Bedside Ultrasound. US Guided Fluid Resuscitation. Michiel J. van Veelen, Emergency Physician, DTM&H

Transcription

1 Bedside Ultrasound US Guided Fluid Resuscitation Michiel J. van Veelen, Emergency Physician, DTM&H

2 Outline Shock and Fluid Resuscitation in ICU Ultrasound in Shock Ultrasound Guided Fluid Resuscitation Other Ultrasound applications in ICU

3 Shock in ICU Cellular and tissue hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization

4 Fluid Resuscitation in ICU

5 Fluid Resuscitation in ICU Inadequate fluid resuscitation results in tissue hypoperfusion and worsening end-organ dysfunction vs. Overresuscitation leading to a positive fluid balance is associated with worsened mortality

6 Shock in ICU?

7 Fluid responsiveness Non-invasive hemodynamics Physical examination Invasive hemodynamics; PAC, CVP, PPV, SVV Passive leg raise test Fluid bolus

8 Fluid responsiveness Fluid responder Cardiac output (CO) increases by 10-15% in response to a fluid bolus Non-responder Decreased CO or minimal increase

9 Several US Shock protocols Goal Directed Echocardiography (GDE) Rapid Ultrasound in Shock (RUSH) Rapid Assessment by Cardiac Echo (RACE)

10 Pros: Effective, noninvasive, rapid and accurately assess hemodynamically unstable patients at the bedside 1-3 Differentiate between hypovolemic, cardiogenic, obstructive, and distributive shock 2-6 Serial exams for monitoring 4,5

11 RUSH exam 2 Easy?

12 Alternative? 1 Just 2 views: - Inferior Vena Cava - The Lungs 2

13 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

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

15 Why Inferior Vena Cava Spontaneous breathing intrathoracic pressure with inspiration draws blood from the vena cava into the heart, leading to collapse Positive pressure ventilation intrathoracic pressure pushes blood from the heart into the vena cava, leading to distention of the vessel.

16 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

17 IVC

18 Why Lung Ultrasound? Ultrasound Guided Fluids LUNGS

19 A B LUNGS

20 LUNGS Ultrasound Guided Fluids

21 Ultrasound Guided Fluids

22 IVC 1

23 IVC Measure diameter <1.5cm Underfilled >2.5cm Distended cm Normal 1

24 Pitfalls

25 IVC Diameter >2.5cm: Hold Fluids <1.5cm: FLUIDS Normal: Step 2

26 Intubated? Yes: Respiratory variation 2A No/Triggering: Lung Ultrasound 2B

27 IVC Respiratory variation: [(D max D min )/D max ] 100% > 12%? 2A

28 Respiratory variation >12%: FLUIDS <12%: Lung Ultrasound 2B

29 LUNGS 2B

30 LUNGS 2B

31 A Lines B Lines 2B Fluid Test Hold Fluids

32 Ultrasound Guided Fluids

33 Ultrasound in ICU Other applications in ICU:

34 Ultrasound in ICU Hypovolemic Cardiogenic? Distributive Obstructive

35 Ultrasound in ICU Vascular access

36 Ultrasound in ICU Pneumothorax?

37 Ultrasound in ICU Infiltrate or Effusion?

38 Ultrasound in ICU Treatable causes in CPR

39 Ultrasound in ICU Or termination of CPR

40 Ultrasound in ICU Free fluid in trauma Ectopic Pregnancy AAA Bladder Galbladder Kidneys.

41 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

42 ?

43 References 1. G.A. Schmidt, S. Koenig, P.H. Mayo: Shock. Ultrasound to guide diagnosis and therapy. Chest. 142 (4): P. Perera, T. Mailhot, D. Riley, D. Mandavia: The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically ill. Emerg Med Clin North Am. 28 (1):29-56, vii February E. Manno, M. Navarra, L. Faccio, et al.: Deep impact of ultrasound in the intensive care unit: the ICU-sound protocol. Anesthesiology. 117 (4): October 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) [ 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 D.A. Lichtenstein, G.A. Mezière: Relevance of lung ultrasound in the diagnosis of acute respiratory failure the BLUE protocol. Chest. 134:

44 Ultrasound Course Bedside Ultrasound Course Registration open 16 th of June Full day course Pre-course material 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 16 th 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 Training is done on first come first serve basis and ONLY after payment is made. Questions: Department of Accident & Emergency E-FAST DVT Cardiac and IVC Aorta Central Venous Access Certificate EMSSA 1250 Pula