Part of the joint International Fluid Academy and World Society of Abdominal Compartment Syndrome workshop at the Emirates Critical Car Conference 2018
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
In patients with septic shock, the administration of fluids during initial hemodynamic resuscitation remains a major therapeutic challenge. We are faced with many open questions regarding the type, dose, and timing of intravenous fluid administration.
There are only four major indications for intravenous fluid administration: aside from resuscitation, intravenous fluids have many other uses including maintenance and replacement of total body water and electrolytes, as carriers for medications, and for parenteral nutrition.
In this lecture, the different fluid management strategies are discussed including early adequate goal-directed fluid management, late conservative fluid management, and late goal-directed fluid removal.
In addition, the concept of the "four D’s" of fluid therapy is introduced, namely drug, dosing, duration, and de-escalation.
During the treatment of patients with septic shock, four phases of fluid therapy should be considered in order to provide answers to four basic questions. These four phases are the resuscitation phase, the optimization phase, the stabilization phase, and the evacuation phase.
The four questions are “When to start intravenous fluids?”, “When to stop intravenous fluids?”, “When to start de-resuscitation or active fluid removal?” and finally “When to stop de-resuscitation?”.
In analogy to the way we handle antibiotics in critically ill patients, it is time for fluid stewardship.
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects.
Many questions remain to be answered indeed:
Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost?
Does HES still have a place in the OR?
Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin?
Is it really impossible to avoid fluid overload by using only crystalloids?
Is there still a definitive place for human albumin?
How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others?
How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy?
What with the fluids beyond resuscitation?
And what do the authors of the big fluid trials do in real life themselves?
The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill.
Date: October 26th 2019, 8:00 - 18:00
In patients with septic shock, the administration of fluids during initial hemodynamic resuscitation remains a major therapeutic challenge. We are faced with many open questions regarding the type, dose, and timing of intravenous fluid administration.
There are only four major indications for intravenous fluid administration: aside from resuscitation, intravenous fluids have many other uses including maintenance and replacement of total body water and electrolytes, as carriers for medications, and for parenteral nutrition.
In this lecture, the different fluid management strategies are discussed including early adequate goal-directed fluid management, late conservative fluid management, and late goal-directed fluid removal.
In addition, the concept of the "four D’s" of fluid therapy is introduced, namely drug, dosing, duration, and de-escalation.
During the treatment of patients with septic shock, four phases of fluid therapy should be considered in order to provide answers to four basic questions. These four phases are the resuscitation phase, the optimization phase, the stabilization phase, and the evacuation phase.
The four questions are “When to start intravenous fluids?”, “When to stop intravenous fluids?”, “When to start de-resuscitation or active fluid removal?” and finally “When to stop de-resuscitation?”.
In analogy to the way we handle antibiotics in critically ill patients, it is time for fluid stewardship.
This talk was recorded as part of the Norwich Anaesthesia Update on 13th January 2021.
Here Dr Pawa Discusses the role of fascial plane blocks in modern anaesthetic practice along with key concepts ranging from mechanisms of action, evidence of efficacy and whether they are here to stay.
The four phases of intravenous fluid therapy: Manu MalbrainSMACC Conference
Manu Malbrain presents the four phases of intravenous fluid therapy. He takes you through the big questions of fluids - What, when, why and how?
To Manu, there are four Ds of fluid therapy: Drug, dose, duration, and de-escalation
Drug
Fluids are drugs. This means, like any drugs, consideration must be taken about the type, indication, contraindication, and adverse effects of fluids whenever prescribing them. The evidence suggests that we should stop using starches in sepsis, albumin in TBI and stop using more than 2L of saline in resuscitation. For maintenance – eliminate the use of unbalanced isotonic fluids, and do not forget to cover daily needs. The bottom line is starting to consider fluids as drugs.
Dose
As Paracelsus famously said “The dose makes the poison”
This holds true when administering fluids. There are different doses for different patients dependent on the indication – whether using fluids for maintenance, resuscitation, or replacement.
Duration
When do you start and stop? You must weigh up the benefit and risk of fluid administration.
Duration should be appropriate – more often than not this means tending towards a shorter duration. Similarly, do not use fluids to treat numbers (such as low CVP or MAP) but rather to treat shock. Finally, fluids can be stopped when shock has resolved.
