Category: Lightning rounds

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Hallie Prescott, pulm/crit physician and co-chair of the recent Surviving Sepsis guideline writing committee, gives some insight into the new document, including a few interesting additions and some points of controversy.

For more thoughts, especially from an EM perspective, Scott Weingart also interviewed Hallie over at EMcrit.

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Takeaway pearls

1. The new guidelines suggest/recommend:
   • Prehospital sepsis screening, and in systems with >60 minutes to hospital evaluation and the appropriate systems in place, prehospital antibiotic administration. (This is a fairly narrow recommendation that won’t apply to many in the US, mostly rural systems with long transport times.)
   • Don’t give anaerobic antibiotic coverage if not suspicious of anaerobic infection
   • Target a MAP >65 in most, but in patients >65 years old, target only >60.
   • Don’t use qSOFA exclusively for screening; use other more sensitive tools like NEWS.
   • Consider SDD (selective decontamination of the digestive tract), the use of targeted local and systemic antibiotics in intubated patients to reduce the bacterial load in the upper GI tract and reduce the risk of VAP. This has a long presence in the literature and is more practiced in Europe than the US, but the data is fairly good.
   • Suggest measuring serum lactate, and perhaps trending it, but not necessarily trying to normalize it.
   • Prolonged infusions of beta-lactam antibiotics are supported (for subsequent doses; the first dose should still be a bolus) due to reasonably positive data.
   • If final cultures are negative, consider deescalating/stopping antimicrobials. (Obviously, this means most patients have already received a few days of therapy by then.)
2. Other old standards like 30 cc/kg fluid boluses and early antibiotic administration remain. Some are upset about this, as they have been translated into US quality measures (the SEP-1 CMS standard) that invoke monetary penalties when not adhered to—a standard that has caused much headache for EM particularly. But Hallie says: this is a global standard with >25 nations involved, and is oriented around medical realities. Translating it into national quality standards, rightly/wrongly, appropriately or bluntly, is not the business of the guideline group, and is purely an American issue.

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Scott Weingart, ED intensivist and seminal educator from the EMCrit podcast, shares his thoughts on how we should be finding truth nowadays: how to read journals, choose experts, use AI, and resolve disagreement.

