Prof. Dr. Iman Riad Mohamed Abdel Aal
|
|
- Timothy Poole
- 5 years ago
- Views:
Transcription
1 The Use of New Ultrasound Indices to Evaluate Volume Status and Fluid Responsiveness in Septic Shock Patients Thesis Submitted for partial fulfillment of MD degree in Anesthesiology, Surgical Intensive Care and Pain Management By Ahmed Mohamed Lotfy Mostafa MBBCh, MSc anesthesia and Surgical Intensive Care and Pain Management Faculty of Medicine, Cairo University Under supervision of Prof. Dr. Iman Riad Mohamed Abdel Aal Professor of Anesthesia and Surgical Intensive Care Faculty of medicine, Cairo University Prof. Dr. Jihan Aly El Kholy Professor of Anesthesia and Surgical Intensive Care Faculty of medicine, Cairo University Dr. Ahmed Mohamed Ibrahim Hasanain Lecturer of Anesthesia and Surgical Intensive Care Faculty of medicine, Cairo University Faculty of Medicine Cairo University 2014
2 Acknowledgments ACKNOWLEDGMENTS First and foremost thanks to "ALLAH" for his help to fulfill this work. I would like to express my deepest gratitude to Professor DR. Iman Riad, professor of anesthesiology, faculty of medicine, Cairo University for her kind guidance and supervision. My thanks to Dr. Jihan Alkholy, Prof. of Anesthesiology, faculty of medicine Cairo University for her continuous encouragement & supervision. Last But not least, I am also expressing my warmest thanks to Dr. Ahmed Hasanin, Lecturer of Anesthesiology, faculty of medicine Cairo University for his generosity & positive attitude. i
3 Abstract This study was conducted in surgical ICU in Cairo University Hospitals to detect the accuracy of new ultrasound indices (IVC caval index, IJV/CCA cross sectional area and IJV aspect ratio) to guide fluid therapy and predict fluid responsiveness (assessed by trans-thoracic echocardiography) in severe sepsis and septic shock spontaneously breathing patients in comparison to traditional CVP measurement. The results of this study showed that the minimum IVC diameter, caval index, IJV area and the ratio IJV/CCA are good predictors of fluid responsiveness. These parameters were significantly different between the two groups of fluid responders and non-responders. A minimum IVC diameter of 0.9 cm predicted fluid responsiveness with a sensitivity of 100% and specificity of 70%. A caval index of 35% had 92% sensitivity and 86% specificity. An IJV area of 0.9 cm 2 and IJV/CCA ratio of 1.7 had a sensitivity of 85% in predicting fluid responders and a specificity of 70% and 62% respectively. Keyword CVP-IJV-CCA- AUROC- PAoP-IVC
4 Index Index: Introduction and aim of work. 1 Review... 3 Chapter I : Sepsis... 4 Management of Severe Sepsis Fluid Therapy (Early Goal Directed Therapy) Infection Management Source Control Chapter II : Ultrasound in ICU Physics of Ultrasound Imaging Modalities Uses of Ultrasound in ICU Cardiac Applications Thoracic Applications Abdominal Applications Chapter III : Fluid Responsiveness Physiology Hemodynamic Measurements of Volume Status and Fluid responsiveness Static Measurements 31 - Dynamic Measurements Stroke Volume Variation And Pulse Pressure Variations Echocardiography Inferior Vena Cava and Superior Vena Cava Diameter Passive Leg Raising Test 46 ii
5 Index - Other Methods of Assessing Fluid Responsiveness...49 Patients and methods.. 51 Ultrasound Measurement Details Statistical Analysis. 55 Results. 56 Demographic Data and Other Patient Characteristics 56 Hemodynamic Data 58 Achievement of Early Goal Directed Therapy in Fluid Responders and Non Responders.. 59 Ultrasound Indices. 61 Sensitivity and specificity of all parameters in prediction of fluid responsiveness Correlation between baseline ultrasound indices and CVP Correlation between IVC minimum diameter and CVP Correlation between IJV area and CVP Correlation between caval index and CVP 75 Correlation between changes in caval index and change in VTI 76 Correlation between changes in IJV area and change in VTI. 77 Discussion.. 78 References. 89 Summery. 107 Arabic Summery. 109 iii
6 Abbreviations Abbreviations: APACHE.. Acute physiology and chronic health evaluation score aptt..... Activated partial thromboplastin time AUC. Area under the curve AUROC... Area under the receiver operating characteristic curve CCA. Common Carotid artery CI. Confidence interval CVP. Central venous pressure DBP. Diastolic blood pressure DIVC Variation in inferior vena cava ED Emergency department EGDT... Early goal-directed therapy F Frequency FAST Focused assessment with sonography for trauma FiO 2... Fraction of inspired oxygen HR. Heart rate Hz.. Hertz IAP. Intra-abdominal pressure ICU. Intensive care unit IJV.. Internal Jugular vein INR. International normalized ratio IVC. Inferior vena cava IVCd Inferior vena cava diameter IVC Dmax... Maximum inferior vena cava diameter IVC Dmin... Minimum inferior vena cava diameter LOS.. Length of ICU stay LV Left ventricle LVEDA Left ventricular end diastolic area iv
7 Abbreviations MAP. Mean arterial pressure MBP. Mean blood pressure MHz. Mega Hertz MSFP... Mean systemic filling pressure PA Pulmonary artery PaO 2. Arterial partial pressure of oxygen PAoP Pulmonary artery occlusion pressure Pcrit.. Critical pressure PCwP... Pulmonary capillary wedge pressure PEEP. Positive end expiratory pressure PLR.. Passive leg raising PPV.. Pulse pressure variation RAP. Right atrial pressure RCTs Randomized controlled trials ROC. Receiver operating characteristic Rv. Resistance to venous flow RV Right ventricle SBP.. Systolic blood pressure ScvO 2... Superior vena cava oxygen saturation SD Standard deviations SICU... Surgical intensive care unit SSC.. Surviving sepsis campaign SV Stroke volume SVC. Superior vena cava SVmax. Maximum stroke volume SVmin.. Minimum stroke volume SvO 2.. Mixed venous oxygen saturation SVV.. Stroke volume variation TEE Trans-oesophageal echocardiography v
