fluid for a septic shock patient with ARDS,and history of CRF?

[ketap]

hi,i need some opinion from all of you..i had a patient who was diagnosed as septic shock because of its clinical signs (high fever, warm extremity, very high heart rate:130-150, low blood pressure with increased pulse pressure (low map:50-60 mmHg), Sa02 90-93% intubated) and also the complete blood count (high leucocytes, low Hb and Ht) and also the high D dimer..the BGA revealed acidosis metabolic with concomitant alkalosis respiratory. PO2/Fio2 ratio < 200 and, from the history, he had a chronic renal failure.

i need opinion from you, after only 1 liters of RL solution, we recognized little rales from this patient's dependent right lung...so ,my friend told me not to give any more fluid because the ARDS causing the increased permeability of pulmonary vasculature and if we gave any more fluid, we can make more pulmonary edema and worsen the oxygenation...but there was no other signs of hypervolemia besides that rales and the blood pressure was still decreasing with no response moderate dose of dobutamine and dopamine and the pulse was still weak. oh , the patient's family resisted to have the invasive procedure such as CVC , PAOP and NIABP for this patient, so we can't measure it by those tools..

what do you think i should do for this patient?

how can i correct the hypovolemia from a patient who had a septic shock with ARDS complication and a history of Chronic Renal Failure? can we give volume rescucitation without causing the pulmonary edema?

please help me with some opinion..thx u

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[jdh71]

hi,i need some opinion from all of you..i had a patient who was diagnosed as septic shock because of its clinical signs (high fever, warm extremity, very high heart rate:130-150, low blood pressure with increased pulse pressure (low map:50-60 mmHg), Sa02 90-93% intubated) and also the complete blood count (high leucocytes, low Hb and Ht) and also the high D dimer..the BGA revealed acidosis metabolic with concomitant alkalosis respiratory. PO2/Fio2 ratio < 200 and, from the history, he had a chronic renal failure.

i need opinion from you, after only 1 liters of RL solution, we recognized little rales from this patient's dependent right lung...so ,my friend told me not to give any more fluid because the ARDS causing the increased permeability of pulmonary vasculature and if we gave any more fluid, we can make more pulmonary edema and worsen the oxygenation...but there was no other signs of hypervolemia besides that rales and the blood pressure was still decreasing with no response moderate dose of dobutamine and dopamine and the pulse was still weak. oh , the patient's family resisted to have the invasive procedure such as CVC , PAOP and NIABP for this patient, so we can't measure it by those tools..

what do you think i should do for this patient?

how can i correct the hypovolemia from a patient who had a septic shock with ARDS complication and a history of Chronic Renal Failure? can we give volume rescucitation without causing the pulmonary edema?

please help me with some opinion..thx u

If there is still room on the O2 sat, the PEEP, and the FiO2, I give the fluids if I think they need it.

 

[Hernandez]

how can i correct the hypovolemia from a patient who had a septic shock with ARDS complication and a history of Chronic Renal Failure? can we give volume rescucitation without causing the pulmonary edema?

don't miss the forest for the trees.

1) how do you know he's hypovolunemic?
2) what's the history of CDkd? dialysis dependent?
3) what type of acidosis?

if the family doesn't want invasive procedures, then the pt needs DNR status, in this situation he can and will loose hands/fingers from vasopressors via a peripheral iv, and he'll quickly be heading to ARF that will necessitate Dialysis,

as far as fluids, give them and then give some more, hemodynamic support takes precedence to lung wetness, and you'll still have other tricks if need be to help with oxygenation. now read the facct trial.

 

[europeman]

The family does not get to 'choose' which invasive procedures and which medications you are going to start.

They either should agree to an aggressive trial of critical care, and sign all your consents (within reason), or should agree to aggressive palliative care.

You can't half ass it.

Why was this patient on dobuatmine and dopamine? that combo doesn't make much sense.

This pt is septic. Who cares if they are getting fluid overloaded... they need fluids based on his/her perfusion status and better airway control w/intubation.

The care you provided was not good.

If you do not provide aggressive critical care APPROPRIATELy, and instead cherry pick this and that procedure/drug/method, then you are actually HURTING THE PATIENT.

that's my opinion at least.

 

[ketap]

hi,Friends..thx u so much for the opinions..those opinions are very valuable to me to evaluate myself..

If there is still room on the O2 sat, the PEEP, and the FiO2, I give the fluids if I think they need it.

jdh71: thx u for the opinion, i guess that's true

Hernandez:

1) how do you know he's hypovolunemic?
2) what's the history of CDkd? dialysis dependent?
3) what type of acidosis?

1. i don't know, that's why i regret that the family didn't want to have any invasive pressure monitoring..i can only use unreliable BP monitoring, BGA and his clinical signs,..
2.yup, he is quiet dialysis dependent..
3. metabolic acidosis with concomitant respiratory alkalosis..