De-escalation
Water is a problem. Just as hypovolaemia is bad, so too is hypervolaemia.
Weigh up the benefit and risk of fluid removal. Manu describes the ROSE acronym – Resuscitation, Organ support, Stabilisation, Evacuation removal. Essentially, after early management with adequate and goal directed fluids, stop ongoing resuscitation, and move to conservative fluid management (de-resuscitation!)
We need to make good fluids better
So let Manu guide you through the complex world of fluids. Answer the four questions, address the four D’s and remember the four phases of ROSE.
For more like this, head to our podcast page. #CodaPodcast
Point of critical care Ultrasound play a pivotal role in management of critically ill patients admitted in ICU . Its usage in this regard is ever growing . Here we discus about pearls and pitfalls of POCUS in Intensive care medicine.
Powerpoint Presentation - exported from Keynote Mac presentation. Introduction to Cardiac Point of Care U/S. Talk was meant for Emergency Medicine Residents PG1-3 level. Modest tweaks of font and spacing required prior to your own use. Associated PDF file in original Keynote format.
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
This talk was recorded as part of the Norwich Anaesthesia Update on 13th January 2021.
Here Dr Pawa Discusses the role of fascial plane blocks in modern anaesthetic practice along with key concepts ranging from mechanisms of action, evidence of efficacy and whether they are here to stay.
The four phases of intravenous fluid therapy: Manu MalbrainSMACC Conference
Manu Malbrain presents the four phases of intravenous fluid therapy. He takes you through the big questions of fluids - What, when, why and how?
To Manu, there are four Ds of fluid therapy: Drug, dose, duration, and de-escalation
Drug
Fluids are drugs. This means, like any drugs, consideration must be taken about the type, indication, contraindication, and adverse effects of fluids whenever prescribing them. The evidence suggests that we should stop using starches in sepsis, albumin in TBI and stop using more than 2L of saline in resuscitation. For maintenance – eliminate the use of unbalanced isotonic fluids, and do not forget to cover daily needs. The bottom line is starting to consider fluids as drugs.
Dose
As Paracelsus famously said “The dose makes the poison”
This holds true when administering fluids. There are different doses for different patients dependent on the indication – whether using fluids for maintenance, resuscitation, or replacement.
Duration
When do you start and stop? You must weigh up the benefit and risk of fluid administration.
Duration should be appropriate – more often than not this means tending towards a shorter duration. Similarly, do not use fluids to treat numbers (such as low CVP or MAP) but rather to treat shock. Finally, fluids can be stopped when shock has resolved.
De-escalation
Water is a problem. Just as hypovolaemia is bad, so too is hypervolaemia.
Weigh up the benefit and risk of fluid removal. Manu describes the ROSE acronym – Resuscitation, Organ support, Stabilisation, Evacuation removal. Essentially, after early management with adequate and goal directed fluids, stop ongoing resuscitation, and move to conservative fluid management (de-resuscitation!)
We need to make good fluids better
So let Manu guide you through the complex world of fluids. Answer the four questions, address the four D’s and remember the four phases of ROSE.
For more like this, head to our podcast page. #CodaPodcast
Point of critical care Ultrasound play a pivotal role in management of critically ill patients admitted in ICU . Its usage in this regard is ever growing . Here we discus about pearls and pitfalls of POCUS in Intensive care medicine.
Powerpoint Presentation - exported from Keynote Mac presentation. Introduction to Cardiac Point of Care U/S. Talk was meant for Emergency Medicine Residents PG1-3 level. Modest tweaks of font and spacing required prior to your own use. Associated PDF file in original Keynote format.
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
Educative power-point presentation for students in paediatrics, paediatric critical care, neonatology, And trainees or fellows in paediatric critical care
Professor Panditrao expresses his views about the day to day challenge, faced in clinical practice. Considered to be a simple surgery, but the anesthetic management is very challenging because of the primary pathology, co-morbidities and repeated surgeries involved.
