EuAsia Day 2: Practical use of fluids in shock in early shock states

Rescue, optimise, stabilise (Cecconi)

CVP – absolute value does not predict fluid responses

CVP changes does not tract CO

ScvO2 in Rivers study was 49%, the modern trials (ARISE, PROMISE) had ScvO2 of 70s

Conclusion

  • Resuscitation can be done with minimally invasive monitoring
  • Goal is always perfusion
  • Being less invasive is not always possible
  • Beware of
    • Technique limitation
    • Accuracy vs precision
    • Haemodynamic strategy vs monitor

2017-04-07 08.13.02 2017-04-07 08.26.20 2017-04-07 08.19.36 2017-04-07 08.18.03

References:

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine

Four phases of intravenous fluid therapy: a conceptual model†

Fluid challenges in intensive care: the FENICE study

Effects of fluid administration on arterial load in septic shock patients

Resuscitation of patients with septic shock: please “mind the gap”! 

Early non-invasive cardiac output monitoring in hemodynamically unstable intensive care patients: A multi-center randomized controlled trial

 

Role of minimally invasive monitoring in fluid management (Xia Di)

Minimally invasive – LidCOrapid, LIDCOplus, FloTrac, etc

Monitor needs to be continuous, fast and able to measure SV

Blood pressure changes can be due to changes in SVR and /or CO – hence the need for a monitor to differentiate

In sepsis, there are 2 problems with regards to fluid management strategy

  • loss of arterial and venous tone
  • fluid status

Positive fluid balance on ICU is associated with poorer outcomes

References:

A rational approach to fluid therapy in sepsis

Reduced mortality with noninvasive hemodynamic monitoring of shock.