8 Abbreviations TTE. Trans-thoracic echocardiography U/S.. Ultrasound VTI.. Velocity Time Index WBC White blood cell vi
9 Tables LIST OF TABLES Table no. Title Page no. Table 1 Diagnostic criteria of sepsis. 4 Table 2 Diagnostic criteria for severe sepsis. 6 Table 3 Grading of evidence. 15 Table 4 Grading of recommendations. 15 Table 5 Demographic data and other patient characteristics. 57 Table 6 Baseline hemodynamic data. 58 Table 7 Hemodynamic data after fluid bolus. 59 Table 8 Acheivement of targets of early goal directed therapy in the two groups. 60 Table 9 Baseline ultrasound indices. 62 Table 10 Ultrasound indices after fluid bolus. 63 Table 11 Table 12 Table 13 Area under the Receiver operating characteristic (ROC) curve for each variable as a predictor of fluid responsiveness. Sensitivity and specificity of each parameter to predict fluid responsiveness at the best cut-off values. Sensitivity and specificity of DIVC in predicting fluid responsiveness vii
10 Figures LIST OF FIGURES Figure no. Title Page no. Fig. 1 : The cardiac function curve representing the relationship between right atrial pressure (RAP) and cardiac output. 26 Fig. 2 : The venous return curve representing the relationship between right atrial pressure (RAP) and venous return. 28 Fig. 3 : Venous return curves is superimposed on cardiac function curves where the cardiac output and right atrial pressure (RAP) are determined at the junction of the curves assuming a theoretical steady state. 30 Fig. 4 : The physiological explanation for the changes in stroke volume and IVC diameter caused by mechanical ventilation. 41 Fig. 5 : Left ventricular end-diastolic area by TEE. 42 Fig. 6 : Distended IVC in 2D mode by TTE. Don t give volume. 45 Fig. 7 : Collapsed IVC in 2D mode by TTE. Give fluids. 46 Fig. 8 : Receiver operating characteristic (ROC) curve for central venous pressure on prediction of fluid responsiveness in septic shock patients. 64 viii
11 Fig. 9 : Receiver operating characteristic (ROC) curve for maximum inferior vena cava diameter (IVC) diameter on prediction of fluid responsiveness in septic shock patients. Figures 65 Fig. 10 : Receiver operating characteristic (ROC) curve for minimum internal jugular vein (IVC) diameter on prediction of fluid responsiveness in septic shock patients. 66 Fig. 11 : Receiver operating characteristic (ROC) curve for Caval index on prediction of fluid responsiveness in septic shock patients. 67 Fig. 12 : Receiver operating characteristic (ROC) curve for internal jugular vein (IJV) area on prediction of fluid responsiveness in septic shock patients. 68 Fig. 13 : Receiver operating characteristic (ROC) curve for internal jugular vein/common carotid artery (IJV/CCA) ratio on prediction of fluid responsiveness in septic shock patients. 69 Fig. 14 : Receiver operating characteristic (ROC) curve for internal jugular vein (IJV) aspect ratio on prediction of fluid responsiveness in septic shock patients. 70 Fig. 15 : Area under the receiver operating characteristic (ROC) curve for each variable on prediction of fluid responsiveness. 72 ix
12 Fig. 16 : Correlation between inferior vena cava (IVC) minimum diameter and central venous pressure (CVP) (r = 0.22). Figures 73 Fig. 17 : Correlation between internal jugular vein (IJV) area and central venous pressure (CVP) (r = 0.41). 74 Fig. 18 : Correlation between caval index and central venous pressure (CVP) (r = -0.23). 75 Fig. 19 : Correlation between change of caval index and change of velocity time index (VTI) (r = 0.15). 76 Fig. 20 : Correlation between change of internal jugular vein (IJV) area and change of velocity time index (VTI) (r = 0.14). 77 x
13 Introduction Introduction Fluid therapy is the corner stone of management of severe sepsis and septic shock and adequate fluid resuscitation is recommended worldwide to improve prognosis. However, assessment of volume status and hence fluid responsiveness can sometimes be challenging to the critical care physician. Invasive hemodynamic monitoring of central venous pressure (CVP) is still considered in directing early resuscitative efforts. Unfortunately, there are limitations of the use of CVP. First, central filling pressures are not systematically available in the initial phase of shock because a central venous catheter is not always available. Second, it has been clearly shown that static indices as CVP do not accurately predict fluid responsiveness, except for values < 5 mmhg. Therefore, fluid challenge is often used to test fluid responsiveness. Nevertheless, about 50% of fluid challenges are not justified. This exposes patients to deleterious fluid overload. Ultrasound examination has recently been used to provide information regarding responsiveness to fluids. Many studies introduced ultrasound examination as a new substitute to the traditional invasive methods, especially static dimensions. 1