Renal Replacement therapy (Dialytic Management) in AKI - Dr.GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/NN9vyWjIPbE
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https://youtu.be/i-Qlf31Vd-Y
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Kidney transplantation, if not contraindicated, is the most preferred renal replacement therapy for patients with end stage renal disease. Generally, live related transplantation is associated with longer term survival of the transplantated kidney as well as the patient. However, it is associated with great physical and psychological challenges for the donor. Therefore, an exhaustive physical workup as well comprehensive psychological counselling go a long way for a happy donor as well as recipient. Laparoscopic donor surgery has helped reduce surgical morbidity and improve acceptance. Moreover, to avoid medicolegal issues, exhaustive documentation is necessary.
PICUDoctor.org is a medical reference e-book that covers the evolving knowledge in physiology and pathophysiology of pediatric cardiac critical care. From preoperative, perioperative and postoperative management through specific topics in critical care treatment, anaesthesia and analgesia, pharmacokinetics and pharmacodynamics, heart failure, circulatory mechanical assist and ECMO, the electronic format of PICUDoctor.org incorporates and allows implementation of up to date knowledge with multimedia.
PICUDoctor.org was first developed in 2011 with contributions from authors around the world. Further edits and the transition to an online e-book followed in 2013 and 2014. Initially a bedside tool, it evolved into a full reference e-textbook with multiple multi-media functions as well as links to PubMed® articles to further support the users’ education. PICUDoctor.org is a not peer reviewed, but open source. To limit costs for publication and distribution, PICUdoctor.org is available in portable document format, iTunes and Google https://www.facebook.com/picudoctor.org/ for more details.
The Capsule, is a monthly newsletter edited, designed and published by Cleveland Clinic Abu Dhabi Pharmacy Quality and Medication Safety team for our caregivers to spread pharmaceutical information, safety and quality practices .
I DON'T need ultrasound monitoring on the ICUAdrian Wong
Taking the con side for this debate at the International Fluid Academy Day - Antwerp, Belgium.
Hopefully it provides some of the limitations of US on the ICU - focussing mostly on lack of governance and system
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
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Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
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Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
44. Summary
Too much fluid is detrimental
Knowing ‘when is too much’ is
crucial
Intergrated, multimodal
POCUS examination can aid
decisions at all stages
45. 7th
#IFAD2018Reviewing recent advances in fluid
management and haemodynamic
and organ function monitoring in
critical care
All specialties welcome!
@Fluid_Academy www.fluidacademy.org
International FluidAcademy Day
The Netherlands
Amsterdam
46. Key
References
Four phases of intravenous fluid therapy: a conceptual model -
https://academic.oup.com/bja/article/113/5/740/2920186
Transthoracic echocardiography: an accurate and precise method for estimating
cardiac output in the critically ill patient -
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5465531/
www.Thinkingcriticalcare.com
Development of a fluid resuscitation protocol using inferior vena cava and lung
ultrasound - https://www.ncbi.nlm.nih.gov/pubmed/26475100
Diastolic dysfunction in anaesthesia and critical care -
https://academic.oup.com/bjaed/article/16/9/287/1743688
IntrarenalVenous Flow:AWindow Into the Congestive Kidney Failure
Phenotype of Heart Failure? -
http://heartfailure.onlinejacc.org/content/jhf/4/8/683.full.pdf
Editor's Notes
These are some of the organisations and societies I contribute to. I have no financial confliction of interests to declare. Perhaps my most important declaration of interest is the fact that I use point-of-care ultrasound in my daily practice.
A little reminder that ultrasound as we know it today was developed from SONAR technology used in submarines. The use of soundwave as a way of imaging has come a long way since then. Early machines had patients submerged in baths of water and look nothing like the devices we know today. Ultrasound and water/fluids have gone hand in hand and today, Im going to revisit this relationship.
You’ve heard it already today and I’ll re-emphasise this key message. Fluids are drugs.
Like all drugs they have got their specific indication and contra-indication. My colleagues have told you about the various considerations that you must play attention to when prescribing fluids.
The harm of associated with excessive fluid is well known. It’s a scenario I’m sure we are all familiar with.
It affects all organ systems of the body and not just the obvious cardiovascular and respiratory system. I would like to focus your attention on the hepatic and renal system as I will come back to these later in my lecture.
Let’s remind ourselves of the 4 phases of fluid management – the ROSE concept. Resuscitation, Optimisation, Stabilisation and de-Escalation
Much of ICU research has focused on the rescue and optimisation phase of the 4 phases. There has been less attention paid to the the later stages. Perhaps it is because of the misconception that if you get the first few 2 stages right, the remaining stages becomes less of an issue.