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Takeaway pearls

1. Scott subscribes to around 60 journals and reads them monthly, meaning skimming the topic index, then for any titles that jump out at him he reads the abstracts, then the actual article for any that still look relevant. He doesn’t recommend doing that. Reading around 10 journals would get you most of the high-yield updates, and you could probably get away with 3–4. It’ll take you about an hour a month.
2. Read at least the methods and results. The discussion, abstract, and conclusion are mostly a mini-review paper. Ask: is this “generalizable,” meaning applicable to me—my patients, my practice, my questions? Could we implement this here? Ask also how your personal clinical expertise bears upon this (sometimes it’s greater than that of the authors). Finally, ask if the rigor of the paper supports the findings, though you may need to turn to methodological experts here given the complexity of modern studies. (Statistical and methodological experts are available out there, whether in your department or on the internet.)
3. Signals of confidence, charisma, or “reasonableness” are no longer useful (if they ever were) markers of good knowledge in experts, authorities, pundits, authors, podcasters, etc. In fact, truth-tellers are often less compelling communicators, as they tend to hedge and equivocate; that’s what the truth looks like, not clear messages, the latter of which are often fabricated.
4. One tool for managing this: seek disconfirmation. When pursuing opinions and expert perspectives, don’t look for those that agree with your prior beliefs, look for those that disagree; that is far more likely to be meaningful and useful data if you’re truly curious about what you’ll find. Even if your mind isn’t changed afterwards, your beliefs will become clearer and deeper. Especially in the current era of algorithms, subcultures, echo chambers, and AI tools that tend to agree with you, you need to actively seek these differing views. You should be able to make the counter-argument to your beliefs better than anyone who truly believes it—that’s when you really understand your own views.
5. When you find a differing view, rather than engaging knee-jerk opposition, ask why? What is different in their population, approach, environment, etc that leads to a differing view from this reasonable person? If your first reaction is “WTF are you talking about?” try to transition into “Hmm… wtf are you talking about?”
6. Clinical experience always needs to be thoughtfully integrated into the literature. The subtle lessons of experience are not always studied, and a large study of pooled patients may not address this specific patient’s situation. However, we also tend to overweigh the value of personal lessons, especially when it comes attached to emotional experiences.
7. A psychological pitfall for educators, and especially modern content creators (podcasters, bloggers, talking heads, YouTubers, etc) is the pull of speaking to create controversy rather than truth. We have lost great scientists and clinicians from the realm of real medicine towards hucksterism by this temptation.
8. AI today is reasonably good at acting as a medical librarian, i.e. “tell me (with references) the major studies addressing this point.” For this purpose, it is probably better than limited attempts at scouring the literature with PubMed, although all it’s doing is scouring the Internet for commentaries that have referred to the literature, and may therefore miss smaller/less known studies. It is less good at answering specific clinical questions, although it can be a useful idea generator, such as suggesting possibilities for your differential you hadn’t considered… since it remembers all facts, and is good at pattern recognition.
9. Fight the natural tendency of AI agents to be agreeable by prompting them towards disconfirmation, i.e. “tell me where I’m wrong.” If you solicit agreement or even use a neutral framing, they will tend to roll with whatever you suggest.
10. When thinking or teaching, you will be more right and righteous if you speak in probabilities or allow the possibility of uncertainty, then if you speak in platitudes. Say you could be wrong, estimate a degree of probability… if you think in certainty, you anchor yourself and can never become more correct with new data.
11. 95% of your decisions should be made in advance, either as shared or internal guidelines, based on your current assessment of our knowledge and how you do what you do. The other 5% will require intensive thought at the time, which is a good thing as long as it’s only 5%, and maybe you can generalize your decisions so that decision will be autopilot next time.
12. Listen to differing perspectives and opinions from different sources to add qualitatively to your market of ideas, without trying too hard to weigh which is a “better” opinion or source, as this is mostly impossible; with that perspective, you don’t need to worry as much about the validity of the source as long as it’s worth hearing.
13. However, give very little weight to “voting,” or considering how often you hear a perspective. In the modern era of algorithmically served content, media echo chambers, and self-selecting subcultures, as well as the growing rise of completely AI-generated content in infinite volumes, you are likely to hear many voices that share the same opinion, regardless of whether it’s right or wrong, and quantity of perceived voices may have no correlation to the actual number of people who believe something. In fact, many seemingly different sources are really just echoing or referring back to one original source, not reflecting new opinions. “I hear it all the time/everyone thinks that” is no longer a useful tool for finding truth.

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We dive into the confusing rabbit hole of medical staffing, credentialing, and privileging, particularly for the critical care APP, with Chris Newman, pediatric critical care PA and Vice Chair for Clinical Performance at the University of Colorado.

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Check out the CHEST Procedural Skills for the Critical Care Clinician course here!

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Takeaway pearls

1. The medical staff office regulates the medical staff, which includes physicians and APPs. The latter may actually be voiting “members” of the medical stuff, or have some kind of affiliate status; the relevance of this is their eligibility to vote and sit on its committees, which sets the policies and manages governance. Either way though, APPs are subject to the medical staff office’s regulation.
2. Credentialing is the process of ensuring medical staff have the right and competence to work in the hospital, mostly confirming basic job requirements like graduating training programs. Privileging is the process of determining what specific things you are allowed to do in the hospital.
3. Privileges are broken into core privileges, which are things any provider should know how to do (i.e. taught in school): perform H&Ps, order meds and tests, interpret them, etc. Special privileges are those that require additional training, usually procedures. Some of the latter may become core privileges over time.
4. Special privileges are needed for anything “infrequent and high risk,” which requires some judgment – i.e. if a procedure is not listed, does that mean you cannot do it, or that it does not even require special privileges? Which procedures are listed is determined by the judgment of the clinicians in medical staffing, and the list is not always perfect.
5. All of these processes are hospital based, usually not part of state law, and are also often subject to Joint Commission regulation. However your hospital handles them, it is expected to follow its own policies consistently.
6. Learners are managed under policies for proctoring, not privileges. A person with procedural privileges can generally supervise a learner without privileges to perform it; if that’s a student, it is considered to be “done” by the proctor, and if by a licensed provider without privileges, it is “done” by the learner under supervision. Such a learner may eventually obtain their own privileges (usually by meeting a requirement of either numbers or observed competence or both). The exact rules of how all this works is governed by a proctoring policy which can be looked up.
7. While many providers may feel it is accepted, or even an ethical obligation, to perform procedures they are trained but not privileged to perform in an emergency (i.e. to save a life when a privileged person is not immediately available), there is usually no explicit allowance for this in hospital policy, so buyer beware.
8. If you don’t like how your processes work, change them.