14 Introduction Inferior vena cava (IVC) collapsibility (greater than 50%) during normal respiration was proved to be strongly associated with low central venous pressure (less than 8 mmhg). Respiratory variation in the IVC diameter was used as a guide for fluid therapy in septic shock in both spontaneous breathing and mechanically ventilated patients. Aim of the work: The aim of this work was to detect the accuracy of new ultrasound indices [IVC collapsibility index, internal jugular vein (IJV)/common carotid artery(cca) cross sectional area and IJV aspect ratio] in predicting fluid responsiveness (assessed by transthoracic echocardiography) in severe sepsis and septic shock spontaneously breathing patients in comparison to traditional CVP measurement. 2
15 REVIEW Chapter I: Sepsis SEPSIS Sepsis is a systemic, deleterious host response to infection. It is defined as systemic inflammatory response to infection. Severe sepsis (acute organ dysfunction secondary to documented or suspected infection) and septic shock (severe sepsis plus hypotension not reversed with fluid resuscitation) are common squeals of sepsis. Severe sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, killing one in four (and often more), and are increasing in incidence. 1 Sepsis induced hypotension is defined as a systolic blood pressure (SBP) < 90 mm Hg or mean arterial pressure (MAP) < 70 mm Hg or a SBP decrease > 40 mm Hg or less than two standard deviations (SD) below normal for age in the absence of other causes of hypotension. Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation. Sepsis-induced tissue hypo perfusion is defined as infectioninduced hypotension, elevated lactate, or oliguria. 1 The diagnostic criteria of sepsis and severe sepsis are shown in tables 1 and 2. 3
FLUID RESUSCITATION AND MONITORING IN SEPSIS PROTOCOLIZED VS USUAL CARE DEEPA BANGALORE GOTUR MD, FCCP ASSISTANT PROFESSOR, WEILL CORNELL MEDICAL
FLUID RESUSCITATION AND MONITORING IN SEPSIS PROTOCOLIZED VS USUAL CARE DEEPA BANGALORE GOTUR MD, FCCP ASSISTANT PROFESSOR, WEILL CORNELL MEDICAL COLLEGE NOVEMBER 10 TH 2017 TEXAS SCCM SYMPOSIUM Disclosures
More informationFluid responsiveness and extravascular lung water
Fluid responsiveness and extravascular lung water Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France Conflicts of interest Member of the Medical Advisory Board of Maquet/Pulsion
More informationShock, Monitoring Invasive Vs. Non Invasive
Shock, Monitoring Invasive Vs. Non Invasive Paula Ferrada MD Assistant Professor Trauma, Critical Care and Emergency Surgery Virginia Commonwealth University Shock Fluid Pressors Ionotrope Intervention
More informationPreload optimisation in severe sepsis and septic shock
Preload optimisation in severe sepsis and septic shock Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris South France Conflicts of interest Member of themedical Advisory Board ofpulsion
More informationTroubleshooting Audio
Welcome! Audio for this event is available via ReadyTalk Internet Streaming. No telephone line is required. Computer speakers or headphones are necessary to listen to streaming audio. Limited dial-in lines
More informationSepsis Wave II Webinar Series. Sepsis Reassessment
Sepsis Wave II Webinar Series Sepsis Reassessment Presenters Nova Panebianco, MD Todd Slesinger, MD Fluid Reassessment in Sepsis Todd L. Slesinger, MD, FACEP, FCCM, FCCP, FAAEM Residency Program Director
More informationShock and hemodynamic monitorization. Nilüfer Yalındağ Öztürk Marmara University Pendik Research and Training Hospital
Shock and hemodynamic monitorization Nilüfer Yalındağ Öztürk Marmara University Pendik Research and Training Hospital Shock Leading cause of morbidity and mortality Worldwide: dehydration and hypovolemic
More informationHemodynamic monitoring beyond cardiac output
Hemodynamic monitoring beyond cardiac output Prof Xavier MONNET Medical Intensive Care Unit Bicêtre Hospital Assistance publique Hôpitaux de Paris FRANCE Conflicts of interest Lilly GlaxoSmithKline Pulsion
More informationThe Use of Dynamic Parameters in Perioperative Fluid Management
The Use of Dynamic Parameters in Perioperative Fluid Management Gerard R. Manecke Jr., M.D. Chief, Cardiac Anesthesia UCSD Medical Center San Diego, CA, USA Thanks to Tom Higgins, M.D. 1 Goals of today
More informationThe Vigileo monitor by Edwards Lifesciences supports both the FloTrac Sensor for continuous cardiac output and the Edwards PreSep oximetry catheter
1 2 The Vigileo monitor by Edwards Lifesciences supports both the FloTrac Sensor for continuous cardiac output and the Edwards PreSep oximetry catheter for continuous central venous oximetry (ScvO2) 3
More informationEffects of mechanical ventilation on organ function. Masterclass ICU nurses
Effects of mechanical ventilation on organ function Masterclass ICU nurses Case Male, 60 - No PMH - L 1.74 m and W 85 kg Pneumococcal pneumonia Stable hemodynamics - No AKI MV in prone position (PEEP 16
More informationStaging Sepsis for the Emergency Department: Physician
Staging Sepsis for the Emergency Department: Physician Sepsis Continuum 1 Sepsis Continuum SIRS = 2 or more clinical criteria, resulting in Systemic Inflammatory Response Syndrome Sepsis = SIRS + proven/suspected
More informationTailored Volume Resuscitation in the Critically Ill is Achievable. Objectives. Clinical Case 2/16/2018
Tailored Volume Resuscitation in the Critically Ill is Achievable Heath E Latham, MD Associate Professor Fellowship Program Director Pulmonary and Critical Care Objectives Describe the goal of resuscitation
More informationHemodynamic Monitoring Pressure or Volumes? Antonio Pesenti University of Milan Italy
Hemodynamic Monitoring Pressure or Volumes? Antonio Pesenti University of Milan Italy antonio.pesenti@unimi.it CCCF 2017 Is it useful? YES: CVP It is an important diagnostic element! Your best guess CVP
More informationPoint-of-Care Ultrasound Closer look at the Inferior Vena Cavae &