In the orginal paper, the authors suggested various forms of monitoring that you could use according to the various phases. Note that cardiac echo/doppler is primarily thought to be for these first 2 phases. Note that ultrasound of the other organs isn’t mentioned and there is precious little suggested help in the later 2 phases.
With that all in mind, I am going to tell you about how I/we can potentially use point-of-care ultrasound with regards the fluids with emphasis on the later stages. It is impossible to talk about everything that POCUS can offer so I am just going to focus on the big headlines.
This is just one of the many papers/statements which has pushed the fact that the ability to use point-of-care ultrasound should be a core competency of the intensivists.
Every single practicing intensivisits out there should have the ability to perform focused examination of the heart, lung and so on by the bedside to aid decision making and devise management strategies.
I will show you that POCUS has a role in all the phases of fluid management.
You’ve seen this before, but essentially, the 4 phases are about asking these 4 questions.
When to start fluids
When to stop fluids
When to start fluid removal
When to stop fluid removal
I’m going to focus on the last 2
Ultrasound/Echocardiography has the ability to tell us when to stop our fluid resuscitation – i.e. stop giving fluids. We need to know when the glass is getting full.
It also helps us to decide when we may have overshot and hence need to start taking off fluid – either by diuretics or renal replacement therapy
Lets talk about basic or core echocardiography. This skill can be acquired and maintained by the average intensivists. I am NOT talking about advanced echocardiography. We are talking about focused examination. In this case, we are going to assess LV function and size. RV function and size. The inferior vena cava.
These are some of the standard views of the echocardiography. PSSX, PSLX, A4C, Subcostal.
Focusing on the LV, from these views we can get an idea of its size and systolic function. Is it grossly dilated? Is it grossly impaired? Or is it very empty which is what you would be looking for if you are considering giving fluids.
With regards to the right ventricle. You can again get an idea of its size and function just by eye-balling it. The RV base should be about 2/3s that of the LV in the apical 4 chamber view.
But I personally like the TAPSe measurement – Use M-mode over the tricuspid annulus and measure how much it moves forward. The magic number is 1.6cm or 16mm.
You could also look at how the two ventricles interact with each other especially how the septum which separated the LV and the RV behaves.
Compare these two images. Normal on the left side of the screen. Look at the right sided image, Notice how the septum bows into the left ventricle as RV pressure exceeds the LV.
Subcostal view of the IVC. Examination of the IVC – strongly advocated in most resuscitative protocols. 2 parameters are measured – absolute diameter and the degree of collapse during the respiratory cycle. If the IVC is small and collapsing, the patient will probably be fluid responsive.
BUT doubts have arisen, it is not as straight forward as we thought. We are not sure how to inteprete, where to measure, how to measure (m-mode, collapse). Caution is advised.
Onto lung ultrasound. We are going to focus on the B-lines and effusions.
Most ppl are comfortable recognizing pleural effusions on ultrasound and indeed the use of ultrasound to guide the draining of the effusion. This is widely accepted as gold standard practice.
B-lines and A-lines are perhaps less well known and established in critical care practice. B-lines represent fluid in the interstitium and at the very basics could be interpreted as the equivalent of crackles on auscultation.
This is a normal ultrasound scan of the lung. Rib shadows here and here. Hortizontal A-lines which are reverberation artifacts from the pleura line.
Notice the occasional vertical streak on the side of that rib shadow. That’s a B-line. You are allowed 2 per rib space.
So you’ve seen a normal ultrasound scan of the lung, compare these two images. I’m sure you can appreciate how different they are compared to the last slide.
Notice that there are much more vertical B-lines. They are so numerous that they almost coalesce. So if you see these images throughout the lung field, you may have overfilled the patient and its time to move to fluid removal.
These are effusions. They are so much easier to pick out compared to that of plain radiographs. The specificity and sensitivity of ultrasound in diagnosis pleural effusions outperforms those of clinical examination and plain radiographs.
Onto more advanced and perhaps experimental techniques. Things that are perhaps in the future compared to the modalities that I’ve already described to you. I would emphasise that all these scans provide that extra bit of information to put together when devising your fluid strategy. They do NOT replace clinical acquiment and history. It does not replace the need or ability to bring all the information together to devise our fluid strategy.
