and forth a whole lot.
Current consensus guidelines now dorecommend hydrocortisone either a 50
milligram bolus every six hours orcontinuous infusion at 200 milligrams
for patients in septic shock.
I will say as a caveat to that, inthe fine print, you know, it says

(46:35):
like if they're still requiringvasopressors after four hours
and there is some nuance to that.
So I'm not saying the second you startfive of  levophed, they need to be chased
with like 50 milligrams of hydrocortisone.
But I do think we all knowwhat boarding is like now.
You know, I do think if they'redownstairs for a few hours, then
they're still requiring  levophed, Iwould definitely give that to them.

(46:56):
The evidence for that was notbased on any mortality benefit.
What it was based on was, inthe meta-analysis, it showed
improved time to shock resolution.
Essentially in patients who receivedsteroids, and the consensus guidelines
felt that since it's a fairly low cost,low risk intervention, the benefits

(47:17):
of steroids outweighed the risk.
But it did not have a mortality benefit.
I will say, as a caveat to a secondpopulation, though, a pretty compelling
meta-analysis of steroids in patientswith severe community-acquired
pneumonia did show reduced mortalityand mechanical ventilation.
So in those patients, even if they'renot requiring pressors if you're
intubating somebody for pneumoniaand sending them to the ICU, or even

(47:40):
if you have them on high flow forpneumonia and they're not requiring
vasopressors, I would still give thatperson some hydrocortisone as well due
to the current best state and evidence.
But again this one haschanged quite a few times.
As sort of a cutting edge, I thinkwe'll see some more studies about
adding fludrocortisone so addingsome additional mineral corticoid
coverage in addition to hydrocortisone.
But that's very much in the researchworld right now and not standard of care.

(48:04):
But for patients with persistentshock requiring levophed in the ED
or patients intubated intubated highflow, et cetera, for pneumonia, I would
give those patients steroids as well.

Sam (48:15):
Now I'm curious, in your practice, are you doing that as just a protocol
event or are you only applying thatto say the ones who you know well,
they're gonna be down here for a while,there's no ICU beds, I'm just gonna do
this as the kind of the final thought?
Or is it just in your protocol like,we're gonna give this and if they happen
to be down here, they're getting it.
If they've already gone to the ICU,then they'll just get it there.

lauren-p--black_1_08-12-2025_115919: My personal protocol is, I give it, but (48:37):
undefined
I'm a sepsis researcher, and I'm mostlyfocused on shock, so I care a lot.
I think so much is lost in handoffsregardless of best intentions.
I think it can be hard totell what happened downstairs
and what was or wasn't done.
So I personally usually doit unless there's a reason I
don't think it's necessary.
Sometimes I start pressers a littlebit earlier than necessary if I think

(49:01):
they need it for a certain reason.
And in that patient who, I think theyjust need some, and this is like personal
practice, not necessarily evidence based,but if I'm starting some  levophed to
just get them through their fluid boluses,'cause they're persistently hypertensive
and I think they can get off of itonce they're more fluid resuscitated,
I don't give it to that patient.
But if I think the patient's gonna stay onpressers, I usually go ahead and give it.

(49:21):
But again, the guideline was pretty clearthat, they put some four hour line on it,
but this is all very consensus based andI think I agree with them the evidence,
does favor shock resolution and patientswho received hydrocortisone, I think
there's probably people who respond reallywell and people who aren't responders.
And that's why we sort ofsee this mixed response.

(49:41):
And I think that's probablysome of the challenge of the
heterogeneity of sepsis in general.

Sam (49:45):
Okay.
And then let's just lastlytouch on blood transfusions.
So, within the last decade we'vechanged to a pretty conservative,
like restrictive blood transfusionpolicies in most hospitals where,
if your hemoglobin is not less thanseven, I'm not even thinking about it.
Is that the same for my septic patients?
Or do I need to have ahigher threshold for that?

lauren-p--black_1_08-12-2025_115919 (50:04):
No.
So the old like caring capacitydays, those have also been retired.
If they don't have some obvioussign, like obvious blood loss
I wouldn't give them blood

Sam (50:14):
Perfect.
All right.

lauren-p--black_1_08-12-2025_115919: Unless their hemoglobin is less than (50:15):
undefined
seven, like the regular indications.