Point-of-Care Ultrasound Closer look at the Inferior Vena Cavae & Brief Introduction to Gross Systolic Function Omar S. Darwish, MS, DO Certified in Point-of-Care Ultrasound Hospitalist University of California,
More informationFluid Resuscitation and Monitoring in Sepsis. Deepa Gotur, MD, FCCP Anne Rain T. Brown, PharmD, BCPS
Fluid Resuscitation and Monitoring in Sepsis Deepa Gotur, MD, FCCP Anne Rain T. Brown, PharmD, BCPS Learning Objectives Compare and contrast fluid resuscitation strategies in septic shock Discuss available
More informationPatient Safety Safe Table Webcast: Sepsis (Part III and IV) December 17, 2014
Patient Safety Safe Table Webcast: Sepsis (Part III and IV) December 17, 2014 Presenters Mark Blaney, RN Regional Nurse Educator CHI Franciscan Health Karen Lautermilch Director, Quality & Performance
More informationSepsis Update: Focus on Early Recognition and Intervention. Disclosures
Sepsis Update: Focus on Early Recognition and Intervention Jessie Roske, MD October 2017 Disclosures I have no actual or potential conflict of interest in relation to this program/presentation. I will
More informationRevision of 10/27/2017 Form #280 Page 1 of 12 PVDOMICS STUDY Clinical Center Right Heart Catheterization (RHC) Results Form #280
Revision of 10/27/2017 Form #280 Page 1 of 12 PVDOMICS STUDY Clinical Center Right Heart Catheterization (RHC) Results Form #280 Instructions: Review PVDOMICS MOP Chapter 100 prior to completing right
More informationObligatory joke. The case for why it matters. Sepsis: More is more. Goal-Directed Fluid Resuscitation 6/1/2013
Obligatory joke Keep your eye on the food. Goal-Directed Fluid Resuscitation Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care University of California, San Francisco The
More informationJarisch A. Kreislauffragen, Dünser et al. Critical Care 2013, 17:326 Sunday, March 30, 14
It was fatal for the development of our understanding of circulation that blood flow is relatively difficult while blood pressure so easy to measure: This is the reason why the sphygmomanometer has gained
More informationAssessing Preload Responsiveness Using Arterial Pressure Based Technologies. Patricia A. Meehan, RN, MS Education Consultant Edwards Lifesciences, LLC
Assessing Preload Responsiveness Using Arterial Pressure Based Technologies Patricia A. Meehan, RN, MS Education Consultant Edwards Lifesciences, LLC Content Description : Fluid administration is a first
More informationBedside Ultrasound. US Guided Fluid Resuscitation. Michiel J. van Veelen, Emergency Physician, DTM&H
Bedside Ultrasound US Guided Fluid Resuscitation Michiel J. van Veelen, Emergency Physician, DTM&H Outline Shock and Fluid Resuscitation in ICU Ultrasound in Shock Ultrasound Guided Fluid Resuscitation
More informationHemodynamic Monitoring
Perform Procedure And Interpret Results Hemodynamic Monitoring Tracheal Tube Cuff Pressure Dean R. Hess PhD RRT FAARC Hemodynamic Monitoring Cardiac Rate and Rhythm Arterial Blood Pressure Central Venous
More informationDESIGNER RESUSCITATION: TITRATING TO TISSUE NEEDS
DESIGNER RESUSCITATION: TITRATING TO TISSUE NEEDS R. Phillip Dellinger MD, MSc, MCCM Professor and Chair of Medicine Cooper Medical School of Rowan University Chief of Medicine Cooper University Hospital
More informationPresented by: Indah Dwi Pratiwi
Presented by: Indah Dwi Pratiwi Normal Fluid Requirements Resuscitation Fluids Goals of Resuscitation Maintain normal body temperature In most cases, elevate the feet and legs above the level of the heart
More informationEarly Goal-Directed Therapy
Early Goal-Directed Therapy Where do we stand? Jean-Daniel Chiche, MD PhD MICU & Dept of Host-Pathogen Interaction Hôpital Cochin & Institut Cochin, Paris-F Resuscitation targets in septic shock 1 The
More informationSepsis: Identification and Management in an Acute Care Setting
Sepsis: Identification and Management in an Acute Care Setting Dr. Barbara M. Mills DNP Director Rapid Response Team/ Code Resuscitation Stony Brook University Medical Center SEPSIS LECTURE NPA 2018 OBJECTIVES
More informationThe cornerstone of treating patients with hypotension,
Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense* Paul E. Marik, MD, FCCM 1 ; Rodrigo Cavallazzi, MD 2 Background: Aim: Data Sources:
More informationImpedance Cardiography (ICG) Application of ICG in Intensive Care and Emergency
Impedance Cardiography (ICG) Application of ICG in Intensive Care and Emergency Aim of haemodynamic monitoring in ICU and ED Detection and therapy of insufficient organ perfusion Answers to common cardiovascular
More informationUsing Functional Hemodynamic Indicators to Guide Fluid Therapy
CE 2.6 HOURS Continuing Education Using Functional Hemodynamic Indicators to Guide Fluid Therapy A more accurate and less invasive way to gauge responsiveness to iv volume replacement. OVERVIEW: Hemodynamic
More informationJan M. Headley, R.N. BS
Fluid First: Using PLR & SVV to Optimize Volume Jan M. Headley, R.N. BS Disclosure Director, Clinical Marketing & Professional Education Edwards Lifesciences Does this Patient NEED Fluid?? WE Have a Problem
More informationIntroduction. Invasive Hemodynamic Monitoring. Determinants of Cardiovascular Function. Cardiovascular System. Hemodynamic Monitoring
Introduction Invasive Hemodynamic Monitoring Audis Bethea, Pharm.D. Assistant Professor Therapeutics IV January 21, 2004 Hemodynamic monitoring is necessary to assess and manage shock Information obtained
More informationPCV and PAOP Old habits die hard!