I’m sure you are all familiar with the use of the passive-leg raise test to test for fluid responsiveness. This is an important test not just an important test in deciding when to give fluid but also it can also tell you when to stop giving fluid – when there is no longer a response increase in cardiac output.
You can use a variety of cardiac output monitors with your PLR. But I would advocate the use of echo ultrasound like this paper here which uses the velocity time integral to measure cardiac output.
To measure the cardiac output, you need these two views – the PSLX and the apical 5 chamber view. From the PSLX, you get the diameter of the aortic outflow tract and in the 5 chamber view, you can measure the velocity of the blood in the outflow tract.
Diastolic function is defined as/describes the filling of the heart during diastole. This means how good the myocardium is at relaxing and complying (blood filling up the heart). Between 30% and 50% of patients with chronic heart failure have preserved LV systolic function.
Again, there are various measures of diastolic dysfunction but here are just two Doppler-based assessments.
In patients with sinus rhythm, conventional pulsed wave (PW) Doppler of trans-mitral blood flow reveals a biphasic waveform. The initial (E) wave represents early, passive LV filling and the following (A) wave results from active atrial contraction. The relationship of these peak velocities is known as the E/A ratio.
Tissue Doppler imaging (TDI) uses a low-pass filter to exclude blood flow and measure tissue velocity, and it can be used to measure the velocity of longitudinal displacement of the LV basal wall as it relaxes and fills in diastole. TDI at of the mitral annulus reveals a waveform that is similar in shape to the E and A waves, the corresponding peak velocities are known as e prime (e′) and a prime (a′).
A bigger image of the E A wave
TDI showing the e’ and a’ wave
You can then put the two together to grade the degree of diastolic dysfunction according to these patterns or you can utilize the ratio of E to e’. If E is conceptualized as LA/LV driving pressure and e′ is the increase in LV volume, then E/e′ represents the relationship between LV pressure and volume change—or, known as elastance, with its reciprocal being compliance. TDI data are important because they are independent of loading conditions and are easy to obtain so they have considerable utility in critically ill patients.
E/e’ ratio < 8 corresponds to normal filling pressure.
POCUS examination of the portal vein seems to be getting more widely discussed. But just to introduce the concept, the normal portal vein waveform normally shows gentle undulations. During RV failure, higher right heart filling pressures are transmitted back to the hepatic veins and sinusoids, which reduce the compliance of these vessels, thus resulting in a more pulsatile waveform. This finding has been clearly associated with elevated right atrial pressure, tricuspid regurgitation, and RV failure and has also been described in cirrhotic and normal thin (body mass index <20 kg/m2) patients, probably reflecting low abdominal and hepatic acoustical damping.
Conceptually, in the right clinical context, PV pulsatility therefore represents the indirect consequence of RV failure.
In this short paper, the authors describe the changes of in portal vein pulsatility as right heart failure and overload were treated. Notice the marked marked pulsatility before treatment got commenced and notice how it all levels off as the patient got better.
Along the same concepts of portal vein pulsatility is the use of doppler studies to study renal blood flow. This is a fascinating concept where arterial and venous flow to the kidneys can be studied in a point-of-care fashion.
Using these concepts, this table just summarises the findings from the more advanced/experimental techniques I talked about, and that of the well-known IVC.
As a quick mention, you can use ultrasound to detect tissue oedema such as this case.
Take home message, the strength of POCUS is that you can examine a number of modalities in order to formulate the appropriate fluid strategy together with clinical examination and history.
Individually, all these modalities have their strength and weakness. The analogy of the blindmen asked to describe an elephant. You only get the true picture by bringing all the pieces of information together.
The combined use of heart, lung and abdominal ultrasound has been pooled to construct RESUSCITATIVE fluid protocols such as RUSH. Heart lung abdominal to describe the pump, tank and pipes.
And also the SESAME protocol by colleagues in Paris.
As mentioned at the start, there is little work on protocols to help deresuscitation – this is one of the first and few. I suspect as our understanding and utilisation of US increases, such protocols will become more common.
So to summarise,
Too much fluid is harmful
A lot of work has focused on giving fluid compared to when to stop giving or indeed removing fluid
I hope to have at least show you that POCUS examination is not only useful for the early stages of fluid resuscitation but may also have a role in guiding fluid removal.