Why was this patient on dobuatmine and dopamine? that combo doesn't make much sense.

This pt is septic. Who cares if they are getting fluid overloaded... they need fluids based on his/her perfusion status and better airway control w/intubation.

The care you provided was not good.

If you do not provide aggressive critical care APPROPRIATELy, and instead cherry pick this and that procedure/drug/method, then you are actually HURTING THE PATIENT.

that's my opinion at least.

i completely agree with you, and i did think so,europeman..i wondered myself because a senior doctor wanted me to do so..that's why i post this case to ask for your opinions because i think the management was quiet wrong and to harsh, hopefully this will be a lesson for me too so i can be better in the future..thx, Europeman oh,btw, can you please explain to me what action that i have made for this patient that you think as the "cherry picking"?

thx u

 

[sluggs]

In the first six hours of your resuscitation you want to push fluids through a CVL until you give the patient approprriate cardiac filling pressures (you can target a CVP or more appropriately a more exquisite measure such as pulse pressure variation or cardiac output). If this does not restore the MAP > 65 you need to start pressors and possibly ionotropes, per Rivers' EGDT. This is the standard of care for septic patients in shock, even if they have heart failure or kidney failure. Advanced hemodynamic monitoring may or may not help you avoid overfilling. If the family will not allow a CVL, you are stuck giving fluids and "hoping for the best". (usually not good).
After the 6 hour resusc window, then focus on dryness for ARDS (FACT TRIAL).

 

[Hernandez]

CVP is a complete waste of time and tells you nothing about volume status. And Boyd et al in feb o this year in ccm show that having cvps in the range of egdt has higher mortality than lower cvp....

 

[jdh71]

CVP is a complete waste of time and tells you nothing about volume status. And Boyd et al in feb o this year in ccm show that having cvps in the range of egdt has higher mortality than lower cvp....

Once you're in the unit, sure, CVP doesn't matter as much.

However, when the gomer presents to the ED and EGDT is started CVP is still helpful within that context at least this is River's defense and his counter point when everyone starts giving him sheet about CVP when I've seen him speak. And while you can throw out CVP in general when you look at all comers, I think trends can often helpful in select patients. Plus if the CVP is 20 or 1 that is helpful information.

 

[Hernandez]

Once you're in the unit, sure, CVP doesn't matter as much.

However, when the gomer presents to the ED and EGDT is started CVP is still helpful within that context at least this is River's defense and his counter point when everyone starts giving him sheet about CVP when I've seen him speak. And while you can throw out CVP in general when you look at all comers, I think trends can often helpful in select patients. Plus if the CVP is 20 or 1 that is helpful information.

I vehemently disagree, I'll pontificate later since if NICU doesn't kill me today

 

[jdh71]

I vehemently disagree, I'll pontificate later since if NICU doesn't kill me today

I await your response.

EDIT: And vehemently?

 

[Hernandez]

EDIT: And vehemently?

worthless tests are worthless, no matter you dress them up.....

 

[jdh71]

worthless tests are worthless, no matter you dress them up.....

I think it's still being sorted out. Boyd's stuff was retrospective in nature, plus it lacked the ability to say much about fluids and CVP BEFORE 12 hours, plus they readily admit that their results may simply be the result if severity if illness. I tend to agree that after a patient has been around awhile the CVP matters much less when you look at all comers. And most likely should not be used as resuscitation goal in and of itself. However, I think you can in the right patients get valuable data, or at least a better guess about things in the absence of bedside echo.

 

[europeman]

ketap,

What i meant is that it's not appropriate to give half ass care.

As a physician, you need to determine if the patient is treatable or futile. Then you come up with a plan, and discuss it with the family after you get a sense the whole situation.

If the goal is to treat the patient for curative intent (or, at the least, to get them back to some sense of quality of life which the patient/family wants) then you have to give them maximum aggressive critical care.

that means doing anything (within reason here) you need to do that. if that means putting in an artieral line and a central line and starting crazy drugs like pressors and doing dialysis then you have to get the family to agree.

They can't be allowed to say "well, you can give one pressor but not two" or somethign crazy like that. They can't be in an ICU and not agree to a central line. Just not acceptable.

When that happens it's, in my opinion, usually the fault of the physician in how they explained/asked the family. When it's done in the appropriate fashion, it's usually not a problem.

I'm a surgeon, so for me it goes a step further, you can imagine, because what I do is MAXIMALLY invasive. So it's even more of an issue for me.

Weingart has a great piece about this sorta topic regarding end of life discussions geared towards ER physicians, but his point is excellent and I think you may enjoy
http://emcrit.org/podcasts/end-of-life-care/

Now of COURSE there are particular situations where this isn't the case, but i'm talking generally.