PCV and PAOP Old habits die hard! F Javier Belda MD, PhD Head of Department Associate Professor Anaesthesia and Critical Care Hospital Clínico Universitario Valencia (SPAIN) An old example TOBACO SMOKING
More informationSepsis. From EMS to ER to ICU. What we need to be doing
Sepsis From EMS to ER to ICU What we need to be doing NEHAL BHATT, MD ATHENS PULMONARY, CRITICAL CARE AND SLEEP Objectives 1. Define the changes to the definition of Sepsis 2. Describe the assessment,
More informationENDPOINTS OF RESUSCITATION
ENDPOINTS OF RESUSCITATION Fred Pieracci, MD, MPH Acute Care Surgeon Denver Health Medical Center Assistant Professor of Surgery University of Colorado Health Science Center OUTLINE Recognition and characterization
More informationGoal-directed vs Flow-guidedresponsive
Goal-directed vs Flow-guidedresponsive therapy S Magder Department of Critical Care, McGill University Health Centre Flow-directed vs goal directed strategy for management of hemodynamics S Magder Curr
More informationR2R: Severe sepsis/septic shock. Surat Tongyoo Critical care medicine Siriraj Hospital
R2R: Severe sepsis/septic shock Surat Tongyoo Critical care medicine Siriraj Hospital Diagnostic criteria ACCP/SCCM consensus conference 1991 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference
More informationFull Disclosure. The case for why it matters. Goal-directed Fluid Resuscitation
Goal-directed Fluid Resuscitation Christopher G. Choukalas, MD, MS Department of Anesthesia and Perioperative Care University of California, San Francisco I own no stocks Full Disclosure The case for why
More informationGoal-directed resuscitation in sepsis; a case-based approach
Goal-directed resuscitation in sepsis; a case-based approach Jorge A Guzman, MD, FCCM Head, Section Critical Care Medicine Respiratory Institute Cleveland Clinic Foundation The challenges to managing septic
More informationPatrick C. Cullinan, DO, NBPNS, FCCM, FACOEP, FACOI Associate Clinical Professor, UIWSOM, San Antonio, Texas Adjunct Assistant Professor, University
Patrick C. Cullinan, DO, NBPNS, FCCM, FACOEP, FACOI Associate Clinical Professor, UIWSOM, San Antonio, Texas Adjunct Assistant Professor, University of Texas Health Science Center, Department of Emergency
More informationICU Volume 12 - Issue 4 - Winter 2012/ Matrix Features
ICU Volume 12 - Issue 4 - Winter 2012/2013 - Matrix Features Fluid Management in Critically Ill Patients: A Guided Approach Prof. Antonio Artigas, MD, PhD ICU Management & Practice Editorial Board Member
More informationEchocardiography Volume assessment. Justin Mandeville 2014
Echocardiography Volume assessment Justin Mandeville 2014 Volume assessment and the intensivist Hypovolaemic shock Fluid tolerance Optimising cardiac output Avoiding overloading Guided fluid removal Add
More informationRuminations about the Past, Present, and Future
Ruminations about the Past, Present, and Future Raymond L. Fowler, MD, FACEP, DABEMS Professor and Chief Division of Emergency Medical Services Department of Emergency Medicine UT Southwestern Medical
More informationCardiovascular Management of Septic Shock
Cardiovascular Management of Septic Shock R. Phillip Dellinger, MD Professor of Medicine Robert Wood Johnson Medical School/UMDNJ Director, Critical Care Medicine and Med/Surg ICU Cooper University Hospital
More informationPiCCO based algorithms
European Society of Anaesthesiologists Annual Meeting 12.-15. June 2010, Helsinki, Finland PiCCO based algorithms Berthold Bein, MD, PhD, DEAA Department of Anaesthesiology and Intensive Care Medicine
More information3/14/2017. Disclosures. None. Outline. Fluid Management and Hemodynamic Assessment Paul Marik, MD, FCCP, FCCM
Fluid Management and Hemodynamic Assessment Paul Marik, MD, FCCP, FCCM Disclosures Stocks Advisory boards Grants Speakers Bureau None Outline Hemodynamic Goals Fluid Resuscitation Historical Perspective
More information6/5/2014. Sepsis Management and Hemodynamics. 2004: International group of experts,
Sepsis Management and Hemodynamics Javier Perez-Fernandez, M.D., F.C.C.P. Medical Director Critical Care Services, Baptist t Hospital of Miamii Medical Director Pulmonary Services, West Kendall Baptist
More informationFluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE
Fluids in Sepsis: How much and what type? John Fowler, MD, FACEP Kent Hospital, İzmir Eisenhower Medical Center, USA American Hospital Dubai, UAE In critically ill patients: too little fluid Low preload,
More informationIDENTIFYING SEPSIS IN THE PREHOSPITAL SETTING
IDENTIFYING SEPSIS IN THE PREHOSPITAL SETTING Christopher Hunter, MD, PhD, FACEP Director, Health Services Department Associate Medical Director, Orange County EMS System Medical Director, Orlando Health
