Response to: Assessment of Fluid responsiveness in the Acute Medical Patient and the Role of Echocardiography

2018 ◽  
Vol 17 (4) ◽  
pp. 236-237
Author(s):  
Adam Seccombe ◽  
Keyword(s):  
Cardiac Output ◽  
Fluid Responsiveness ◽  
Fluid Resuscitation ◽  
Medical Patient ◽  
Fast Response ◽  
Fluid Bolus ◽  
Response Device ◽  
Acute Medicine ◽  
Passive Leg Raise

Sirs, I read the article, ‘Assessment of Fluid responsiveness in the Acute Medical Patient and the Role of Echocardiography’ by Dr Parulekar and Dr Harris with interest. It rightly highlights the challenges posed when assessing for fluid resuscitation in a pressured setting with limited information. This scenario is a routine one for our speciality, which is why it is a concern that the evidence-base outside of intensive care remains limited. Of particular relevance to the Acute Medical specialist, the article acknowledges that performing a focussed-echocardiogram on all acutely-unwell patients is “impractical”. Developing a quick and straightforward approach to fluid resuscitation assessment should be a high research priority for Acute Medicine. However, there are several statements described in the article which warrant correction, particularly as they reflect misconceptions that are rife in the Intensive Care literature: The assumption that fluid responsiveness is equivalent to hypovolaemia: As the article acknowledges, “No suitably powered RCT has assessed the role of stroke volume guided fluid administration as a resuscitation goal.” Furthermore, fluid responsiveness has been demonstrated in healthy volunteers suggesting it may be a normal physiological condition. Even if there was a unanimous agreement for its use, it is currently a poorly-defined concept with no consensus definition. Therefore, significant question marks remain about the diagnostic ability of fluid responsiveness and much work is needed before it can be reliably used as a test for hypovolaemia. 2. The contradiction between the stated utility of IVC measurements and that of CVP: The article states that “IVC [inferior vena cava] size decreases in hypovolaemia” and later notes “a very small collapsing IVC in a shocked patient suggests fluid tolerance”. It goes on to say that “IVC diameter predicts central venous pressure [CVP]”. Then the article contradicts this link by stating that “CVP has little or no role in volume assessment”. The final statement is based on a systematic review in 2008, as acknowledged in the article. The review was updated in 2013. Both compared the ability of CVP to predict fluid responsiveness, however, they did so based on the assumption that fluid responsiveness predicts hypovolaemia. This is far from proven, as discussed above. Therefore, the utility of CVP remains unclear and should be explored along with IVC measurements as a fluid assessment tool. 3. The meaning of the transient response to a fluid bolus: Finally, the article suggests that a “fast response device” should be used to measure cardiac response before and after a passive leg raise, because the subsequent “changes in cardiac output may be transient”. This transient change is not unique to a passive leg raise. The haemodynamic improvements that follow an intravenous fluid bolus are similarly temporary. One study found that cardiac output returned to baseline values 90 minutes after a bolus in fluid responsive patients. Instead of finding a “fast response device” to measure transient haemodynamic improvements, we should be asking if the benefit of fluid resuscitation is also transient, particularly in conditions such as sepsis. We should also question whether rapid fluid boluses cause harm from subsequent oedema, and explore whether this harm persists after the haemodynamic benefit has disappeared. Are we temporarily boosting physiological markers whilst at the bedside, only for the fluid to leak into the interstitium after we have moved on to our next patient? In conclusion, I applaud the authors for the highlighting the important topic of fluid assessment. Despite nearly two centuries of use, the benefits and harms of intravenous fluid are still poorly understood. This is a vital research topic for our speciality, so I hope they will join me and others in addressing the evidence gaps and research questions that are highlighted by this letter. Yours faithfully, Adam Seccombe BSc (Hons) MBChB MRCP (Acute Medicine)

scholarly journals Assessment of Fluid responsiveness in the Acute Medical Patient and the Role of Echocardiography

2018 ◽  
Vol 17 (2) ◽  
pp. 104-109
Author(s):  
Prashant Parulekar ◽  
◽  
Tim Harris ◽  
Keyword(s):  
Fluid Responsiveness ◽  
Point Of Care ◽  
Medical Patient ◽  
Assessment Tools ◽  
Point Of Care Ultrasound ◽  
Limited Evidence ◽  
Acute Medicine ◽  
Skill Sets ◽  
Poor Outcomes