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As for CVP, it is certainly *NOT* the "standard of care" for septic patients. It may be at your institution where they make you believe that, but it's certainly not the national standard of care. I'm in a tertiary new york city hospital and we *NEVER* use CVP. I AGREE, pretty worthless number/trend.

 

[Xerxes1729]

I'm with you, europeman. Medicine is not a mix-and-match menu - you do not get to choose one from column A, one from column B, and refuse column C. Families and patients are the ones who set the big goals, i.e., curative therapy versus comfort, but physicians get to make decisions about central and arterial lines. I remember a time in medical school when there was a patient in the unit, tubed, on pressors, etc. She eventually needed dialysis, but the family refused, and the attending sat them down and said, "She's in the ICU, which means we're going to do everything we can to get her better, and that includes dialysis now. If you want to change the goals of care, that's fine and we can move her out of the unit, but if we don't start dialysis, then none of this other stuff will matter because she'll die of renal failure." Except she said it more tactfully. My current hospital has this ridiculous critical care consent form where you have to consent patients to all sorts of procedures individually. So you end up with people consented for paracentesis but not thoracentesis, or vice versa. People who you can float a Swann on but can't put an a-line in. Or who are okay with intubation but not TEE. It's bizarre, and it takes forever to do.

 

[jdh71]

As for CVP, it is certainly *NOT* the "standard of care" for septic patients. It may be at your institution where they make you believe that, but it's certainly not the national standard of care. I'm in a tertiary new york city hospital and we *NEVER* use CVP. I AGREE, pretty worthless number/trend.

The surviving sepsis campaign uses it in their guidelines, for better or worse, there it is . . . it's turning out that it probably should not be an end goal of resuscitation as per Rivers' EGDT. Though with the right clinical context it can be helpful.

And as for "standard of care" - that's a difficult one to throw around, because you can't have "your" standard of care and I can have "my" standard of care. Something either is standard of care or, it is not. And often standards are not always driven by the literature or science - peer-review and EBM are not some sort of end all, be all either . . . bottom line is if most people are doing it and you are not, and I'm not explicitly saying that CVP is "SOC", then you may be in trouble if something goes wrong.

 

[SLUser11]

The surviving sepsis campaign uses it in their guidelines, for better or worse, there it is . . . it's turning out that it probably should not be an end goal of resuscitation as per Rivers' EGDT. Though with the right clinical context it can be helpful.

And as for "standard of care" - that's a difficult one to throw around, because you can't have "your" standard of care and I can have "my" standard of care. Something either is standard of care or, it is not. And often standards are not always driven by the literature or science - peer-review and EBM are not some sort of end all, be all either . . . bottom line is if most people are doing it and you are not, and I'm not explicitly saying that CVP is "SOC", then you may be in trouble if something goes wrong.

Agree 100%.

CVP is not perfect, but it's not worthless, either. It's simply one tool in your toolbox to use on complicated ICU patients. Obviously, you shouldn't use the CVP numbers to change treatment if they don't fit the clinical picture...but the same goes for lots of tests and measurements in the ICU.

Since we're sort of on the topic of ICU measurement devices, how many of you are currently using central lines that measure SvO2? We did it for a while around 2006-2008, and used it to direct resuscitation. This was a part of a Pulm/CC-developed sepsis protocol.

However, during the late years of my residency, I almost never used them....not only because I was using different toys to guide resuscitation, but also because the catheter itself was too stiff and finicky.

 

[jdh71]

Agree 100%.

CVP is not perfect, but it's not worthless, either. It's simply one tool in your toolbox to use on complicated ICU patients. Obviously, you shouldn't use the CVP numbers to change treatment if they don't fit the clinical picture...but the same goes for lots of tests and measurements in the ICU.

Since we're sort of on the topic of ICU measurement devices, how many of you are currently using central lines that measure SvO2? We did it for a while around 2006-2008, and used it to direct resuscitation. This was a part of a Pulm/CC-developed sepsis protocol.

However, during the late years of my residency, I almost never used them....not only because I was using different toys to guide resuscitation, but also because the catheter itself was too stiff and finicky.

I don't use the special catheter. If I feel like getting a venous o2 sat I just pull it off of the central line I have in and correlate things clinically. The purest get all twisted about the differences between the Scv02 and the Sv02. If it's 40 or 95 the difference between the two would be pretty much academic. Thing is lactate is just as good of a marker per the recent literature, so I'm using lactate more these days and I trend them, but I can usually get a central venous o2 sat back a lot faster, so when I've got someone who's really sick, I'll send an o2 sat from the line I'm putting in along with a lactate. I think the two together initially give me a better idea of what I'm dealing with.

