DOCSLIB.ORG

Effects of Fluids on the Macro- and Microcirculations Victoria A

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Effects of Fluids on the Macro- and Microcirculations Victoria A Bennett et al. Critical Care (2018) 22:74 https://doi.org/10.1186/s13054-018-1993-1 REVIEW Open Access Effects of Fluids on the Macro- and Microcirculations Victoria A. Bennett*, Alexander Vidouris and Maurizio Cecconi this is lost in some disease states. This overview explores Abstract the effects of the fluid on the macro- and microcircula- This article is one of ten reviews selected from the tions and how we can monitor these effects. Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found Indications for Fluid online at https://www.biomedcentral.com/collections/ Classically, the need for fluid therapy is identified using annualupdate2018. Further information about the Annual information from the clinical history, examination, Update in Intensive Care and Emergency Medicine is measurement of hemodynamic variables and markers of available from http://www.springer.com/series/8901. tissue hypoperfusion [7]. Markers of hypoperfusion may include lactate, prolonged capillary refill time and skin Background mottling [6]. A fluid challenge is given when tissue hy- Intravenous fluid administration is one of the most poperfusion is suspected [7]. Fluid is given to optimize frequently performed interventions in the intensive care cardiovascular status with the aim of ensuring adequate unit (ICU) and in hospital in general. In fact, most inpa- end-organ perfusion and improving oxygen delivery to tients will receive fluids at some point during their the tissues. Fluid is given as a fluid challenge so that re- hospital stay [1]. In critically ill patients, fluid resuscita- sponse can be assessed and the need for ongoing fluid tion is a vital component of patient management. It has therapy ascertained. To mitigate against the risk of fluid been shown that both too little and too much fluid can overload in those who do not require additional intra- be detrimental. A positive cumulative fluid balance on vascular volume, the smallest volume that provides an day four of a critical care admission has been associated effective challenge of the cardiovascular system should with increased morbidity [2, 3]. Both perioperatively and be used [8]. during sepsis, a U-shaped curve has been described for Most often, measures of the macrocirculation are used volume of fluid administered and morbidity. Higher to assess and treat hemodynamic compromise in the mortality is observed at both extremes of volume of fluid critically ill patient and measures of the microcirculation given [4, 5]. are not routinely used at the bedside. Resuscitation However, despite extensive research in the field, con- based on macrocirculatory endpoints is expected to re- troversy remains regarding the best approach to fluid sult in parallel improvement in the microcirculation [9]. therapy. The FENICE study focused on the fluid challenge and found wide disparity in practice; from fluid Macrocirculation choice to method of administration and clinician response The macrocirculatory response to intravenous fluid to the result [6]. To help guide decision making around administration is based on the principles of the Frank- fluid administration, the effects, both desirable and poten- Starling law of the heart. Venous return is always equal tially detrimental ones, need to be considered. This can be to cardiac output. The Frank-Starling principle describes considered at both the macrocirculatory and the microcir- how the heart is able to accommodate increased venous culatory level. Whilst in health coherence between the return and then eject the increased volume from the macrocirculation and microcirculation can be assumed, heart, with an increase in stroke volume. Increased venous return increases ventricular filling, which results in increased stretch of the cardiac myocyctes. This in- * Correspondence: [email protected] Department of Intensive Care Medicine, St George’s University Hospital NHS creased stretch results in increased contractility, or in Foundation Trust, London, UK other words, the increased diastolic expansion results in © Bennett et al. 2018 Bennett et al. Critical Care (2018) 22:74 Page 2 of 6 increased systolic contraction [10, 11]. Administration of this patient is fluid responsive. At C, although an ad- fluid aims to challenge this and assess whether a patient equate fluid challenge is given, as demonstrated by an can accommodate an increased preload with an in- increase in Pmsf, no significant increase in stroke creased stroke volume. volume is seen at point D – this patient is not fluid re- The hemodynamic response to a fluid challenge can sponsive. If an inadequate fluid challenge, of too small a be understood by considering the effects at different volume to increase Pmsf, is given at point A, an increase points on the cardiovascular system. The first change in stroke volume is not seen at point E and the patient seen is an expansion of the intravascular volume. Intra- would incorrectly be labeled as non-responsive to fluid. vascular volume can be divided into stressed and Cecconi et al. demonstrated that a change in the pres- unstressed volumes. The unstressed volume fills the ves- sure gradient of venous return, defined as the difference sels but does not generate any pressure. The stressed between the Pmsf and central venous pressure (CVP), volume causes stretch of the vessel walls and increases following a fluid challenge was seen in responders but the pressure within the vessels. Mean systemic filling not in non-responders. In the non-responders, the in- pressure (Pmsf) is the measurement of the pressure crease in Pmsf was mirrored by an increase in CVP [14]. when there is no flow in the