Both hyper and hypovolaemia have been associated with poor outcomes. Assessment of fluid responsiveness is challenging in the acute medical patient, due to time constraints, limited evidence and quite often the lack of accurate assessment tools on the Acute Medicine Unit (AMU). This article explains how focused echo assessment is quick and easy to use for this purpose on the acute medical take and highlights key principles to bear in mind when assessing for hypovolaemia and whether to administer fluid therapy. The increasing familiarity with focused echo such as Focused Intensive Care Echocardiography (FICE) and Point Of Care Ultrasound (POCUS) makes extension of these skill sets to assess for fluid responsiveness a relatively straightforward next step for acute physicians.

scholarly journals Non-invasive assessment of fluid responsiveness to guide fluid therapy in patients with sepsis in the emergency department: a prospective cohort study

2021 ◽  
pp. emermed-2020-209771
Author(s):  
Nienke K Koopmans ◽  
Renate Stolmeijer ◽  
Ben C Sijtsma ◽  
Paul A van Beest ◽  
Christiaan E Boerma ◽  
...  
Keyword(s):  
Cohort Study ◽  
Fluid Responsiveness ◽  
Prospective Cohort Study ◽  
Fluid Therapy ◽  
Prospective Cohort ◽  
Fluid Challenge ◽  
Fluid Bolus ◽  
Non Invasive ◽  
Similar Patient ◽  
Passive Leg Raise

BackgroundLittle is known about optimal fluid therapy for patients with sepsis without shock who present to the ED. In this study, we aimed to quantify the effect of a fluid challenge on non-invasively measured Cardiac Index (CI) in patients presenting with sepsis without shock.MethodsIn a prospective cohort study, CI, stroke volume (SV) and systemic vascular resistance (SVR) were measured non-invasively in 30 patients presenting with sepsis without shock to the ED of a large teaching hospital in the Netherlands between May 2018 and March 2019 using the ClearSight system. After baseline measurements were performed, a passive leg raise (PLR) was done to simulate a fluid bolus. Measurements were then repeated 30, 60, 90 and 120 s after PLR. Finally, a standardised 500 mL NaCl 0.9% intravenous bolus was administered after which final measurements were done. Fluid responsiveness was defined as >15% increase in CI after a standardised fluid challenge.Measurements and main resultsSeven out of 30 (23%) patients demonstrated a >15% increase in CI after PLR and after a 500 mL fluid bolus. Fluid responders had a higher estimated glomerular filtration rate (eGFR) (64 (44–78) vs 37 (23–47), p=0.009) but otherwise similar patient and treatment characteristics as non-responders. Baseline measurements of cardiac output (CO), CI, SV and SVR were unrelated to PLR fluid responsiveness. The change in CI after PLR was strongly positive correlated to the change in CI after a 500 mL NaCl 0.9% fluid bolus (r=0.88, p<0.001).ConclusionThe results of the present study demonstrate that in patients with sepsis in the absence of shock, three out of four patients do not demonstrate a clinically relevant increase in CI after a standardised fluid challenge. Non-invasive CO monitoring in combination with a PLR test has the potential to identify patients who might benefit from fluid resuscitation and may contribute to a better tailored treatment of these patients.

scholarly journals A New Ratio for Protocol Categorization

2014 ◽  
Vol 2014 ◽  
pp. 1-8
Author(s):  
Pierre Squara
Keyword(s):  
Cardiac Output ◽  
Cardiac Response ◽  
Present Review ◽  
Past Study ◽  
Fluid Bolus ◽  
Step Process ◽  
Output Response ◽  
Coefficient Corrélation ◽  
Passive Leg Raise ◽  
Random Fluctuations

The present review describes and validates a new ratio “S” created for matching predictability and balance between TP and TN. Validity ofSwas studied in a three-step process as follows: (i)Swas applied to the data of a past study predicting cardiac output response to fluid bolus from response to passive leg raise (PLR); (ii)Swas comparatively analyzed with traditional ratios by modeling different 2 * 2 contingency tables in 1000 hypothetical patients; (iii) precision ofSwas compared with other ratios by computing random fluctuations in the same patients. In comparison to other ratios,Sperforms better in predicting the cardiac response to fluid bolus and supports more directly the clinical conclusions. When the proportion of false responses is high,Sis close to the coefficient correlation (CC). When the proportion of true responses is high,Sis the unique ratio that identifies the categorization that balances the proportion of TP and TN. The precision ofSis close to that of CC. In conclusion,Sshould be considered for creating categories from quantitative variables; especially when matching predictability with balance between TP and TN is a concern.