 

[europeman]

CVP is not just "another tool in your toolbox"

it's literally a worthless number

I mean, if flipping a coin is a number which is another tool in your toolbox, then, by all means use it.

too many variables to make its value worthwhile.

besides, now a days there are so many other better methods of assessing volume status, why do CVP (unless you aren't willing to use these skillls or have the devise). For example, arterial line wave variation in the right patient, and bedside dynamic ultrasuond (to look at heart or ivc variation, etc). Jeez, you're better off just giving 6 liters of fluid blindly and if that doesn't work give pressors!

The critical care literature is filled with examples of therapies that were initially supported by physiological observations; many of these therapies were latershown to be worthless/harmful. Examples include high tidal volumes to improve blood gases, aggressive transfusion practice to improve oxygen carrying capacity, aggressive ventilation to correct respiratoryacidosis, dopamine to increase urine output, dobutamine to increase oxygendelivery, etc

And, cvp is next in line. It will not be in the next surviving sepsis guidelines i'll tell you that!

Simply said, the only studies which show outcomes with CVP are improved are clinical. And that's not good enough! There are NO SOUND PHYSIOLOGICAL studies to my knolwedge showing cvp works. I guess the argument goes that since there are no sound physiological studies showing that CVP has worth to begin with, then it simply doesn't make sense to put it into a study to test for outcome. To put it another way, if another measurement that made no physiologic sense was put into the Rivers study instead of CVP, say, the number of freckles that a patient has as a proxy to their fluid responsiveness, and you still got a better outcome with the cases versus the controls, surely you wouldn't be convinced that was convincing data.


let me kindly refer you to a wonderful article in chest...

marik, baram, vahid. Does Central Venous Pressure Predict Fluid Responsiveness?*Chest July 2008 134:172-178

 

[Hernandez]

we have the flotrac catheters but I only use them if I'm in the mood to use it or were putting it in for the research project going on.

and out comes the tale of seven mares. I'm with euroman, I typically have a quarter on hand in my white coat, I might as well use it. and if you're using a test that likey won't change your management, why are you using it in the first place?

 

[SLUser11]

CVP is not just "another tool in your toolbox"

it's literally a worthless number

I think calling it "worthless" is going a little too far.

I also believe it's dangerous to think and talk in absolutes.


As I mentioned in this thread, people who talk like that, experts or not in their field, will most likely be eating a lot of their words in as little as 10-15 years on many topics, because our evidence-based medicine is changing all the time.

There are plenty of "universal truths" that are being challenged all the time, and our voodoo is constantly being exposed....in my field, it is things like bowel preps, bowel rest, perioperative antibiotics, to explore or not, to divert or not, etc.

I think people who are well-read and real students of medicine should not develop a dismissive, know-it-all attitude that results in these absolute statements. Instead, we should be more Socratic, and acknowledge that we are knowledgeable because we know that we don't know.

I'll be the first to admit that there are lots of things I do in patient care that are more voodoo than stone cold facts.

 

[SLUser11]

and if you're using a test that likey won't change your management, why are you using it in the first place?

But it does change my management...I just take the number with a grain of salt. On a similar note, if I'm placing a central line, and there's heavy backflow of blood through the cook needle, I know that the patient is likely fluid overloaded...of course, I doubt any good evidence can back that up....but I use that to guide therapy.

And I don't recommend the cook needle thing to anybody...when most people see it, it means they are in the artery.

 

[jdh71]

You have to take the whole clinical picture into consideration for "end goals" of resuscitation - people keep chasing magic variables and cut-offs. Bottom line any doctor that can be replaced by an algorithm, should be.

CVP is probably a bad marker for end resuscitation goals, no one is arguing otherwise. To say that it's not useful or meaningful in anyway is plainly wrong. Don't think it measures anything? Dial up the PEEP and you'll see the CVP go up as well. It is measuring something, and can be very helpful information into what you're got going on hemodynamically on the right side of things. There are so many more variables going on with the distribution of blood on the left side of things, first through the lungs, and then through the systemic circulation within the context of whatever particular pathophysiology you have going on that by itself CVP shouldn't be used in isolation and never should have in the first place. Completely tossing it is getting rid of the baby with the bathwater.

 

[Hernandez]

To say that it's not useful or meaningful in anyway is plainly wrong. Don't think it measures anything? Dial up the PEEP and you'll see the CVP go up as well.

stop the presses, CVP measures pressures and is affected by extrinsically applied pressures. let's take it a step further, should we drop esophageal probes down everyone who's intubated? what about pleural manometry? Swan? continuous Left atrial pressure monitoring? CVP gives such a small sliver of information, that it's touted purpose is woefully inadequate to the job. I can't say I never hook a CVP up, but I can say I never use it to guide resuscitative end points in any fashion. I use it to confirm line placement in the hypotensive pts I'm not 100% sure about before I dilate and in ards pts I'm trying to follow the FACCT trial protocol in.

