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

More documents

Recommendations

Info

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. This article does not contain studies on human or animal subjects. References 1. Angus DC, van der Poll T (2013) Severe sepsis and septic shock. N Engl J Med 369:840–851 2. Wu BU, Banks PA (2013) Clinical management of patients with acute pancreatitis. Gastroenterology 144:1272–1281 3. Nadeau-Fredette AC, Bouchard J (2013) Fluid management and use of diuretics in acute kidney injury. Adv Chronic Kidney Dis 20:45–55 4. Bhave G, Neilson EG (2011) Volume depletion versus dehydration: how understanding the difference can guide therapy. Am J Kidney Dis 58:302– 309 5. Vincent JL, De Backer D (2014) Circulatory shock. N Engl J Med 370:583 6. Vincent JL, Ince C, Bakker J (2012) Clinical review: circulatory shock—an update: a tribute to Professor Max Harry Weil. Crit Care 16:239 7. Gross CR, Lindquist RD, Woolley AC, Granieri R, Allard K, Webster B (1992) Clinical indicators of dehydration severity in elderly patients. J Emerg Med 10:267–274 8. Stephan F, Flahault A, Dieudonne N, Hollande J, Paillard F, Bonnet F (2001) Clinical evaluation of circulating blood volume in critically ill patients— contribution of a clinical scoring system. Br J Anaesth 86:754–762 9. Koziol-McLain J, Lowenstein SR, Fuller B (1991) Orthostatic vital signs in emergency department patients. Ann Emerg Med 20:606–610 10. McGee S, Abernethy WB III, Simel DL (1999) The rational clinical examination. Is this patient hypovolemic? JAMA 281:1022–1029 11. Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT (2005) Does this dyspneic patient in the emergency department have congestive heart failure? JAMA 294:1944–1956 12. Badgett RG, Lucey CR, Mulrow CD (1997) Can the clinical examination diagnose left-sided heart failure in adults? JAMA 277:1712–1719 13. Killip T III, Kimball JT (1967) Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol 20:457–464 14. Saugel B, Ringmaier S, Holzapfel K, Schuster T, Phillip V, Schmid RM et al (2011) Physical examination, central venous pressure, and chest radiography for the prediction of transpulmonary thermodilutionderived hemodynamic parameters in critically ill patients: a prospective trial. J Crit Care 26:402–410 15. Chung HM, Kluge R, Schrier RW, Anderson RJ (1987) Clinical assessment of extracellular fluid volume in hyponatremia. Am J Med 83:905–908 16. Dossetor JB (1966) Creatininemia versus uremia. The relative significance of blood urea nitrogen and serum creatinine concentrations in azotemia. Ann Intern Med 65:1287–1299 17. Schrier RW (2007) Decreased effective blood volume in edematous disorders: what does this mean? J Am Soc Nephrol 18:2028–2031 18. Swedko PJ, Clark HD, Paramsothy K, Akbari A (2003) Serum creatinine is an inadequate screening test for renal failure in elderly patients. Arch Intern Med 163:356–360 19. Carvounis CP, Nisar S, Guro-Razuman S (2002) Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure. Kidney Int 62:2223–2229 20. Pepin MN, Bouchard J, Legault L, Ethier J (2007) Diagnostic performance of fractional excretion of urea and fractional excretion of sodium in the evaluations of patients with acute kidney injury with or without diuretic treatment. Am J Kidney Dis 50:566–573 21. Wo CC, Shoemaker WC, Appel PL, Bishop MH, Kram HB, Hardin E (1993) Unreliability of blood pressure and heart rate to evaluate cardiac output in emergency resuscitation and critical illness. Crit Care Med 21:218–223 22. Kjelland CB, Djogovic D (2010) The role of serum lactate in the acute care setting. J Intensive Care Med 25:286–300 23. Howell MD, Donnino M, Clardy P, Talmor D, Shapiro NI (2007) Occult hypoperfusion and mortality in patients with suspected infection. Intensive Care Med 33:1892–1899 24. Nguyen HB, Rivers EP, Knoblich BP, Jacobsen G, Muzzin A, Ressler JA et al (2004) Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 32:1637–1642 25. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al (2010) Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 23:685–713 (quiz 86–8) 26. Feissel M, Michard F, Faller JP, Teboul JL (2004) The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med 30:1834–1837 27. Weekes AJ, Tassone HM, Babcock A, Quirke DP, Norton HJ, Jayarama K et al (2011) Comparison of serial qualitative and quantitative assessments of caval index and left ventricular systolic function during early fluid resuscitation of hypotensive emergency department patients. Acad Emerg Med 18:912–921 28. Tetsuka T, Ando Y, Ono S, Asano Y (1995) Change in inferior vena caval diameter detected by ultrasonography during and after hemodialysis. ASAIO J 41:105–110 29. Fields JM, Lee PA, Jenq KY, Mark DG, Panebianco NL, Dean AJ (2011) The interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients. Acad Emerg Med 18:98–101 30. Yanagawa Y, Nishi K, Sakamoto T, Okada Y (2005) Early diagnosis of hypovolemic shock by sonographic measurement of inferior vena cava in trauma patients. J Trauma 58:825–829 31. Yanagawa Y, Sakamoto T, Okada Y (2007) Hypovolemic shock evaluated by sonographic measurement of the inferior vena cava during resuscitation in trauma patients. J Trauma 63:1245–1248 (discussion 8) 32. Sefidbakht S, Assadsangabi R, Abbasi HR, Nabavizadeh A (2007) Sonographic measurement of the inferior vena cava as a predictor of shock in trauma patients. Emerg Radiol 14:181–185 33. Corl K, Napoli AM, Gardiner F (2012) Bedside sonographic measurement of the inferior vena cava caval index is a poor predictor of fluid responsiveness in emergency department patients. Emerg Med Australas 24:534–539 34. Neskovic AN, Hagendorff A, Lancellotti P, Guarracino F, Varga A, Cosyns B et al (2013) Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations. Eur Heart J Cardiovasc Imaging 14:1–11 35. Lancellotti P, Price S, Edvardsen T, Cosyns B, Neskovic AN, Dulgheru R et al (2015) The use of echocardiography in acute cardiovascular care: recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care 4:3–5 36. Levitov A, Marik PE (2012) Echocardiographic assessment of preload responsiveness in critically ill patients. Cardiol Res Pract 2012:819696 37. Ely EW, Haponik EF (2002) Using the chest radiograph to determine intravascular volume status: the role of vascular pedicle width. Chest 121:942– 950 38. Halperin BD, Feeley TW, Mihm FG, Chiles C, Guthaner DF, Blank NE (1985) Evaluation of the portable chest roentgenogram for quantitating extravascular lung water in critically ill adults. Chest 88:649– 652 39. Milne EN, Pistolesi M, Miniati M, Giuntini C (1984) The vascular pedicle of the heart and the vena azygos. Part I: the normal subject. Radiology 152:1–8 40. Ely EW, Smith AC, Chiles C, Aquino SL, Harle TS, Evans GW et al (2001) Radiologic determination of intravascular volume status using portable, digital chest radiography: a prospective investigation in 100 patients. Crit Care Med 29:1502–1512 41. Theodoro D, Owens PL, Olsen MA, Fraser V (2014) Rates and timing of central venous cannulation among patients with sepsis and respiratory arrest admitted by the emergency department. Crit Care Med 42:554–564 42. Reade MC, Huang DT, Bell D, Coats TJ, Cross AM, Moran JL et al (2010) Variability in management of early severe sepsis. Emerg Med J 27:110–115 43. Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F et al (2014) A randomized trial of protocol-based care for early septic shock. N Engl J Med 370:1683–1693 332 | Medizinische Klinik - Intensivmedizin und Notfallmedizin 4 · 2017
Page 1 and 2: Übersichten Med Klin Intensivmed N
Page 3 and 4: Abstract · Zusammenfassung evaluat
Page 5: Übersichten Patient admitted to ED

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?