vessels, or in circulatory In those that respond, the maximal change in cardiac arrest. Whilst Pmsf cannot be measured under the output is seen one minute after completion of the fluid circumstances with which it was initially described, alter- challenge. The increase in cardiac output is a transient native techniques have been validated [12]. If an effective response; a return to baseline values is seen ten minutes fluid challenge is given, it will, at least transiently, in- post-fluid administration [13]. crease the stressed volume and cause a rise in Pmsf. This The decision to give fluids should be based on whether increases cardiac preload, which ultimately increases an increase in cardiac output is likely to occur with fluid cardiac output in preload-responsive patients. The re- loading and whether it would be likely to improve tissue sponse to the increase in cardiac preload can be explained perfusion. These are clinical questions that the clinician by the Frank-Starling principle. should ask before considering giving fluids. A patient In a patient who is fluid responsive, an effective fluid who is non-responsive is unlikely to benefit from further challenge will result in a significant increase, of more fluid loading. Not all patients who are responsive to fluid than 10%, in the stroke volume or cardiac output. If a require the additional volume [8]. For example, in a fluid challenge is given, which is effective in significantly study of healthy volunteers, by definition not in shock, a increasing Pmsf, but no subsequent increase in cardiac significant increase in stroke volume was seen following output is seen, the patient is labeled as non-responsive a head down tilt (mimicking a fluid challenge). Despite [13]. This is demonstrated in Fig. 1: an adequate fluid being fluid responsive these healthy volunteers were challenge administered at point A, increases Pmsf and a unlikely to need fluid resuscitation or have evidence of significant increase in stroke volume is seen at point B – tissue hypoperfusion [15]. Fig. 1 Assessment of fluid responsiveness using a fluid challenge; effects on mean systemic filling pressure (Pmsf) and stroke volume, explained using the Frank Starling Curve. See text for explanation Bennett et al. Critical Care (2018) 22:74 Page 3 of 6 Other hemodynamic parameters, used more historically, upon smooth muscle. They respond to physical stimuli in include static endpoints, such as heart rate. However, a the microcirculation, such as increased blood pressure, change in heart rate in response to fluid administration is causing constriction in the arterioles of the microcircula- not a sensitive marker of fluid responsiveness and can be tion. Some of the molecules that are active in the vascula- influenced by numerous other factors [13]. ture of the microcirculation are released from the CVP has historically also been used to guide fluid ad- endothelial wall including prostaglandins, nitric oxide ministration. Targeting a CVP of 8–12 cmH2O was part (NO) and endothelin, which are released as a result of of several optimization protocols in the past [16, 17]. The shear stress on the vessels. NO release can also be stimu- role of CVP in predicting fluid responsiveness has since lated by other vasoactive peptides. Metabolic stimuli, such been refuted. Use of the CVP as an indicator of fluid as adenosine, hydrogen ions, carbon dioxide and oxygen responsiveness has been shown to be unreliable [18, 19]. tension, generated in tissues also control blood flow in the It does not provide accurate information about blood microcirculation via dilation of the vessels [9]. The func- volume [20]. Monitoring trends in CVP over time may tion of the microcirculation is also controlled by the per- provide information about cardiovascular function but meability of the capillaries, their structure, the osmotic should not
Load more

Recommended publications
  • The Effect of Passive Leg Raising Towards Hemodynamics on Patient with Hypovolemic Shock at the Emergency Ward of Dustira Cimahi Hospital
    International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi The Effect of Passive Leg Raising towards Hemodynamics on Patient with Hypovolemic Shock at the Emergency Ward of Dustira Cimahi Hospital Evangeline Hutabarat Nursing Science Dept., Stikes Jenderal Achmad Yani Cimahi Email: [email protected] Abstract One of the conditions needing immediate response in the emergency ward is hypovolemic shock. The patient in shock requires close monitoring for clinical signs and hemodynamic status and intravascular status. It is due to circulatory assistance and medication provision on the patient is given based on the accuracy of the intravascular volume status of the patient. Fluid responsiveness can be considered as basis for considering administering fluid only or inotropic and vasopressor medication for the patient to maintain her circulatory homeostatic. Passive Leg Raising (PLR) may be a reversible method to evaluate fluid responsiveness. The study aims at evaluating the effect of PLR on hemodynamic. It employs the quasi-experimental design with the within subject repeated measurement design approach. 48 respondents took part as samples, with the consecutive sampling method implemented. The samples were then categorized into responsive and non-responsive groups based on the increase of pulse pressure amounting to or beyond 9% during PLR implementation. The data was tested using the dependent and independent t test to provide analysis for uni-variate and bivariate data. The results indicated that 34 respondents belonged to the responsive group while 14 respondents were categorized as non-responsive. There was a significant relationship between PLR and hemodynamic parameters of systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pulse pressure (p>0.05).