I for one await the PRoCCess study's results.

You have to take the whole clinical picture into consideration for "end goals" of resuscitation - people keep chasing magic variables and cut-offs. Bottom line any doctor that can be replaced by an algorithm, should be.

CVP is probably a bad marker for end resuscitation goals, no one is arguing otherwise. To say that it's not useful or meaningful in anyway is plainly wrong. Don't think it measures anything? Dial up the PEEP and you'll see the CVP go up as well. It is measuring something, and can be very helpful information into what you're got going on hemodynamically on the right side of things. There are so many more variables going on with the distribution of blood on the left side of things, first through the lungs, and then through the systemic circulation within the context of whatever particular pathophysiology you have going on that by itself CVP shouldn't be used in isolation and never should have in the first place. Completely tossing it is getting rid of the baby with the bathwater.

with this line of reasoning we might as well start swaning everyone again. without having a way to determine the compliance of the vessels non-or minimally invasively, then a static pressure measurement will never be able to guide fluid resuscitation. clinical exam and variables such as urine output, straight reg raising and +/- on SVV are going to remain the mainstays of how I manage fluids in a septic pt. especially in light of Boyds article I referee too earlier.

 

[jdh71]

stop the presses, CVP measures pressures and is affected by extrinsically applied pressures. let's take it a step further, should we drop esophageal probes down everyone who's intubated? what about pleural manometry? Swan? continuous Left atrial pressure monitoring? CVP gives such a small sliver of information, that it's touted purpose is woefully inadequate to the job. I can't say I never hook a CVP up, but I can say I never use it to guide resuscitative end points in any fashion. I use it to confirm line placement in the hypotensive pts I'm not 100% sure about before I dilate and in ards pts I'm trying to follow the FACCT trial protocol in.

You make my points. CVP's no good for end of resuscitation goals (which no one claimed, so I'm not sue who you're arguing against), but it's still useful.

And as far as esophageal probes, pleural monometry, and swans go, I guess you could do any of those to get the SAME information CVP is already giving you, but why?

with this line of reasoning we might as well start swaning everyone again. without having a way to determine the compliance of the vessels non-or minimally invasively, then a static pressure measurement will never be able to guide fluid resuscitation. clinical exam and variables such as urine output, straight reg raising and +/- on SVV are going to remain the mainstays of how I manage fluids in a septic pt. especially in light of Boyds article I referee too earlier.

It'd be silly to swan everyone again, they've never shown benefits. In fact, I'd like to know one vascular "monitoring" modality that we've tried or currently use that has actually shown it demonstrates any sort of mortality benefit.

And I talked about Boyd's article. It was interesting, but cannot say too much in the end. It was a retrospective sub-group analysis in patients who were never enrolled in the original study to look at CVP. The higher CVP (12+) group had worse outcomes. Ok. So what? The study can't do what I think you want it to.

 

[Hernandez]

You're almost sounding like neglect here jdh, on one hand you say it's useful in the ED but not in the icu but it's still useful. Then just how is cvp useful? I can pull the data that higher cvp is an independent risk factor for renal dysfunction, or morbidity, and post Mariks operator receiver curve which shows cvp does not predict fluid responsiveness, so just where do you find cvp useful? And if it's not for resuscitation end points (and I'd argue people use it for that every damn day) what are you using it for?

As far as the other invasive things I posted, they all measure slightly different intrathoracic pressures and have different uses, so if cvp is so useful perhaps you should combine it with the rest if the data. And you can jut ignore Boyds data, as this is exactly how it started with swan data, and it was a typical sepsis study, so how can you ignore that in a well done sepsis study that Pts with higher cvp had higher mortality?

 

[jdh71]

You're almost sounding like neglect here jdh, on one hand you say it's useful in the ED but not in the icu but it's still useful. Then just how is cvp useful? I can pull the data that higher cvp is an independent risk factor for renal dysfunction, or morbidity, and post Mariks operator receiver curve which shows cvp does not predict fluid responsiveness, so just where do you find cvp useful? And if it's not for resuscitation end points (and I'd argue people use it for that every damn day) what are you using it for?

You know Hern, this is one of the reasons why I like pulmonary better. And I don't know why it is, but there seems to be no room for people to disagree in critical care. You see this all the time at meetings. People trying to mother**** each other, toss each other under the bus, make the other guy look like he doesn't know what he's doing. No room to disagree without being disagreeable . . . pulling the neglect card is bull****, especially with someone I count as a friend, but there it is . . . classy. Thanks man.

