Equipoise in Appropriate Initial Volume Resuscitation for Patients in Septic Shock With Heart Failure: Results of a Multicenter Clinician Survey.

PURPOSE: International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. METHODS: We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration. RESULTS: A total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3%). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4% of respondents. A minimum fluid challenge of ∼30 mL/kg or more was deemed appropriate in septic shock by only 56.4% of respondents for patients with concomitant HFrEF, compared to 89.1% of respondents for patients without HFrEF (P < .01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF. CONCLUSIONS: Clinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.

Typologies of Decision-Makers in the ICU: A Qualitative Study of Patients With Acute Respiratory Distress Syndrome and Sepsis and Their Surrogates.

To develop hypotheses of patient and surrogate's rationale for decision-making. DESIGN: We pursued a qualitative study of patients with acute respiratory distress syndrome or sepsis and their surrogates. Fourteen patients and 28 surrogates were given semistructured interviews while in the ICU and again 30 days later. The interviews focused on goal outcomes for the ICU stay and why a patient or surrogate would want a specific intervention (e.g., intubation and cardiopulmonary resuscitation). SETTING: ICU of tertiary care academic hospital. PATIENTS: Fourteen acute respiratory distress syndrome or sepsis patients and 28 of their surrogates. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Interviews were analyzed using grounded theory and the constant comparative method on NVivo 10.0 (QSR International, Melbourne, Australia). We identified the following four typologies of decision-making rationale: 1) "Timers"-determined decisions based on the length of time on life support; 2) "Natural Livers"-rejected interventions using a "machine"; 3) "Deferrers"-relied on physician for decision-making and prognosis; and 4) "Believers"-relied on a higher power for guidance. CONCLUSIONS: Our hypothesized typologies need validation in a prospective observational trial. If validated, they may allow for better clinician communication.

Object familiarity modulates the relationship between visual object imagery and haptic shape perception.

Although visual cortical engagement in haptic shape perception is well established, its relationship with visual imagery remains controversial. We addressed this using functional magnetic resonance imaging during separate visual object imagery and haptic shape perception tasks. Two experiments were conducted. In the first experiment, the haptic shape task employed unfamiliar, meaningless objects, whereas familiar objects were used in the second experiment. The activations evoked by visual object imagery overlapped more extensively, and their magnitudes were more correlated, with those evoked during haptic shape perception of familiar, compared to unfamiliar, objects. In the companion paper (Deshpande et al., this issue), we used task-specific functional and effective connectivity analyses to provide convergent evidence: these analyses showed that the neural networks underlying visual imagery were similar to those underlying haptic shape perception of familiar, but not unfamiliar, objects. We conclude that visual object imagery is more closely linked to haptic shape perception when objects are familiar, compared to when they are unfamiliar.