More informationBedside assessment of fluid status
Bedside assessment of fluid status 2nd AKI Academy October 18 th 2014 David Treacher Guy s & St Thomas NHS Trust Assessing the circulation - the 3 key questions v Is my patient adequately filled? v What
More informationSurviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 Mitchell M. Levy MD, MCCM Professor of Medicine Chief, Division of Pulmonary, Sleep, and Critical Care
More informationDepartment of Intensive Care Medicine UNDERSTANDING CIRCULATORY FAILURE IN SEPSIS
Department of Intensive Care Medicine UNDERSTANDING CIRCULATORY FAILURE IN SEPSIS UNDERSTANDING CIRCULATORY FAILURE IN SEPSIS a mismatch between tissue perfusion and metabolic demands the heart, the vasculature
More informationSurviving Sepsis Campaign Guidelines 2012 & Update for David E. Tannehill, DO Critical Care Medicine Mercy Hospital St.
Surviving Sepsis Campaign Guidelines 2012 & Update for 2015 David E. Tannehill, DO Critical Care Medicine Mercy Hospital St. Louis Be appropriately aggressive the longer one delays aggressive metabolic
More informationการอบรมว ทยาศาสตร พ นฐานทางศ ลยศาสตร เร อง นพ.ส ณฐ ต โมราก ล ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาวทยาลยมหดล
การอบรมว ทยาศาสตร พ นฐานทางศ ลยศาสตร เร อง นพ.ส ณฐ ต โมราก ล ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร โรงพยาบาลรามาธ บด มหาวทยาลยมหดล Distributive shock Severe sepsis and Septic shock Anaphylactic shock Neurogenic
More informationIV fluid administration in sepsis. Dr David Inwald Consultant in PICU St Mary s Hospital, London CATS, London
IV fluid administration in sepsis Dr David Inwald Consultant in PICU St Mary s Hospital, London CATS, London The talk What is septic shock? What are the recommendations? What is the evidence? Do we follow
More informationSepsis Early Recognition and Management. Therese Hughes, PhD, MPA, RN
Sepsis Early Recognition and Management Therese Hughes, PhD, MPA, RN 1 Sepsis a Deadly Progression Affects millions around the world each year, killing one in four Contributes to approximately 50% of all
More informationFUNDAMENTALS OF HEMODYNAMICS, VASOACTIVE DRUGS AND IABP IN THE FAILING HEART
FUNDAMENTALS OF HEMODYNAMICS, VASOACTIVE DRUGS AND IABP IN THE FAILING HEART CINDY BITHER, MSN, ANP, ANP, AACC, CHFN CHIEF NP, ADV HF PROGRAM MEDSTAR WASHINGTON HOSPITAL CENTER CONFLICTS OF INTEREST NONE
More informationShock - from Diagnostic to Therapeutic Implications
Shock - from Diagnostic to Therapeutic Implications Rui Moreno, MD, PhD, Professor UCINC, Hospital de São José Centro Hospitalar de Lisboa Central, E.P.E. LEARNING OBJECTIVES Review the markers of tissue
More informationSEPSIS: Seeing Through the. W. Graham Carlos MD, MSCR, ATSF, FACP
SEPSIS: Seeing Through the W. Graham Carlos MD, MSCR, ATSF, FACP Objectives Forget everything you have known about sepsis Learn new things Objectives Define sepsis Explain why Early Goal Directed Therapy
More informationEchocardiography as a diagnostic and management tool in medical emergencies
Echocardiography as a diagnostic and management tool in medical emergencies Frank van der Heusen MD Department of Anesthesia and perioperative Care UCSF Medical Center Objective of this presentation Indications
More informationEchocardiography to guide fluid therapy in critically ill patients: check the heart and take a quick look at the lungs
Editorial Echocardiography to guide fluid therapy in critically ill patients: check the heart and take a quick look at the lungs Federico Franchi 1 *, Luigi Vetrugno 2 *, Sabino Scolletta 1 1 Department
More informationIN THE NAME OF GOD SHOCK MANAGMENT OMID MORADI MOGHADDAM,MD,FCCM IUMS ASSISTANT PROFESSOR
IN THE NAME OF GOD SHOCK MANAGMENT OMID MORADI MOGHADDAM,MD,FCCM IUMS ASSISTANT PROFESSOR The ability to evaluate and manage a critically ill patient is one of the most important skills any intensivist
More informationHEMODYNAMIC ASSESSMENT
HEMODYNAMIC ASSESSMENT INTRODUCTION Conventionally hemodynamics were obtained by cardiac catheterization. It is possible to determine the same by echocardiography. Methods M-mode & 2D echo alone can provide
More informationCogent 2-in-1 Hemodynamic Monitoring System
Cogent 2-in-1 Hemodynamic Monitoring System Minimally invasive and invasive hemodynamic monitoring technologies in a single, lightweight system with wireless communication The flexibility you ve been asking
More information(Peripheral) Temperature and microcirculation
(Peripheral) Temperature and microcirculation Prof. Jan Bakker MD, PhD Chair dept Intensive Care Adults jan.bakker@erasmusmc.nl www.intensivecare.me Intensive Care Med (2005) 31:1316 1326 DOI 10.1007/s00134-005-2790-2
More informationThe Hemodynamic Puzzle