Sam (50:18):
Excellent.
And then there are some specialpopulations that were discussed
in the paper, like the elderly, wetouched on the one with cirrhosis
and end stage renal disease.
Other than the fact that those withcirrhosis may have that persistent lactic
acidosis and that they're risk becausethey're relatively immunocompromised.
What else do we need to knowabout our cirrhotic patients?

lauren-p--black_1_08-12-2025_115919: I think it's, still maintaining a (50:39):
undefined
high index of suspicion because Ithink sometimes some of their vital
signed arrangements in a lot of thosemore complicated populations can be
attributed to their disease state, butmay actually not be normal for them.

Sam (50:52):
Hmm.

lauren-p--black_1_08-12-2025_115919: And I think recognizing that some of our (50:53):
undefined
complicated patient populations may havemore subtle signs of organ dysfunction and
still having a high index of suspicion.

Sam (51:02):
Yes, I can recall several cirrhotic patients who like live at a systolic
blood pressure of 91 and then have likezero capacity for any kind of infection,
and then will syncopize immediately.
So I'm always worried aboutmy cirrhotic with syncope and
going, well, you live at 91.
I mean, there's really not awhole lot of pressure left.

lauren-p--black_1_08-12-2025_115919 (51:23):
And I think, remembering the unique infections
that can happen in those populations.
So I think, making sure you look for SBPin the right patients, considering in ESRD
patients who are on peritoneal dialysisconsidering, whether or not they have
SBP or, related to PD I think looking atlines for patients who have indwelling
lines for dialysis and just keeping a highindex of suspicion for unique sources that

(51:46):
impact some of these patient populations.

Sam (51:48):
Okay, so we're at the end of our time and we spent a lot of
time talking about CMS sep one.
Where in the future are there some areasmaybe for advancement or improvement
in SEP one as we look towards betterapplying it to populations in sepsis?

lauren-p--black_1_08-12-2025_115919: I would say I think we should at (52:06):
undefined
least have some acknowledgement thatCMS sep one has some challenges.
And I think as we see it slatedto become a pay for performance
measure, it's pretty complicated.
And I think there are somethings that are intention.
I think we're increasingly seeingthis, like one size fits all approach

(52:26):
to sepsis being questioned, I thinkrightly so in the research community.
I think honestly, some of theseclinical trials failed not because
the interventions, I'm not the onlyperson who thinks this, not because the
interventions themselves didn't work, butwe just don't know who to use them in.
There's probably some patients whorespond better to some of these
things and some patients who don't.
And when we study them as awhole, the effect washes out.
But there probably are people who may havesome benefits to some of these things.

(52:49):
Same with clovers and restrictiveversus liberal fluids.
There might be some patients who reallydo need a restrictive fluid approach.
We just don't know exactlywho those are right now.
So I think that CMS sep one stillretains this one size fits all
approach, I think is challengingin light of the current evidence.
I think the lack of nuance regardingfluids, though I think most
patients can handle some fluids.

(53:10):
But the lack of nuance to thatdefinition, the tension with antibiotic
administration, especially as we see somepushes from consensus guidelines to move
it earlier, I think doesn't represent theindividual nature of patients that well.
And I think emergency medicine providersare smart enough that we can, you
know, have some individualizationto our approach to the patient.
And I think there is some tension there.
And you've seen our EM societiesmake some statements, questioning

(53:34):
whether or not some of thesethings need to be updated.
And I think it's at least worthhaving some of that discussion about
what is the best thing for patientsin light of what we know in 2025.

Sam (53:44):
Thank you so much for coming on the podcast, sharing your wisdom
with us, and also for being an author.
This is a fantastic article, sothank you and your other co-authors
for taking the time to write it.
I think it does a tremendous jobsummarizing where we are in sepsis
today in 2025, and I really lookforward to hearing more from all of you.

(54:06):
And I hope you'll come back onthe podcast and share your wisdom
with us again in the future.

lauren-p--black_1_08-12-2025_115919: Thank you so much for your time. (54:10):
undefined
It was fun.

Sam (54:13):
And that's a wrap for this month's episode.
I hope you found iteducational and informative.
Don't forget to go to ebmedicine.netto read the article and claim your CME.
And of course, check out all threeof the journals and the multitude of
resources available to you, both foremergency medicine, pediatric emergency
medicine, and evidence based urgent care.
Until next time, everyone be safe.