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We chat with Melissa Nestor, clinical pharmacist in neurocritical care, about tho subtleties of glucose and insulin management in the ICU.

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We explore the practical intricacies of nebulized medications, including timing, dosing, types of devices, and more, with Keith Lamb (@kdlamb1), RRT, RRT-ACCS, FAARC, FCCM.

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We dive into the common dilemma of when to give stress-dose corticosteroids in septic shock, with Dr. David Janz, pulm/crit intensivist with a Masters of Science in Clinical Investigation, former director of the Clinical Research Unit for the critical care section at LSU, founding member of the Pragmatic Critical Care Research Group, and associate Chief Medical Officer for LCMC.

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Takeaway lessons

1. The purported effect of corticosteroids in septic shock is to increase sensitivity of peripheral catecholamine receptors, either to endogenous or exogenous adrenergic hormones.
2. In the four large RCTs of this topic, two showed a beneficial outcome effect and two did not. The two positive trials also added fludrocortisone to the backbone steroid (usually hydrocortisone), though it seems dubious that this was the key difference (fludro has also been studied separately without effect). Those trials also generally enrolled sicker patients, i.e. on higher doses of pressor and more organ failure.
3. It is probably reasonable to add steroids when on escalating doses of your first-line pressor (e.g. norepinephrine), or when thinking of adding vasopressin, though the SCCM/Surviving Sepsis guidelines now suggest just giving steroids to everyone in septic shock, presumably to simplify decision-making, particularly for non-experts.
4. Most trials have used hydrocortisone 50 mg q6h or thereabouts, or an equivalent dose as a continuous infusion. The latter makes some physiologic sense but has not been shown to be beneficial head-to-head trials. Most likely, the exact dosing strategy is not too important. Alternate steroids are probably also reasonable, i.e. any moderate-dose parenteral corticosteroid probably gets you the desired effect.
5. Many trials continued steroids until the patient left the ICU, even if pressors have been weaned off. Most clinicians would probably stop them sooner than this, although we should acknowledge that their effect in raising blood pressure is reliable (sometimes helping to discontinue pressors as much as several days sooner), so continuing them longer could conceivably help with disposition (i.e. help them leave and stay out of the ICU), which is a good thing for hospitals and probably patients.
6. Dr. Janz stops steroids when the pressors are stopped, with no taper or wean. Some would do a short taper, but the more complex you make the process in a busy ICU, the more likely that someone will forget to discontinue them altogether, and that the patient will stay on steroids for their whole hospitalization (or forever). There is no physiologic suppression of the native steroid production with these durations of steroid therapy (usually 3-4 days, almost always <1 week), and an abrupt halt is what was done in the trials.
7. Etomidate has been repeatedly shown to cause a measurable decrease in cortisol levels, even after single doses (e.g. for intubation). However, this has not been shown to be associated with any negative outcome (most recently in the EVK trial).
8. There is very little data on whether steroids should be used in shock from other etiologies. It may make some sense in other inflammatory states, such as pancreatitis, post-CPB vasoplegia, etc. But we really don’t know. In a mixed shock state where sepsis is present along with something else like cardiogenic shock, Dr. Janz uses steroids; otherwise no.
9. Whether to always augment the home steroid dose in chronic steroid users, even without shock, has shifted—in the past, endocrinology guidelines were to always do this empirically (e.g. in steroid users undergoing surgery or some other stressor), now they still generally favor this but are moving towards increasing the home dose only if signs of adrenal crisis develop.

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We explore the fascinating intricacies and unique features of the burned critically ill patient, with Clint Leonard, NP in the burn ICU at Vanderbilt and ABLS instructor.

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Want to work at the University of Kentucky? UK’s Anesthesia Critical Care department is hosting a hiring webinar on November 20, 2025 at 4:00PM EST.