5 The fluro project: a review of the approach and understanding of fluid resuscitation in a military tertiary centre from the perspective of care providers in the emergency setting

2018 ◽  
Vol 164 (3) ◽  
pp. 225.2-225
Author(s):  
J Lowe ◽  
L Stevenson ◽  
D Wilding ◽  
D McLaughlin ◽  
M West
Keyword(s):  
Fluid Resuscitation ◽  
Emergency Setting ◽  
Care Providers ◽  
Fluid Bolus ◽  
Acute Medicine ◽  
Tertiary Centre ◽  
Working Environments ◽  
Administration Time ◽  
Multiple Patients ◽  
Audit Standards

IntroductionThe term fluid resuscitation (FR) is defined as the use of fluids to restore a state of normovolaemia, or to correct a hypovolaemic state. To establish normovolaeamia via FR, the term ‘fluid bolus’ is used to describe a prescribed fluid volume. As such, the authors looked to investigate the understanding of this term and to review approaches to fluid resuscitation by those healthcare workers closely associate with critically unwell patients.MethodsA questionnaire was distributed to all clinical staff across Emergency Medicine (EM), Anaesthesia and Theatres (AT), Intensive Care Medicine (ICM) and Acute Medicine (AM). The questionnaire recorded role, area of responsibility, training grade, type, volume and administration time, time to reassessment and parameters to be assessed in relation to a clinical vignette. The results were then compared directly to the NICE Clinical Audit Standards (NCAS) for FR.Results153 responses were received from across all working environments. Overall, 52% of respondents gave volumes aligned with NCAS (500 ml). 99% of respondents suggested crystalloid use with 88% giving an appropriate time for administration of less than 15 min. 55% of respondents suggested appropriate review times (0–5 min). 99% of respondents agreed heart rate and blood pressure should be reassessed, but other parameters for monitoring were poorly recognised.Between specialties, EM suggested larger volumes while ICM were more likely to continuously review the patient during a bolus. AM were the only group to administer fluids over 60 min. EM and ICM were more likely to review lactate as a marker for effect. Higher specialist trainees were more likely to give a larger volume when compared to other grades.DiscussionThe overall perception of a fluid bolus varies between specialties and training grades. Most responses were aligned to NCAS with notable outliers. This suggests a discrepancy in the understanding of the term fluid bolus. This may also cause issues in fluid administration with multiple patients. It is therefore suggested that further work be undertaken on clarifying the term ‘fluid bolus’, aiming to minimise uncertainty and increase understanding to prevent adverse effects.

scholarly journals Role of Inferior Vena Cava Parameters as Predictors of Fluid Responsiveness in Pediatric Septic Shock: A Prospective Study

2021 ◽  
Vol 11 (01) ◽  
pp. e49-e54
Author(s):  
Ahmed Ahmed EL-Nawawy ◽  
Omneya Magdy Omar ◽  
Hadir Mohamed Hassouna
Keyword(s):  
Septic Shock ◽  
Inferior Vena Cava ◽  
Fluid Responsiveness ◽  
Inferior Vena ◽  
Vena Cava ◽  
Tissue Perfusion ◽  
University Hospital ◽  
Predict Fluid Responsiveness ◽  
Fluid Bolus

AbstractFluid resuscitation is the initial therapy for septic shock worldwide. Prediction of fluid responsiveness is essential for optimizing fluid administration. Only few pediatric studies have evaluated the role of inferior vena cava (IVC) as a reliable predictor of fluid responsiveness. The aim of this study was to evaluate the role of IVC parameters as predictors of fluid responsiveness in children (under the age of 5 years) having septic shock at different times from admission. A prospective observational study included 51 children having septic shock. It was conducted in the nine-bedded pediatric intensive care unit of a university hospital from January 1, 2018, to the August 31, 2018. Echocardiography was used to assess minimal and maximal IVC diameters and its distensibility index with simultaneous assessment of stroke volume (SV), at 1, 6, and 24 hours from admission. The decision to give fluid in these children was thereby based on the presence of at least one sign of inadequate tissue perfusion. SV was reassessed directly after administration of a fluid bolus of 10 mL/kg over 10 minutes. Fluid responsiveness was considered adequate when there was ≥ 10% increase in SV after fluid bolus. Minimal IVC diameter indexed to body surface area and its distensibility index can be predictors of fluid responsiveness at all times: 1 hour (area under curve [AUC] = 0.88; 95% confidence interval [CI] = 0.77–0.96), 6 hours (AUC = 0.86; 95% CI = 0.67–0.97), and 24 hours (AUC = 0.77; 95% CI = 0.6–0.95). IVC distensibility index can also predict fluid responsiveness at 1 hour (AUC= 0.87; 95% CI = 0.74–0.95), 6 hours (AUC = 0.86; 95% CI = 0.73–0.94), and 24 hours (AUC = 1; 95% CI = 0.77–1). The cutoff points of each parameter differed from time to time (contradicts with previous statement that says it is predictor at all times). The maximum IVC diameter could not predict fluid responsiveness at any time from admission. Minimal IVC diameter and its distensibility index were feasible noninvasive surrogates of fluid responsiveness in pediatric septic shock at different times from admission.

