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

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fluid challenge, the use of the mean arterial pressure as the clinical endpoint and the CVP as the “safety limit” has been proposed [61] and is feasible in the ED setting. Although it has been shown that B- type natriuretic peptide is not able to accurately predict fluid responsiveness in patients with acute circulatory failure [64], it might be to identify patients with systolic cardiac dysfunction and a high risk for fluid overload prior to a fluid challenge test. Innovative continuous noninvasive concepts for advanced hemodynamic monitoring: the future in the ED? The commonly used hemodynamic measures in the ED are heart rate and intermittently obtained noninvasive blood pressure measurements using oscillometry. In recent years, however, large studies revealed severe limitations of the oscillometric method, for example, in obese and arrhythmic patients [65, 66]. Moreover, clinically relevant discrepancies between invasive arterial catheter-derived and oscillometrically obtained blood pressure were demonstrated in critically ill patients [67]. Invasive advanced hemodynamic monitoring technologies can still usually not be applied in an ED setting. In the future, however, innovative technologies allowing for a continuous and completely noninvasive estimation of blood pressure, CO, and other hemodynamic variables (e.g., pulse pressure variation, stroke volume variation) might allow advanced hemodynamic monitoring even in ED patients. Among the multiple applications, the option to monitor changes in CO in real time during functional tests (PLR, fluid challenge) via noninvasive continuous CO measurements appears particularly intriguing. Since CO and stroke volume are the hemodynamic variables that are most reliable in the prediction of fluid responsiveness [63], their continuous recording would help to identify those patients who are not fluid responsive, and thus might be harmed by further fluid administration [60]. Together with a potentially reduced probability of missing rapid changes in vital parameters [68, 69], continuous noninvasive monitoring of arterial pressure and blood flow in the ED may therefore markedly improve both patient safety and optimization of volume status and blood flow. A variety of noninvasive technologies have been proposed during the past years that might contribute to assessing a patient’s volume status, fluid responsiveness, and guiding fluid therapy in the ED in the future. The vascular unloading technique, for example, has already been proven to be feasible in continuous noninvasive blood pressure measurements in the ED setting [68, 69]. This method uses an inflatable finger cuff applying pressure to the finger and contains an infrared transmission plethysmograph to measure the finger artery diameter (i.e., blood volume) [70]. The arterial blood pressure waveform can then be indirectly deduced from the pressure that is needed to keep the volume in the finger artery constant throughout the cardiac cycle. Another noninvasive technology that allows continuous blood pressure monitoring and the estimation of CO is radial artery applanation tonometry [71– 74]. Additional techniques that allow for the estimation of CO include thoracic electrical bioimpedance, thoracic bioreactance, and pulse wave transit time [75]. As mentioned above, the use of these noninvasive technologies for continuous hemodynamic monitoring during the functional tests for fluid responsiveness might pose a powerful approach. In this context, it is important that Cecconi et al. determined dynamic arterial elastance (Ea dyn ) by using arterial pulse pressure analysis obtained by the aforementioned vascular unloading technology in spontaneously breathing patients [76]. Ea dyn was defined as the ratio between pulse pressure variation and stroke volume variation during one respiratory cycle. Importantly, patients who had an increase in MAP of ≥ 10 % after a fluid challenge possessed a significantly higher preinfusion- Ea dyn value than nonresponders. As a result, a preinfusion-Ea dyn > 1.06 identified fluid responders with both sensitivity and specificity of 88.2 %. While awaiting further validation, these findings underscore the potential of noninvasive arterial pulse pressure analysis for the assessment of fluid responsiveness that appears particularly well suited for the ED. At this point, however, these innovative technologies for continuous advanced hemodynamic monitoring still need to be further evaluated in the ED setting with regard to their clinical applicability and their measurement performance [77, 78]. Conclusions The correct assessment of the patient’s volume status and fluid responsiveness constitutes a fundamental and yet challenging task for the effective management of a wide variety of medical conditions that physicians encounter in the ED. In this review, we provide a detailed guide through a variety of methods applicable in the ED environment for the assessment of a patient’s intravascular volume status and fluid responsiveness. Based upon history, physical examination, laboratory tests, and ultrasound we propose an algorithm to estimate the intravascular volume status (. Fig. 1). In addition, we describe the functional tests to assess fluid responsiveness and their limitations in an ED setting. In the future, innovative noninvasive means of continuous hemodynamic monitoring may allow advanced hemodynamic monitoring in the ED. Authors’ contributions. C. Maurer was responsible for the conception and drafting of the review. J.Y. Wagner has made substantial contributions to the conception, was involved in drafting, and revised the manuscript for important intellectual content. R.M. Schmid revised the manuscript for important intellectual content. B. Saugel was responsible for the conception and drafting of the review. All authors read and approved the final manuscript. Corresponding address B. Saugel MD Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf Martinistrasse 52, 20246 Hamburg bernd.saugel@gmx.de Medizinische Klinik - Intensivmedizin und Notfallmedizin 4 · 2017 | 331

Übersichten Compliance with ethics guidelines Conflict of interest. B. Saugel collaborates with Pulsion Medical Systems SE (Feldkirchen, Germany) as a member of the Medical Advisory Board. Saugel received honoraria for giving lectures and refunds of travel expenses from Pulsion Medical Systems SE (Feldkirchen, Germany). Saugel received institutional research grants, unrestricted research grants, and refunds of travel expenses from Tensys Medical Inc. (San Diego, CA, USA). BS received honoraria for giving lectures and refunds of travel expenses from CNSystems Medizintechnik AG (Graz, Austria). J.Y. Wagner received institutional research grants, unrestricted research grants, and refunds of travel expenses from Tensys Medical Inc. (San Diego, CA, USA). J.Y. Wagner received refunds of travel expenses from CN- Systems Medizintechnik AG (Graz, Austria). For C. Maurer and R.M. Schmid there is no conflict of interest to disclose. 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