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08 Assessment of volume status and fluid responsiveness in the emergency department


include paroxysmal nocturnal dyspnea and orthopnea whereas dyspnea on exertion is the most sensitive anamnestic hint. During physical examination, jugular venous distention and abdominojugular reflux may secure the diagnosis of heart failure (however, these signs have very low sensitivity). Among the more sensitive findings, lower extremity edema and rales on lung auscultation may provide evidence for hypervolemia and heart failure. In cardiac patients, the synopsis of clinical findings can be used to assign the patient to a Killip class that was initially proposed for risk stratification in patients with myocardial infarction [13]. Taken together, we consider the clinical examination as an immediately available and cost-effective means to evaluate a patient’s volume status early after his arrival in the ED, which can help to guide the initial resuscitation therapy. However, clinical studies revealed significant limitations of clinical signs and symptoms in the assessment of a patient’s volume status [8, 10, 14, 15]. Laboratory parameters Blood urea nitrogen/ creatinine ratio Volume depletion induces a neurohumeral response which enhances the reabsorption of sodium and water in the proximal tubule. Since urea reabsorption occurs passively in this very part of the nephron, volume depletion also causes an increase in urea reabsorption. The blood urea nitrogen (BUN)/serum creatinine ratio is approximately 10:1 in normal subjects but may be substantially elevated in hypovolemic states [16]. In a state called “prerenal azotemia,” true volume depletion or decreased effective arterial blood volume (EABV) go along with BUN/creatinine ratios of 20:1 and higher. Decreased EABV volume may occur in edematous disorders such as cardiac failure, liver cirrhosis, and more rarely nephrotic syndrome [17]. Although there are quite a few confounding conditions such as intake of steroid medication or upper gastrointestinal bleeding, the BUN/creatinine ratio remains an easily obtainable tool for volume status assessment. We would like to point out that mere creatinine levels are poor indicators of kidney function in the elderly, and the use of formulas to estimate glomerular filtration rate is strongly suggested in this patient group [18]. Urinary sodium and fractional excretion of urea Urinalysis is often performed in the ED during the evaluation of common symptoms such as fever or abdominal discomfort. A “spot urine” sample may also aid in evaluating volume status. The aforementioned neurohumeral response to volume depletion or decreased EABV induces the kidneys to retain sodium and subsequently water in order to (re-)expand the extracellular fluid compartment. Chung and colleagues were able to demonstrate that in contrast to clinical assessment by two experienced nephrologists the spot urinary sodium concentration was highly sensitive to distinguish between hypovolemic and euvolemic patients with hyponatremia [15]. In their study, a spot urinary sodium concentration of less than 30 mmol/L was 100 % specific and 80 % sensitive to detect patients with hyponatremia who had elevated plasma renin and norepinephrine concentrations, responded to infusion of isotonic saline, and were thus deemed to be hypovolemic. However, when hypovolemia occurs due to an overzealous use of loop and thiazide diuretics, low urinary sodium concentrations lose their sensitivity to detect volume depletion. As sodium and water are reabsorbed in the proximal tubulus, the fractional excretion of urea (FE UN ) remains unaffected. In patients with renal hypoperfusion, a FE UN of ≤ 35 % was found to be indicative of kidney injury due to hypovolemia or decreased EABV even after administration of diuretic therapy (sensitivity and specificity of 90 and 96 %, respectively [19]). However, these results were challenged by another study in which the diagnostic accuracy of FE UN was explored prospectively. Pépin et al. demonstrated that FE UN performed rather poorly, irrespective of whether diuretics had been administered or not [20]. In summary, a urinary spot sodium of less than 30 mmol/L is very specific and moderately sensitive to detect hypovolemia. After diuretic therapy, a FE UN of ≤ 35 % may still be able to support the diagnosis of hypovolemia, although reports on its diagnostic accuracy are contradictive. Blood lactate Screening for hypotension alone might miss patients at risk for circulatory failure [21]. Elevated serum lactate levels indicate ongoing tissue hypoxia and are associated with a worse prognosis in acutely ill patients [22], independent of age, blood pressure, or other comorbidities [23]. Therefore, we advocate a liberal use of sequential [24] lactate measurements in the ED while being aware of potential confounders such as biguanide or antiretroviral medications and liver disease. Bedside ultrasound Bedside ultrasound may provide valuable information on circulatory function that cannot be obtained by clinical assessment. It may detect the presence of pericardial and pleural effusions or ascites, which may give important diagnostic clues both for patients suspected to have decreased EABV and patients with fluid loss to the abdominal or thoracic compartment (e.g., pancreatitis). Furthermore, the diameter of the inferior vena cava (IVC) can be used to estimate right cardiac function and central venous pressure (CVP). According to current guidelines, a low right atrial pressure (0–5 mmHg) can be inferred from an IVC diameter of ≤ 2.1 cm that collapses > 50 % with a sniff. On the contrary, an IVC diameter > 2.1 cm without a collapse of 50 % with a sniff suggests a high right atrial pressure (10–20 mmHg). Values found in between are considered indeterminate and an intermediate pressure is then assumed [25]. The IVC diameter is not affected by the neurohumeral stress response but will adapt to changes in CVP such as volume depletion or fluid resuscitation [26, 27]. In particular, the expiratory IVC (IVCe) diameter correlated well with complete blood volume, as determined by I131-labeled albumin dilution, in patients with iatrogenic volume depletion, that is hemodialysis [28]. Although ultrasonographic Medizinische Klinik - Intensivmedizin und Notfallmedizin 4 · 2017 | 327