One of Rivers arguments is that CVP gives you more important information when the patient hits the door than later - if the CVP is low when the patient hits the door, and then responds with fluids, you can say the patient was definitely fluid down, and giving the fluids was definitely needed (Hell, even Boyd's paper says that CVP may be helpful for resuscitation early septic shock right in the abstract). I tried explaining this to you earlier, but you simply were not hearing what I was saying. CVP is going to give me an idea of what is going on on the venous side of things. The problem here being there is a whole lot more patient and pathophysiology between where the CVP is measuring through the heart, lungs, arterial system, and back to the tissues to make any clear claims that CVP can be used to decide or define the end of resuscitation.

As far as the other invasive things I posted, they all measure slightly different intrathoracic pressures and have different uses, so if cvp is so useful perhaps you should combine it with the rest if the data. And you can jut ignore Boyds data, as this is exactly how it started with swan data, and it was a typical sepsis study, so how can you ignore that in a well done sepsis study that Pts with higher cvp had higher mortality?

I'm not ignoring it. It's interesting, but is likely showing exactly what we already know, sicker patient's die (something we al know). The information isn't teased out, outside of a statistical association.

Your question is like saying, "how can you ignore the fact that in a well done spesis study patient's with blue eyes had higher mortalities?" I'm not ignoring what the study said, but it's retrospective, and the original VASST trial was not set up to look at CVP as a marker for end of resuscitation, or to look at CVP as any kind of end point. These guys did what many of us do and mined their data for interesting and provocative statistical associations that could not only get published, but continue the discussion and drive future investigation. I'm simply being honest in what it has the power to say and not say. Boyd's data is not a reason to not measure CVP or take it into consideration from a whole patient perspective when making bedside decisions.

 

[Hernandez]

You know Hern, this is one of the reasons why I like pulmonary better. And I don't know why it is, but there seems to be no room for people to disagree in critical care. You see this all the time at meetings. People trying to mother**** each other, toss each other under the bus, make the other guy look like he doesn't know what he's doing. No room to disagree without being disagreeable . . . pulling the neglect card is bull****, especially with someone I count as a friend, but there it is . . . classy. Thanks man.

try to understand my confusion. CVP does not predict fluid responsiveness accurately. and it may have downsides (i.e. invasive procedure, cost, increased mortality, etc). I point this out and you give me the "but it has its uses", I'm still wanting specifics. So below you say if it's low and they respond to fluid, then it's useful. if a pt's bp is low and they respond to fluid then I can say the same. so you tell me it's not useful for ressustation goals...ok I agree...and your reply is that it's giving you information on the right side of the heart...ok fine, but how does that help you? how do you use that information to change your managment?

Here is were I see CVP being useful, in an intubated pt where you see massive swings in CVP with the respiratory cycle, or when you can feel the respiratory variation while putting in a central line. but that's the same thing as Pulse pressure variation and in limited circumstances has been validated.

One of Rivers arguments is that CVP gives you more important information when the patient hits the door than later - if the CVP is low when the patient hits the door, and then responds with fluids, you can say the patient was definitely fluid down, and giving the fluids was definitely needed

I've ready Rivers point-counter point with Schimit and listened to the pod-casts, I'm in Schmit's camp on this one. the fact of the matter is that there is enough evidence that their is an NIH funded study comparing EGDT with a protocalized arm that does not need CVP in it to see if it's the agressive care or the interventions themselves that matter.

(Hell, even Boyd's paper says that CVP may be helpful for resuscitation early septic shock right in the abstract).

That's because the intervention in the VASST trial started at 12 hours, not within 6 hours, so by design they were not set up to adderss the EGDT protocal in any fashion, but studied or not, there are intensivists who use CVP goals to direct fluid managment.

I tried explaining this to you earlier, but you simply were not hearing what I was saying. CVP is going to give me an idea of what is going on on the venous side of things. The problem here being there is a whole lot more patient and pathophysiology between where the CVP is measuring through the heart, lungs, arterial system, and back to the tissues to make any clear claims that CVP can be used to decide or define the end of resuscitation.

and that's where I was going with adding in the Swan, espogheal probe, and pleural manaometry, if CVP is flawed, then fix it by getting more of the system numbers.....but swan's did that and they do not affect outcomes and have higher rates of complications.

 

[jdh71]

try to understand my confusion. CVP does not predict fluid responsiveness accurately. and it may have downsides (i.e. invasive procedure, cost, increased mortality, etc). I point this out and you give me the "but it has its uses", I'm still wanting specifics. So below you say if it's low and they respond to fluid, then it's useful. if a pt's bp is low and they respond to fluid then I can say the same. so you tell me it's not useful for ressustation goals...ok I agree...and your reply is that it's giving you information on the right side of the heart...ok fine, but how does that help you? how do you use that information to change your managment?