Effect of fluid bolus triggers and their combination on fluid responsiveness in optimization phase of severe sepsis and septic shock resuscitation

MedPharmRes ◽  
2018 ◽  
Vol 2 (3) ◽  
pp. 27-32
Author(s):  
Bien Le ◽  
Dai Huynh ◽  
Mai Tuan ◽  
Minh Phan ◽  
Thao Pham ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Septic Shock ◽  
Severe Sepsis ◽  
Fluid Responsiveness ◽  
Statistical Significance ◽  
Venous Pressure ◽  
Fluid Bolus ◽  
Low Blood Pressure ◽  
Low Central Venous Pressure ◽  
Sepsis And Septic Shock

Objectives: to evaluate the fluid responsiveness according to fluid bolus triggers and their combination in severe sepsis and septic shock. Design: observational study. Patients and Methods: patients with severe sepsis and septic shock who already received fluid after rescue phase of resuscitation. Fluid bolus (FB) was prescribed upon perceived hypovolemic manifestations: low central venous pressure (CVP), low blood pressure, tachycardia, low urine output (UOP), hyperlactatemia. FB was performed by Ringer lactate 500 ml/30 min and responsiveness was defined by increasing in stroke volume (SV) ≥15%. Results: 84 patients were enrolled, among them 30 responded to FB (35.7%). Demographic and hemodynamic profile before fluid bolus were similar between responders and non-responders, except CVP was lower in responders (7.3 ± 3.4 mmHg vs 9.2 ± 3.6 mmHg) (p 0.018). Fluid response in low CVP, low blood pressure, tachycardia, low UOP, hyperlactatemia were 48.6%, 47.4%, 38.5%, 37.0%, 36.8% making the odd ratio (OR) of these triggers were 2.81 (1.09-7.27), 1.60 (0.54-4.78), 1.89 (0.58-6.18), 1.15 (0.41-3.27) and 1.27 (0.46-3.53) respectively. Although CVP < 8 mmHg had a higher response rate, the association was not consistent at lower cut-offs. The combination of these triggers appeared to raise fluid response but did not reach statistical significance: 26.7% (1 trigger), 31.0% (2 triggers), 35.7% (3 triggers), 55.6% (4 triggers), 100% (5 triggers). Conclusions: fluid responsiveness was low in optimization phase of resuscitation. No fluid bolus trigger was superior to the others in term of providing a higher responsiveness, their combination did not improve fluid responsiveness as well.

Ghrelin and Obesity-An Update

2017 ◽  
Vol 9 (1) ◽  
Author(s):  
Gandhi M. ◽  
Swaminathan S.
Keyword(s):  
Diabetes Mellitus ◽  
Cardiac Output ◽  
Energy Balance ◽  
Vascular Resistance ◽  
The Body ◽  
Ghrelin Receptor ◽  
Type2 Diabetes ◽  
Type2 Diabetes Mellitus ◽  
Natural Hormones

Ghrelin as human natural hormones is involved in fundamental regulatory process of eating and energy balance. It is a stomach derived hormone that acts as at the ghrelin receptor in multiple tissues throughout to the body. Its properties includes increasing appetite, decreasing systemic inflammation, decreasing vascular resistance ,increasing cardiac output, increasing glucose and IGF-1 levels, Hence it may play a significant role in Diabetes mellitus. Many studies have linked ghrelin to obesity and this paper is an attempt to bring out recent findings on the role of ghrelin in Diabetes Mellitus, particularly type2 Diabetes mellitus.

Role of the Pulmonary Circulation in the Distribution of Human Fetal Cardiac Output During the Second Half of Pregnancy

Circulation ◽  
1996 ◽  
Vol 94 (5) ◽  
pp. 1068-1073 ◽  
Author(s):  
Juha Rasanen ◽  
Dennis C. Wood ◽  
Stuart Weiner ◽  
Abraham Ludomirski ◽  
James C. Huhta
Keyword(s):  
Cardiac Output ◽  
Pulmonary Circulation
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