The Hemodynamic Puzzle SVV NIRS O 2 ER Lactate Energy Metabolism (Oxygen Consumption) (Ml/min/m 2 ) Oxygen Debt: To Pay or Not to Pay? Full Recovery Possible Delayed Repayment of O 2 Debt Oxygen Deficit
More informationVasopressors in septic shock
Vasopressors in septic shock Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France Questions 1- Why do we use vasopressors in septic shock? 2- Which first-line agent? 3- When
More informationFunctional Hemodynamic Monitoring and Management A practical Approach
Functional Hemodynamic Monitoring and Management A practical Approach Daniel A. Reuter Center of Anesthesiology and Intensive Care Medicine Hamburg-Eppendorf University Hospital Hamburg, Germany Euronaesthesia
More informationInitial Resuscitation of Sepsis & Septic Shock
Initial Resuscitation of Sepsis & Septic Shock Dr. Fatema Ahmed MD (Critical Care Medicine) FCPS (Medicine) Associate professor Dept. of Critical Care Medicine BIRDEM General Hospital Is Sepsis a known
More informationTopics to be Covered. Cardiac Measurements. Distribution of Blood Volume. Distribution of Pulmonary Ventilation & Blood Flow
Topics to be Covered MODULE F HEMODYNAMIC MONITORING Cardiac Output Determinants of Stroke Volume Hemodynamic Measurements Pulmonary Artery Catheterization Control of Blood Pressure Heart Failure Cardiac
More informationDepartment of General Medicine, Kilpauk Medical College and Hospital, Chennai, Tamil Nadu, India * Corresponding author
Original Research Article Study on clinical assessment of volume status and correlation to the respiratory variation in inferior vena cava diameter by echocardiography, a non-invasive method of measuring
More informationWhat is. InSpectra StO 2?
What is InSpectra StO 2? www.htibiomeasurement.com What is InSpectra StO 2? Hemoglobin O 2 saturation is measured in three areas: 1) Arterial (SaO 2, SpO 2 ) Assesses how well oxygen is loading onto hemoglobin
More informationHow to resuscitate the patient in early sepsis? A physiological approach. J.G. van der Hoeven, Nijmegen
How to resuscitate the patient in early sepsis? A physiological approach J.G. van der Hoeven, Nijmegen Disclosure interests speaker (potential) conflict of interest Potentially relevant relationships with
More informationThe Cardiac Cycle Clive M. Baumgarten, Ph.D.
The Cardiac Cycle Clive M. Baumgarten, Ph.D. OBJECTIVES: 1. Describe periods comprising cardiac cycle and events within each period 2. Describe the temporal relationships between pressure, blood flow,
More informationPurist? or Pragmatist? Assessment & Management of ICU Volume Status
Assessment & Management of ICU Volume Status 9 th Annual Rocky Mountain Hospital Medicine Symposium Denver, Colorado Paula Dennen, MD Assistant Professor of Medicine Nephrology and Critical Care Medicine
More informationCath Lab Essentials: Basic Hemodynamics for the Cath Lab and ICU
Cath Lab Essentials: Basic Hemodynamics for the Cath Lab and ICU Ailin Barseghian El-Farra, MD, FACC Assistant Professor, Interventional Cardiology University of California, Irvine Department of Cardiology
More informationUpdates On Sepsis Updates based on 2016 updates on sepsis from The International Surviving Sepsis Campaign
Updates On Sepsis Updates based on 2016 updates on sepsis from The International Surviving Sepsis Campaign Dr. Joseph K Erbe, DO Medical Director Hospitalist Division of Medicine Objectives 1. Review the
More informationCore Measures SEPSIS UPDATES
Patricia Walker, RN-BC, BSN Evidence Based Practice Manager Quality Management Services UCLA Health System, Ronald Reagan Medical Center Core Measures SEPSIS UPDATES Severe Sepsis and Septic Shock Based
More informationReview Article Echocardiographic Assessment of Preload Responsiveness in Critically Ill Patients
Cardiology Research and Practice Volume 2012, Article ID 819696, 7 pages doi:10.1155/2012/819696 Review Article Echocardiographic Assessment of Preload Responsiveness in Critically Ill Patients Alexander
More informationMechanical Ventilation & Cardiopulmonary Interactions: Clinical Application in Non- Conventional Circulations. Eric M. Graham, MD
Mechanical Ventilation & Cardiopulmonary Interactions: Clinical Application in Non- Conventional Circulations Eric M. Graham, MD Background Heart & lungs work to meet oxygen demands Imbalance between supply
More informationEVOLUCIÓN DE LA MONITORIZACIÓN CARDIOVASCULAR EN LA UCI
EVOLUCIÓN DE LA MONITORIZACIÓN CARDIOVASCULAR EN LA UCI Antonio Artigas Critical Care Center Sabadell Hospital CIBER Enfermedades Respiratorias Autonomos University of Barcelona Spain aartigas@tauli.cat
More informationSepsis: Management ANUPOL PANITCHOTE, MD. Division of Critical Care Medicine Department of Medicine, Khon Kaen University, Thailand