I can't tell you how it's going to change management, if at all, outside of the clinical context of the entire patient. In general though, I think that if you've got reasonable CVP readings in a patient, and the end points of "reasonable" can be debated, you can generally infer that there is plenty of fluid in the venous system. Now this cannot in and of itself mean that you've reached a resuscitation end goal as "resuscitation" means more than just having enough fluid in the venous system, or more properly a certain pressure in the SVC. So everything else being equal or fine, you could consider backing off on the fluids in that kind of situation if everything else is working - the context is the entire patient - you've got AAOx3 mentation, good UOP, normal or normalizing lactate, etc. If the CVP is reasonable and things are still ****ed up, you need more interventions, and you can infer that the patients are obvious much sicker. Like I said there is a whole lot of organ systems, vasculature, and pathophysiology between where you measure your CVP and end organ tissue perfusion.

That's because the intervention in the VASST trial started at 12 hours, not within 6 hours, so by design they were not set up to adderss the EGDT protocal in any fashion, but studied or not, there are intensivists who use CVP goals to direct fluid managment.

There are

and that's where I was going with adding in the Swan, espogheal probe, and pleural manaometry, if CVP is flawed, then fix it by getting more of the system numbers.....but swan's did that and they do not affect outcomes and have higher rates of complications.

It's not the CVP is "flawed" as much as what we were trying to do with it was flawed

 

[europeman]

why use a proxy (cvp) when you can actually *SEE* what's going on the left side with an ultrasound? i know i know... evidence....

i'm still grabbing the ultrasound... ivc, heart, etc. freaking awesome.

 

[jdh71]

why use a proxy (cvp) when you can actually *SEE* what's going on the left side with an ultrasound? i know i know... evidence....

i'm still grabbing the ultrasound... ivc, heart, etc. freaking awesome.

Are you for real?

Honestly are you always this much of a meathead? High five me Todd.

Bedside U/S is very nice, where and when available, and no one has said otherwise.

 

[europeman]

Are you for real?

Honestly are you always this much of a meathead? High five me Todd.

Bedside U/S is very nice, where and when available, and no one has said otherwise.

Hey JDH. No need for name calling.

Now a days, most ICU's have ultrasound.

Whether the clinicians have facility in it is another story.

The point of my comment was IMHO, bedside ultrasound, despite its lack of evidence at this time (i'm optimistic it will come about though), is a much more powerful tool for assessing fluid status than CVP.

I'm sure many would agree...

Thanks for your comment though.

 

[jdh71]

Hey JDH. No need for name calling.

Now a days, most ICU's have ultrasound.

Whether the clinicians have facility in it is another story.

The point of my comment was IMHO, bedside ultrasound, despite its lack of evidence at this time (i'm optimistic it will come about though), is a much more powerful tool for assessing fluid status than CVP.

I'm sure many would agree...

Thanks for your comment though.

Most ICUs do not have U/S readily available unfortunately, the trend is moving that direction, but the economy sucks and money is short. Getting used to one in the academic setting is no guarantee you'll have one outside of the university SICU.

The use of U/S as a bedside tool to gauge fluid status in septic shock is fairly well established in the literature, most of it initially came from the surgeons.

 

[europeman]

Most ICUs do not have U/S readily available unfortunately, the trend is moving that direction, but the economy sucks and money is short. Getting used to one in the academic setting is no guarantee you'll have one outside of the university SICU.

The use of U/S as a bedside tool to gauge fluid status in septic shock is fairly well established in the literature, most of it initially came from the surgeons.

there is a lack of clinical evidence demonstrating supeior outcomes that is...

Every ICU I have seen have had access to ultrasound.

I am referring to tertiary centers, not community ICU's though. In the community, you may be right

 

[jdh71]

there is a lack of clinical evidence demonstrating supeior outcomes that is...

This is ultimately true and the problem with EBM and the search for the magical variable or test. We need to treat patients, not CVPs, not flowtrack numbers, not TEEs, but patients, the whole clinical picture. Any doctor that can be replaced by a computer algorithm, should be.

 

[souljah1]

I don't put much stock in CVP at all. Most residents (as well as some fellows and attendings) think that CVP is a marker for "venous return". Right atrial pressure is a terrible marker for VENOUS CAPACITANCE. Pressure should be thought of on the arterial side. Capacitance should be thought of on the venous side. When hypovolemic, some degree of fluid resuscitation is necessary to maximize venous return through optimization of capacitance. CVP tells you nothing about where you are on the Starling curve.

I like bedside ultrasound. I can quickly put on a probe and get a sense of how compressible the IJ is, how collapsible the IVC is, how underfilled and hyperkinetic the LV is, and whether or not the RV is suggestive of pressure/volume overload. Our first year fellows get training in bedside ultrasound and are expected to use is as part of their hemodynamic assessment, especially if things aren't straightforward.

