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the ICU
To bolus or not to bolus
that is the question.
PulmCrit.com
Case
49
yo M is BIB ambulance after being found down by friends last seen 48 hours earlier
Initial
PE
In
ED: Intubated, anti-bx, 2L crystalloid, Levofed. After intubation requiring 80% FIO2/10
PEEP for sats 92%
Initial
Bedside
CXR
BNP
Case
The
What
do you do next?
Objectives
Define
Understand
Review
Aim
Increase
Fluid
Predictors
lactate levels
Oliguria
Altered
mental status/confusion
Cardiac Output
CO=SVxHR
Frank-Starling curve
Preload
Arthur
Venous
ARDSNet
breathing patients:
In
MV pts:
Hemodynamic effects of
mechanical ventilation
MV effects on PPV
CVP/PCWP
CXR
PiCCO
EVLW
One
leg raise
End-expiratory
Ultrasound:
Systolic
(SVV)
occlusion test
Low
Despite
Perfusion
PVI:
http://www.masimo.cn/pvi/
Echocardiography
Respiratory
Assumes
Feissel
SVC
Major
Removes
Stroke
Stroke volume variation (SVV) - using mechanical ventilationinduced changes in preload resulting in variation of stroke volume
Pulse pressure variation (PPV) - using mechanical ventilationinduced changes in preload resulting in variation of pulse pressure
Pulse pressure variation (PPV) = (PPmax PPmin) / Ppmean
PPV
SVV
Both
SVV
and PPV have been found to be far better predictors than static
indicators
Spontaneous
ARDS
PEEP
Arrhythmia
Low
Open
chest
Right
Meds:
Equipment
SVV
SVV
FloTrac/Vigileo systems
CNAP
PPV
This difference explained by the fact that pulse pressure is not only a
direct measure of stroke volume, but also depends on arterial
compliance
One
Volume
The
only predictor of MAP increase was Eadyn (AUC, 0.986 0.02; 95% CI,
0.84-1)
occlusion test
PEEPinduced
Fluid
Measuring
Problem
PLR
Case
The
What
do you do next?
References
Marik PE, Cavallazzi R. Does the central venous pressure (CVP) predict fluid responsiveness: an update meta-analysis
and a plea for some common sense. Crit Care Med 2013;41:177481.
Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid
responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009
Sep;37(9):2642-7.
Feissel M, Michard F, Mangin I, et al. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness
in ventilated patients with septic shock. Chest 2001; 119: 86773.
Maizel J, Airapetian N, Lorne E, et al. Diagnosis of central hypovolemia by using passive leg raising. Intensive Care Med
2007; 33: 11338.
Lamia B, Ochagavia A, Monnet X, et al. Echocardiographic prediction of volume responsiveness in critically ill patients
with spontaneously breathing activity. Intensive Care Med 2007; 33: 112532.
Boyd JH, Forbes J, Nakada T, et al: Fluid resuscitation in septic shock: A positive fluid balance and elevated central
venous pressure increase mortality. Crit Care Med 39:259-265, 2011
Barbier C, Loubires Y, Schmit C, Hayon J, Ricme JL, Jardin F, et al. Respiratory changes in inferior vena cava diameter
are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med. 2004;30(9):17406.