Sepsis: Management ANUPOL PANITCHOTE, MD. Division of Critical Care Medicine Department of Medicine, Khon Kaen University, Thailand Vital signs Symptoms LAB BT > 38.3 or < 36 ๐ C HR > 90 bpm RR > 20 /min
More informationThe Septic Patient. Dr Arunraj Navaratnarajah. Renal SpR Imperial College NHS Healthcare Trust
The Septic Patient Dr Arunraj Navaratnarajah Renal SpR Imperial College NHS Healthcare Trust Objectives of this session Define SIRS / sepsis / severe sepsis / septic shock Early recognition of Sepsis The
More informationOnline Supplement. Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography
Online Supplement Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography A Comparative Study Philippe Vignon, MD, PhD; Emmanuelle Begot,
More informationSepsis & Beyond Guidelines & Goal-Directed Therapy
Sepsis & Beyond Guidelines & Goal-Directed Therapy Canadian Association of Critical Care Nurses 2014 Quebec City Presented by: Nicole Kupchik RN, MN, CCNS, CCRN, PCCN Objectives Review the 2012 Surviving
More informationCardiorespiratory Interactions:
Cardiorespiratory Interactions: The Heart - Lung Connection Jon N. Meliones, MD, MS, FCCM Professor of Pediatrics Duke University Medical Director PCVICU Optimizing CRI Cardiorespiratory Economics O2:
More informationSepsis Management: Past, Present, and Future
Sepsis Management: Past, Present, and Future Benjamin Ferrell, MD Tennessee ACP Meeting October 28, 2017 Learning Objectives Identify the most updated definition and clinical criteria for sepsis Describe
More informationSHOCK and the Trauma Victim. JP Pretorius Department of Surgery & SICU Steve Biko Academic Hospital.
SHOCK and the Trauma Victim JP Pretorius Department of Surgery & SICU Steve Biko Academic Hospital. Classification of Shock Cardiogenic - Myopathic Arrythmic Mechanical Hypovolaemic - Haemorrhagic Non-haemorrhagic
More informationUnderstand the scope of sepsis morbidity and mortality Identify risk factors that predispose a patient to development of sepsis Define and know the
Understand the scope of sepsis morbidity and mortality Identify risk factors that predispose a patient to development of sepsis Define and know the differences between sepsis, severe sepsis and septic
More informationHow and why I give IV fluid Disclosures SCA Fluids and public health 4/1/15. Andrew Shaw MB FRCA FCCM FFICM
How and why I give IV fluid Andrew Shaw MB FRCA FCCM FFICM Professor and Chief Cardiothoracic Anesthesiology Vanderbilt University Medical Center 2015 Disclosures Consultant for Grifols manufacturer of
More informationFluids in Sepsis Less is more. Dr Anand Senthi Joondalup Health Campus ED MBBS, MAppFin, GradCertPubHlth,
Fluids in Sepsis Less is more Dr Anand Senthi Joondalup Health Campus ED MBBS, MAppFin, GradCertPubHlth, FRACGP @drsenthi Summary Discussion of the evidence for/against fluid resuscitation in septic shock
More informationCardiopulmonary System
Dana Oakes, BA, RRT NPS Author/Speaker Cardiopulmonary System Main Purpose Main Function Main Goal Oxygen Delivery Adequate Perfusion (deliver adequate oxygen and nutrients; remove metabolic waste) Tissue
More informationDoppler Basic & Hemodynamic Calculations
Doppler Basic & Hemodynamic Calculations August 19, 2017 Smonporn Boonyaratavej MD Division of Cardiology, Department of Medicine Chulalongkorn University Cardiac Center, King Chulalongkorn Memorial Hospital
More informationCHAPTER 13. Fluid Responsiveness
CHAPTER 13 Fluid Responsiveness SECTION 1 Introduction Administration of an intravenous fluid challenge is a common medical intervention in the hypotensive or hypovolemic patient. Ideally, a fluid challenge
More informationSHOCK. Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital
SHOCK Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital 1 Definition Shock is an acute, complex state of circulatory dysfunction
More informationSepsis Bundle Project (SEP) Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: April 2015 Most recent Revision: December 2018
Sepsis Bundle Project (SEP) Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: April 2015 Most recent Revision: December 2018 Objectives 1. To identify the symptom of severe sepsis and septic shock syndrome.
More informationThe right heart: the Cinderella of heart failure
The right heart: the Cinderella of heart failure Piotr Ponikowski, MD, PhD, FESC Medical University, Centre for Heart Disease Clinical Military Hospital Wroclaw, Poland none Disclosure Look into the Heart
More informationEarly lactate clearance rate is an indicator of Outcome in severe sepsis and septic shock
Early lactate clearance rate is an indicator of Outcome in severe sepsis and septic shock Sultana R, Ahsan ASMA, Fatema K, Ahmed F, Hamid T, Saha DK, Saha M, Nazneen S, Dr. Rozina Sultana FCPS (Medicine)
More information