At our institution, most people like to use ScvO2 to gauge fluid responsiveness. Pull a ScvO2 prior to a fluid bolus and look for a bump in ScvO2 after. Did it happen? If so, you improved cardiac output through your fluid resuscitation REGARDLESS of CVP.

Passive leg raises are fun in spontaneously breathing patients but is a bit laborious. Arterial waveform interpretation can be somewhat useful in ventilated patients.

For early goal directed therapy, just give the damn fluids and look for augmentation of cardiac output - with an expectation that you might need to add pressors.

The issue is more muddied for critical care patients who develop shock after a prolonged ICU stay when they are hypoalbuminemic, anasarcic, and have not been studied very well at the population level. I see residents trending CVP, lactates and ScvO2 for like 144 hours...It is pointless.

Rivers EGDT was a SINGLE CENTER study. The fact that it made the SSC is kind of funny. People treat it like it is the bible. Blood is likely overrated. And, if you investigate - intensivists were coming down to the ED to manage the patients in the treatment arm - talk about confounders....

Anyway, carry on gentlemen and gentlewomen.

 

[jdh71]

What are the folks doing with the large patients, the BMI >50 types.

Bedside U/Sing is real freaking difficult.

We talked about Swaning a patient like this.

 

[Hernandez]

if not afib or on hfov/aprv ppv/svv can be useful. or TEE. I've been trying to get our group to get tee training going

 

[jdh71]

if not afib or on hfov/aprv ppv/svv can be useful. or TEE. I've been trying to get our group to get tee training going

I think all intensivists will need to have some sort of availability for basic TEE in the future. The gas guys are way ahead of us here on this one. And I'd be interested if the guys trained for in the OR TEE have been using it in the unit much.

 

[proman]

I think all intensivists will need to have some sort of availability for basic TEE in the future. The gas guys are way ahead of us here on this one. And I'd be interested if the guys trained for in the OR TEE have been using it in the unit much.

Cardiology is the obstacle. They want to own all the non-OR TEE but don't want to work past 5. I've done plenty of ICU exams in non-CSICU ICUs but only when cardiology doesn't show up. After reading a fair amount of TTE exams in intubated patients, the study quality is typically so marginal it's not worth it. If they are intubated, it should be a TEE. As an aside, in my opinion, cardiac anesthesiologists should be doing the exams in CSICU population since their advanced TEE exam plus knowledge of the operations is a combination not found in another specialty.

 

[Hamhock]

Cardiology is the obstacle. They want to own all the non-OR TEE but don't want to work past 5. I've done plenty of ICU exams in non-CSICU ICUs but only when cardiology doesn't show up. After reading a fair amount of TTE exams in intubated patients, the study quality is typically so marginal it's not worth it. If they are intubated, it should be a TEE. As an aside, in my opinion, cardiac anesthesiologists should be doing the exams in CSICU population since their advanced TEE exam plus knowledge of the operations is a combination not found in another specialty.

I agree with both proman and jdh...(1) cardiothoracic trained-anesthesiologists are far ahead of most other folks in this area and (2) TEE is the future.

However, there are plenty of other areas that other primary specialties far exceed anesthesiology-based intensivists.

Instead of arguing who is 'best' prior to fellowship, we should collectively work towards a definition of a true intensivist (regardless of base specialty) who can handle all basic CCM procedures - including diagnostic bronch, TEE (must have good TTE and other beside UTS skills - that means you too Mr. Pulm/IM/CCM and anes/CCM - why should you guys argue for TEE when you can't even measure CBD or identify LE DVT), thoracentesis, emergent pericardiocentesis, diagnostic thoracentesis, etc.

Of course, I am just some silly CCM-EM wannabe

HH

 

[jdh71]

I agree with both proman and jdh...(1) cardiothoracic trained-anesthesiologists are far ahead of most other folks in this area and (2) TEE is the future.

However, there are plenty of other areas that other primary specialties far exceed anesthesiology-based intensivists.

Instead of arguing who is 'best' prior to fellowship, we should collectively work towards a definition of a true intensivist (regardless of base specialty) who can handle all basic CCM procedures - including diagnostic bronch, TEE (must have good TTE and other beside UTS skills - that means you too Mr. Pulm/IM/CCM and anes/CCM - why should you guys argue for TEE when you can't even measure CBD or identify LE DVT), thoracentesis, emergent pericardiocentesis, diagnostic thoracentesis, etc.

Of course, I am just some silly CCM-EM wannabe

HH

I'll put a needle anywhere, and I'm very comfortable with bedside U/S.

The context of the discussion has turned to modalities for use in the really huge patient for providing information of fluid status. You get over a BMI of 50 and put on positive pressure ventilation, then even finding an IVC from the outside, the information will be suspect.

I think that thing on your shoulder is a chip. It's not entirely clear to me why you have it . . .