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Furthermore, living in a country which values the freedom of speech and the freedom to tell the truth, this letter will be published in its entirety on the Internet.

Yours Sincerely, Paul Marik, MD===A Youtube Lecture Paul Linked to on EGDT===From: Marik, Paul E.

Furthermore, a number of RCT’s are about to initiated worldwide.

An essential component of our strategy to improve the outcome from sepsis is a conservative, physiologic based approach to fluid management (see Steps to the Cure, Below).

Having done Webinars with multiple health systems across this country they believe that the Federal Government has a gun to their heads (namely SEP-1); they are torn between doing the right thing for their patients and what the Federal Government wants them to do.

As clinicians our primary responsibly is and will always be to do what is right for the patient. I have become acutely aware of the enormous impact and power of the Internet and Social Media to influence behavior and dialogue.

However, the mandate to give a 30 ml/kg bolus of fluid may lead to “salt water drowning”,[13] and is unsupported by the scientific literature.

It is remarkable that the Federal Government has mandated that physicians use a therapeutic intervention that is scientifically unproven; this is unprecedented in the history of medicine.

These authors demonstrated that patients in septic shock were unable to increase left ventricular end-diastolic volume (LVEDV) and stroke volume in response to a fluid challenge.[11,12] It is important to emphasize that some patients with sepsis are dehydrated (due to poor oral intake, etc) and may respond to SMALL boluses of fluid.In my opinion, as well as many other thought leaders in our country and abroad that the continued enforcement of the SEP-1 protocol is scientifically, morally and ethically unacceptable.[1,2] It is noteworthy that in response to the publication of the 2016 Surviving Sepsis Campaign Guidelines (SSC),[3,4] Dr’s Timothy Buchman and Elie Azoulay the Editors of Critical Care Medicine and Intensive Care Medicine respectively have stated that “As clinicians, we are bound to deviate from guidelines when such deviation is reasonably expected to improve an individual patient outcome.As clinical scientists, we are bound to evaluate the prevailing standard against emerging alternatives. We therefore caution against any quality metric or reimbursement policy that mandates slavish adherence to a particular recommendation.” [5] Furthermore in sworn testimony under oath (January 2017), Dr Mitchell Levy one of the architects of SEP-1, has stated that the SSC Guidelines do not represent the best distillation of scientific information, that they do not need to be rigidly followed and that a 20 ml/kg fluid bolus may be harmful![3,4] Both the Federal Government and the authors of the SSC decree there are NO EXCEPTIONS to this rule; astonishingly, they mandate that patients with pneumonia or Acute Lung Injury be intubated so that they can receive the potentially harmful 30ml/kg fluid bolus [6]. this can only be described as reckless and medical malpractice (see Trial Verdicts below).It is critical to stress that the SSC recommendation and the SEP-1 mandate are devoid of any scientific evidence, indeed, a strong body of scientific evidence suggests that such an approach may be harmful.

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A simple understanding of cardiovascular physiology and the pathological changes that occur with sepsis together with a review of the medical literature clearly highlights the dangers of the SEP-1 mandate forcing physicians to give qualifying patients a 30ml/kg bolus of crystalloid.

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