Point of care ultrasound guided volume management in sepsis and complicated patient
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Presentation at APSR Australia sydney. Bedside ultrasound to assess volume status. This topic cover pitfall in basic that mostly ignore by bedside ultrasound. WIthout doppler you can learn a lot for sepsis patient with both good and bad ef. You can download our application resus ultrasound on APP storre(free) or visit https://www.facebook.com/resusultrasound/ Presentation at APSR Australia sydney. Bedside ultrasound to assess volume status. This topic cover pitfall in basic that mostly ignore by bedside ultrasound. WIthout doppler you can learn a lot for sepsis patient with both good and bad ef. You can download our application resus ultrasound on APP storre(free) or visit https://www.facebook.com/resusultrasound/ Apsr 2017 suthaporn lumlertgul
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Point of care ultrasound guided volume management in sepsis and complicated patient
- 2. Fluid needed? or no? Diarrhea in the past days
- 5. Half of hospitalized patients who receive fluid resuscitation has increase in stroke volume 50%
- 6. Frank-Starling Law Cardiacoutput Cardiogenic shock End diastolic volume Normal Volume dependent Volume independent CHF
- 9. Lung How to differentiate between CHF and ARDS
- 10. Each parameters has its own good! Consider them all
- 11. Myth in hemodynamic parameter Static Dynamic IVC Size Vary of size
- 13. Any thing that measure static have less accuracy!
- 14. Spontaneous breathing <0.9cm Volume needed Ventilated <1.2 cm Volume needed > 2,5 cm High CVP
- 15. SHOCK, Vol. 47, No. 5, pp. 550–559, 2017 IVC ultrasound small and collapse good for predict (specificity of 0.77) Negative IVC ultrasound cannot be used to rule out fluid responsiveness, with a pooled sensitivity of 0.52
- 16. Large IVC Volume non-responsive may be … Raised CVP(pntx,MI,PE)
- 18. Use 1 time is diagnostic ultrasound Hemodynamic ultrasound is how organ “change” after treatment IVC ultrasound is not reliable if…
- 19. LV area = LV preload Passive leg raising Mitral valve E/AIVC collapsiblity Myth IVC CI Jugular vein CI
- 22. SCV correlate with IVC =0.61 > moderate IJV correlate with IVC =0.38 > poor
- 23. Easily compressed Not compress
- 24. So no use?
- 25. Case study: Active GI bleeding Why only one vein is abnormally large? Need fluid resuscitation (Not CVP assessment)
- 26. Subclavian vein Lt Internal Jug vein Rt Internal Jug vein1 2 3
- 27. SVC IVC
- 30. Myth in hemodynamic parameter Static Dynamic Heart(2D) Ejection fraction Dynamic EF After treatment? Size(End systolic area) ESA, EDA after fluid Cardiac output
- 31. How to?
- 32. Which view?
- 34. L L A R Septum should be horizontal Criteria of adequate PLAX Apex of LV shouldn’t be seen Aorta Rv LA each take 1/3 of the screen Mitral valve and Aortic valve should be paperthin Tricuspid valve should not be seen Get a good view!
- 35. Systolic thickening more than 50% good systolic function
- 36. Systolic thickening Mitral Valve Opening = Diastolic Phase Implied
- 37. Systolic thickening E-point septum seperation
- 38. Treatment? normal our patient hyperkinetic hypokinetic
- 40. What about other view? What more can we get from focus?
- 41. 9
- 42. EF < 40% n = 27 EF > 40% n = 63
- 43. Systole Diastole
- 44. SystoleDiastole 100% sensitive for detecting hypovolemia but only 30% specific for predicting volume responsiveness.
- 45. B. LVEDA Variation * Cheung AT. ANESTHESIOLOGY 1994, Feissel M. CHEST 2001 FLUID CHALLANGE FLUID CHALLANGE FLUID CHALLANGE 10% REPRODUCIBILITY of LVEDA measurement * © WINFOCUS’**CRITICAL CARE ECHOCARDIOGRAPHY
- 46. Before 500 cc After 500 cc Document it!
- 50. (tra axis kin trop rec dob ute sup wo urin ogr gas vea (lef rec sam (rig old pul car (tra dem kin wa infu AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 168 2003 Dobutamine (5 mcg/kg/minute)
- 51. DIASTOLIC SYSTOLIC Good EFSeptic Shock Bad EF
- 53. Rt Lt Apical 4 chamber: look at RV to LV ratio
- 54. Look at longitudinal function for RV failure, LV failure
- 56. Myth in hemodynamic parameter Static Dynamic Heart(PW) VTI VTI after passive leg raising test Diastolic dysfunction
- 58. http://www.criticalecho.com/ VTI > 12% indicate sensitivity of 100% and a specificity of 89%.
- 59. EF 60% average Mechanical ventilated 50 patients
- 60. On minimal ECMO flows (About 1 to 1.5L/min) *aortic / LVOT VTI >10 cm *LVEF >20–25% *TDSa >6 cm/s TAPSE > 12mm
- 64. Air > Fluid Fluid > Air B line A line No Lung Sliding Pleural Effusion Lung ultrasound Air to fluid ratio make different lung ultrasound findings. Pulmonary edema ARDS Pneumonia Pleural fibrosis Pulmonary contusion Pneumothorax Pleurodesis Pleural fibrosis Apnea One lung intubation (atelctasis) *No Lung Sliding Resus Ultrasound
- 67. CHF