Bedside Ultrasoundbsiccm.org/sites/default/files/Conference/Event Files/US... · · 2017-06-07US...

US Guided Fluid ResuscitationMichiel J. van Veelen, Emergency Physician, DTM&H

Bedside Ultrasound

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Ultrasound Guided Fluids

Outline

• Shock and Fluid Resuscitation in ICU

• Ultrasound in Shock

• Ultrasound Guided Fluid Resuscitation

• Other Ultrasound applications in ICU

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Shock in ICU

“Cellular and tissue hypoxia due to reduced oxygendelivery and/or increased oxygen consumption or inadequate oxygen utilization”


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Fluid Resuscitation in ICU


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Fluid Resuscitation in ICU

Inadequate fluid resuscitation results in tissue hypoperfusion and worsening end-organ

dysfunction

vs.

Overresuscitation leading to a positive fluid balanceis associated with worsened mortality


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Shock in ICU


?

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Fluid responsiveness

• Non-invasive

hemodynamics

• Physical examination

• Invasive hemodynamics;

PAC, CVP, PPV, SVV…

• Passive leg raise test

• Fluid bolus


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Fluid responsiveness

Fluid responderCardiac output (CO) increases by 10-15% in response

to a fluid bolus

Non-responderDecreased CO or minimal increase


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Several US Shock protocols

• Goal Directed Echocardiography (GDE)

• Rapid Ultrasound in Shock (RUSH)

• Rapid Assessment by Cardiac Echo (RACE)


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Pros:

• Effective, noninvasive, rapid and accurately assesshemodynamically unstable patients at the bedside 1-3

• Differentiate between hypovolemic, cardiogenic, obstructive, and distributive shock 2-6

• Serial exams for monitoring 4,5


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Easy?

RUSH exam2


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Alternative?

Just 2 views:

- Inferior Vena Cava- The Lungs

1

2


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C. Lee, P. Kory, R. Arntfield.

Development of a fluid resuscitation protocol using

inferior vena cava and lung ultrasound

Journal of Critical Care, Volume 33, June 2016


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Systematic review of current literature

Evaluation of Ultrasound guided resuscitation studies using two (2) views:

• Inferior Vena Cava• Lung Ultrasound

Proposal of an easy to use algorithm

Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound


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Why Inferior Vena Cava

Spontaneous breathingintrathoracic pressure with inspiration draws blood from the vena cava into the heart, leading to collapse

Positive pressure ventilationintrathoracic pressure pushes blood from the heart

into the vena cava, leading to distention of the vessel.


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Interpretation

Static measurement of IVC diameter and variation with spontaneous respiration correlates with central venous pressure (CVP) 3,4

A change in IVC diameter with respiration of 12 -18% is associated with fluid responsiveness in mechanically ventilated patients 4-6


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IVC


LUNGS

Why Lung Ultrasound?


A B

LUNGS


LUNGS


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IVC

1


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IVC Measure diameter

<1.5cm Underfilled>2.5cm Distended1.5-2.5cm Normal

1


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IVC Diameter

>2.5cm: Hold Fluids

<1.5cm: FLUIDS

Normal: Step 2


Intubated?

Yes: Respiratory variation

No/Triggering: Lung Ultrasound

2A

2B


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IVC

Respiratory variation:[(Dmax − Dmin)/Dmax] × 100% > 12% ?

2A


Respiratory variation

>12%: FLUIDS

<12%:Lung Ultrasound 2B


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LUNGS

2B


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LUNGS2B


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A Lines

Fluid Test

B Lines

Hold Fluids

2B


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Ultrasound in ICU

Other applications in ICU:

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Hypovolemic Cardiogenic

Distributive Obstructive

?

Ultrasound in ICU

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Vascular access

Ultrasound in ICU

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Pneumothorax?

Ultrasound in ICU

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Infiltrate or Effusion?

Ultrasound in ICU

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Treatable causes in CPR

Ultrasound in ICU

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Or termination of CPR

Ultrasound in ICU

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Free fluid in traumaEctopic Pregnancy

AAABladder

GalbladderKidneys

….

Ultrasound in ICU

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Take home messages

• US is a reliable, affordable and rapid bedside test to evaluate for fluid responsiveness in the ICU patient in shock

• CAVE: Do not forget the entire clinical picture!

• US is operator dependent and requires practice

• US has many potential applications in ICU


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References

1. G.A. Schmidt, S. Koenig, P.H. Mayo: Shock. Ultrasound to guide diagnosis and therapy. Chest. 142 (4):1042-1048 2012

2. P. Perera, T. Mailhot, D. Riley, D. Mandavia: The RUSH exam: Rapid Ultrasound in SHockin the evaluation of the critically ill. Emerg Med Clin North Am. 28 (1):29-56, vii February 2010

3. E. Manno, M. Navarra, L. Faccio, et al.: Deep impact of ultrasound in the intensive care unit: the “ICU-sound” protocol. Anesthesiology. 117 (4):801-809 October 2012

4. A. Dipti, Z. Soucy, A. Surana, S. Chandra. Role of inferior vena cava diameter in assessment of volume status: a meta-analysis. Am J Emerg Med, 30 (8) (2012) [1414–1419.e1]

5. C.Lee, P. Kory, R. Arntfield. Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound, Journal of Critical Care, Volume 33, June 2016, Page 267

6. D.A. Lichtenstein, G.A. Mezière: Relevance of lung ultrasound in the diagnosis of acute respiratory failure the BLUE protocol. Chest. 134:117-125 2008


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Ultrasound Course

Bedside Ultrasound

Course

What

One-day SA college of EM accredited introduction course provided

by international faculty: E-FAST, DVT, Cardiac, Aorta and IV acces.

Target Audience

Doctors of all specialties interested in improving their bedside

diagnostic skills using US, especially in acute settings

When and where

Friday 16th of June 2017, Faculty of Health Sciences 246, Room

xxx

Costs

1250 Pula, incl. online study material, certificate, food and drinks

Registration

Payment is made at Vote P0129, please mention Ultrasound

course. Deliver receipt to UB teaching Hospital, ground floor, Office

1004. Training is done on first come first serve basis and ONLY

after payment is made.

Questions: [email protected]

Department of Accident &

Emergency

Registration open

16th of June

Full day course

Pre-course material

• E-FAST• DVT• Cardiac and IVC• Aorta• Central Venous Access

Certificate EMSSA

1250 Pula

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