🩺 THIS WEEK IN EM
The Fluid Restrictive Sepsis Approach Is Non-Inferior. You Don't Have to Drown Them.
The CLOVERS trial (NEJM, 2023) randomized 1,563 patients with sepsis-induced hypoperfusion to restrictive vs. liberal fluid strategy within 4 hours of ED arrival. Restrictive patients got vasopressors earlier and less crystalloid; liberal patients got more upfront fluid per existing guidelines.
90-day mortality: 14.0% restrictive vs. 14.9% liberal. No significant difference. Median 24-hour fluids: 3.3 L restrictive vs. 5.0 L liberal. The restrictive patients didn't crash. Going to vasopressors earlier isn't failure — it's physiology.
The 30 mL/kg bolus embedded in Sepsis-3 bundles was never really evidence-based to begin with. CLOVERS didn't prove restrictive is better, just that it's not worse.
Bottom line: A restrictive fluid strategy with earlier vasopressors is non-inferior to liberal fluids in early sepsis. You don't need 3–4 liters on board before considering pressors.
NHLBI PETAL Network. N Engl J Med. 2023;388(7):613-623.
Balanced vs. Saline: The PLUS Trial Says Plasmalyte Isn't Magic Either
PLUS trial (NEJM, 2022): 5,037 ICU patients randomized to Plasmalyte-148 vs. normal saline for all IV fluid throughout admission. 90-day mortality: 26.3% balanced vs. 27.1% saline. Not significant. No difference in AKI, RRT, or discharge outcomes.
This complicated the SMART trial narrative from 2018. PLUS was larger and more controlled — the benefit of balanced crystalloids isn't as universal as we thought. For patients getting large volumes or with existing acidosis, balanced crystalloids are still a reasonable preference. But it's not the slam dunk we were selling.
Bottom line: Balanced crystalloids aren't clearly superior to saline in unselected critically ill patients — but minimizing hyperchloremia still makes sense when large volumes are needed.
Finfer et al. N Engl J Med. 2022;386(9):815-826.
IV Vitamin C in Sepsis: LOVIT Buries It. Stop Giving It.
The LOVIT trial (NEJM, 2022): 872 ICU sepsis patients, high-dose IV vitamin C (200 mg/kg/day × 4 days) vs. placebo. Primary outcome: death or persistent organ dysfunction at 28 days.
Vitamin C was worse. Primary outcome: 44.5% vitamin C vs. 38.5% placebo (p=0.03). This is the cautionary tale version of EM enthusiasm — a single before-after study with a plausible mechanism generated widespread adoption before an RCT was ever done. Activated protein C says hi.
Bottom line: High-dose IV vitamin C in sepsis does not improve outcomes and may cause harm. Stop using it.
Lamontagne et al. N Engl J Med. 2022;386(25):2387-2398.
📚 STILL CHANGING PRACTICE
EGDT Is Dead. And That's Fine.
ProCESS, ARISE, and ProMISe (all NEJM, 2014–2015) collectively randomized 4,200+ patients with septic shock to EGDT vs. usual care. All three showed the same thing: no benefit from the Rivers protocol over modern usual care. EGDT patients received more blood transfusions, more vasopressors, and more unnecessary ICU admissions.
The useful takeaways from EGDT still stand — early antibiotics, fluid for hypoperfusion, timely vasopressors, lactate clearance. The rigid CVP targets and ScvO2 monitoring? Retired.
Bottom line: EGDT as a protocol is obsolete. Early antibiotics, lactate-guided resuscitation, and timely vasopressors remain the core of sepsis management.
ProCESS Investigators. N Engl J Med. 2014;370(18):1683-1693.
Next week: TTM2 rewrote the post-arrest protocol — what do you do now? Plus cardiogenic shock, ECMO timing, and whether immediate cath post-OHCA is still a thing.
The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.