Bedside assessment of fluid status
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1 Bedside assessment of fluid status 2nd AKI Academy October 18 th 2014 David Treacher Guy s & St Thomas NHS Trust
2 Assessing the circulation - the 3 key questions v Is my patient adequately filled? v What s the cardiac output? v Is tissue perfusion adequate?
3 Assessing the circulation - the 3 key questions Is my patient adequately filled?
4 Ensure that your patient is adequately filled Ø quickly! Ø before starting vaso-active agents
5 How are you going to prevent?.
6
7 Timing and need for admission to ICU Ø 46% patients receive inadequate care prior to admission to ICU Ø Ø referred and admitted late substantial number could have been avoided McQuillan P BMJ 1998;316:1853
8 Identification Signs are there but no-one does anything! Clinical antecedents to in-hospital cardiac arrest. Schein MH Chest 1990;98:
9 Based on bedside clinical skills
10 Early goal directed therapy in the treatment of severe sepsis Rivers E, Nguyen B, Havstad S Depts Emergency & Internal Medicine & Surgery Henry Ford Health Systems, Detroit, USA NEJM 2001; 345:
11 Goal-Directed Resuscitation for patients with early septic shock (ARISE) v No benefit from EGDT ( 18.6% vs 18.8%) v Volume in 1 st 6hrs: 1964ml vs 1713ml v Time in ER post randomisation: 1.4 vs 2.0hrs
12 Case History 1 74 yr old man admitted to HDU with acute abdomen HR 110/min; MAP 77; cold; CRT>3secs oligo-anuric: 10/5/5 ml/hr RR 24/min confused vomiting PMH: Smoker, COPD, Diabetes, old MI
13 When you arrive, what do you need to know? ü History/ drugs etc from staff, family, patient ü Conventional examination to include: -? peripheral perfusion: CRT, temp, estimate SVR -? pulse characteristics: rate, rhythm, estimate SV -? skin turgor/mucous membranes /peripheral oedema -? MAP -? JVP/CVP/RAP -? HS:? Gallup/3 rd HS ü -? central temp Review charts: urine output, fluid balance, drugs ü Key Ix: CXR/ECG/ABG/lactate/urine Na/AXR/U/S/Echo
14 Bedside measurements hypotension is a late sign: - MAP no guarantee of adequate filling or CO splanchnic hypo-perfusion occurs early oliguria: resist the frusemide reflex! beware unexplained HR & RR explain base deficit on ABG: watch trend timely response: fluids/ antibiotics/ CPAP etc Intervene EARLY to prevent late shock
15 ? Adequately filled Key Bedside Measurements Peripheral perfusion/ skin turgor Mucous membranes Central pulse volume, HR Urine output ( don t forget urinary Na) Na & Creatinine/urea relationship but.. CVP, wedge or PAOP pressures -pitfalls? SijO2/SvO2/CO * Intra-vascular vs Extra-vascular depletion *
16 Subsequent progress of our 74yr old Ø JVP/CVP/RA +1 (+7) Ø Urinary Na: 2mmol/L Ø ECG no evidence of ant MI on ECG Ø Estimated CO 3.1l/min (SVR:25; SV 30; VO2 240ml/min) Ø Filled ++ : 1.5L Hartmanns & Gelo (!) & RBC ordered Ø Transferred to ICU & intubated prior to theatre Ø MAP 79; JVP/CVP/RA +4; SVR 18; CO 4.1, U/O:25,30 Ø Lactate 2.6mmol/l; SijO2 63%; Ø? fill further;? vaso-active agent Ø Dynamic tests: Valsalva
17 EPSS Cambridge UCH Hammersmith STH
18
19 Fluid challenge 200 ml of colloid over 10min Observe effect on CVP/MAP/HR/CO 5min later CVP <3mmg Hg & improvement consider further fluid CVP >3mmHg & no improvement no further fluids at that stage
20
21 Case History 2 v 31 yr old man v Empyema after pneumonia v VATS procedure v Well on return to GCCU v Extubated v WWP; U/O >80ml/hr v HR 86sr/ Map 88/ CVP + 5
22 Case history 2-3 hours later Ø Cool at edges; U/O,10ml/hr Ø HR 120sr MAP 60mmHg CVP +12mmHg Is he empty?
23 Case History 2 Ø Norepinephrine started: up to 0.25mcg/kg/min Ø HR 136sr; MAP 64mmHg Ø CVP +16mmHg Lactate 5.1mmol/L What do you do?
24 Does he need filling?
25 Subsequent progress of 31yr old?
26 Pulmonary artery catheter : conventional for LAP/PAOP/CO & PAP
27 Case History 2 v CVP +19mmHG v PAOP 24mmHG v CI 1.6l/min/m 2 What do you do?
28 RA +19 Wedge +24 MAP 62 CO 3.1 Lact 6mmol/l Norepi/Dobutamine ++
29 Pitfalls in relying on CVP/RAP to assess adequacy of iv filling q q q q RV function PAP RA to LA relationship Intrathoracic pressure Systemic venous compliance
30 Bedside tests of intravascular volume Dynamic tests > Static BP resp swing Ventilator disconnect Effects of sedation Straight leg raise Valsalva manoeuvre
31 Conclusions Dynamic > static tests Rapid, bedside assessment + Prompt treatment Avoids
32
33 Valsalva Manoeuvre Is this patient underfilled?
34 Thank you for your attention?
35 Questions?
36 If I like what I find.
37 If not.. Invade & measure!
38
39 Six Key CirculatoryVariables Ø RAP or CVP Ø LAP or PAOP/PAWP Ø MAP Ø PAP Ø Cardiac output Ø Heart rate Pre- load pressures After- load pressures Stroke Volume
40 Juniors being taught central line insertion at St Thomas ICU.
41 We now have v SijO2 v SpO2 v Hb
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