Abstract · Zusammenfassung evaluation is known to be dependent on sonographer experience, M-Mode IVC diameter measurements as perfomed by ED residents after a short course of training had a high degree of interrater reliability [29]. IVCe was consistently and significantly lower in hypovolemic trauma patients with confirmed or suspected blood loss [30–32]. Weekes and colleagues showed that in hypovolemic ED patients, the IVCe diameter and caval index increased and decreased, respectively, after a mean fluid bolus of 2580 mL [27]. In summary, IVCe diameter and caval index provide a noninvasive, quickly obtainable, and reproducible tool to assess intravascular volume status before and after fluid resucitation that seems well suited for the ED. However, ultrasonographic examination of the IVC diameter has several limitations: in patients with right ventricular failure the IVC diameter will be elevated even in the presence of hypovolemia and shock. Despite its ability to estimate CVP and intravascular volume status, IVC diameter and collapsibility index will not provide information on a patient’s fluid responsiveness. Corl and colleagues showed that neither the initial nor the dynamic (i.e., after a passive leg raise maneuver) caval index could predict fluid responsiveness in an ED patient cohort [33]. Echocardiography plays a crucial role in the initial evaluation of ED patients for the differentiation of different etiologies of hemodynamic instability or shock [34, 35]. Besides the differential diagnosis of cardiac and noncardiac causes of shock, echocardiography allows the estimation of left and right ventricular dysfunction and valvular dysfunction [34]. In addition to static parameters, it provides noninvasive means to examine dynamic parameters of volume responsiveness (for details please see below) [36]. Stroke volume and cardiac output (CO) can be estimated by measuring the velocity–time integral of the aortic outflow and the aortic valve area in the apical five-chamber and parasternal long-axis view, respectively. Med Klin Intensivmed Notfmed 2017 · 112:326–333 © Springer-Verlag Berlin Heidelberg 2015 Chest x-ray Results obtained from a chest x-ray (CXR) will add additional information on the presence or absence of hypervolemia. However, classic radiographic signs of volume overload such as pleural effusions or peribronchial cuffings correlate poorly with the invasive determination of volume status or extravascular lung water [14, 37, 38]. Unlike those classic signs of increased pulmonary hydration, the vascular pedicle width (VPW)—that is, the distance between a perpendicular line from the point where the left subclavian artery exits the aortic arch and the crossing of the superior vena cava and the left main DOI 10.1007/s00063-015-0124-x C. Maurer · J.Y. Wagner · R.M. Schmid · B. Saugel Assessment of volume status and fluid responsiveness in the emergency department: a systematic approach Abstract When treating acutely ill patients in the emergency department (ED), the successful management of a variety of medical conditions, such as sepsis, acute kidney injury, and pancreatitis, is highly dependent on the correct assessment and optimization of a patient’s intravascular volume status. Therefore, it is crucial that the ED physician knows and uses available means to assess intravascular volume status to adequately guide fluid therapy. This review focuses on techniques for volume status assessment that are available in the ED including basic clinical and laboratory findings, apparatus-based tests such as sonography and chest x-ray, and functional tests to evaluate fluid responsiveness. Furthermore, we provide an outlook on promising innovative, noninvasive technologies that might be used for advanced hemodynamic monitoring in the ED. Keywords Shock · Sepsis · Volume therapy · Fluid deficiency · Passive leg raising · Fluid challenge · Advanced hemodynamic monitoring · Noninvasive cardiac output Die Bestimmung des Volumenstatus und der Volumenreagibilität in der Notaufnahme – ein systematischer Ansatz Zusammenfassung Bei der Behandlung akut kranker Patienten in der Notaufnahme hängt die erfolgreiche Behandlung einer Reihe von Erkrankungen (z. B. Sepsis, akutes Nierenversagen, Pankreatitis) in hohem Maße von der korrekten Einschätzung und Optimierung des intravaskulären Volumenstatus des Patienten ab. Daher ist es entscheidend für eine adäquate Steuerung der Volumentherapie, dass der Notfallmediziner die verschiedenen Methoden zur Abschätzung des intravaskulären Volumenstatus kennt und zur Anwendung bringt. Dieser Übersichtsartikel behandelt Methoden zur Abschätzung des Volumenstatus, die in der Notaufnahme verfügbar sind, wie grundlegende klinische und laborchemische Untersuchungen, Ultraschallund Röntgendiagnostik und funktionelle Tests zur Beurteilung der Volumenreagibilität. Desweiteren wird ein Ausblick gegeben auf vielversprechende, innovative, nicht-invasive Technologien, die für ein erweitertes hämodynamisches Monitoring in der Notaufnahme verwendet werden könnten. Schlüsselwörter Schock · Sepsis · Volumentherapie · Volumenmangel · Passive leg raising · Fluid challenge · Erweitertes hämodynamisches Monitoring · Nicht-invasives Herzzeitvolumen bronchus—and the cardiothoracic ratio (CTR) seem to provide a more robust estimation of cardiac preload [39]. Ely and colleagues divided mechanically ventilated intensive care unit patients into groups of high and low/normal volume status after measuring pulmonary artery occlusion pressure (PAOP) [40]. By integrating the objective parameters VPW and CTR into the analysis of a portable supine CXR, radiologists were able to increase the likelihood ratio of the CXR to correctly determine volume status. The optimal cutoff for the distinction between high and normal/low volume status in this investigation was 70 mm for VPW and 0.55 for CTR. Limitations of this cost-effective and 328 | Medizinische Klinik - Intensivmedizin und Notfallmedizin 4 · 2017

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