    [Show full text]
  • 100% NON-INVASIVE FLUID MANAGEMENT Proper Fluid Management May Improve Clinical Outcomes, Potentially Saving Millions in Operating Costs1,2
    100% NON-INVASIVE FLUID MANAGEMENT Proper Fluid Management May Improve Clinical Outcomes, Potentially Saving Millions in Operating Costs1,2 The Starling fluid management monitoring system provides a full hemodynamic profile within seconds. The effect of fluids can be monitored at any time and treatment modified accordingly, across the continuum of care: ED > ICU > OR > RRT In a retrospective, matched, single-center study of nearly 200 patients, researchers from the University of Kansas Health System evaluated stroke volume (SV) guided resuscitation in 100 ICU patients with severe sepsis and septic shock and found1: Initiation of Acute % ICU Length of Stay -2.89 DAYS Dialysis Therapy -13.25 Save an estimated Risk of Mechanical % $14,498 per Ventilation -51 treated patient3 $14K Starling - Over 80% of hospitalized patients receive IV fluids.4 Yet studies show that giving too little or too much fluid can lead to serious complications and contribute to rising healthcare costs.5,6 - Studies also show that only ~50% of hemodynamically unstable patients will respond to IV fluid by increasing cardiac output and perfusion. Assessing whether fluid may help or harm a patient is a critical step in optimizing treatment.7 - Using only blood pressure, urine output and heart rate to measure fluid responsiveness may provide limited and inconclusive information.7 TAKE THE GUESSWORK OUT OF YOUR FLUID ASSESSMENT WITH STARLING - Provides a dynamic assessment of fluid responsiveness — accurately, precisely and 100% non-invasively. - Supports individualized fluid therapy without requiring an invasive arterial or central line, potentially reducing the risk of hospital-acquired infections and other complications.8 - Independently validated vs.
    [Show full text]
  • Passive Leg Raise Testing Effectively Reduces Fluid Administration In
    Rameau et al. Ann. Intensive Care (2017) 7:2 DOI 10.1186/s13613-016-0225-6 RESEARCH Open Access Passive leg raise testing effectively reduces fluid administration in septic shock after correction of non‑compliance to test results Arjanne Rameau, Eldert de With and Evert Christiaan Boerma* Abstract Background: Fluid resuscitation is considered a cornerstone of shock treatment, but recent data have underlined the potential hazards of fluid overload. The passive leg raise (PLR) test has been introduced as one of many strategies to predict ‘fluid responsiveness.’ The use of PLR testing is applicable to a wide range of clinical situations and has the potential to reduce fluid administration, since PLR testing is based upon (reversible) autotransfusion. Despite these theoretical advantages, data on the net effect on fluid balance as a result of PLR testing remain scarce. Methods: We performed a prospective single-center multi-step interventional study in patients with septic shock to evaluate the effect of implementation of PLR testing on the fluid balance (FB) 48 hours after ICU admission. All patients were equipped with a PiCCO® device for pulse contour analysis to guide fluid administration. An increase in stroke volume (SV) 10% was considered a positive test result. ≥ Results: Before introduction of PLR testing, 21 patients were prospectively included in period 1 with a median FB of 4.8 [3.3–7.8]L. After an extensive training program, PLR testing was introduced and 20 patients were included in period 2. Median FB was 4.4 [3.3–7.5]L and did not differ from period 1 (p 0.72).
    [Show full text]
  • The Use of Passive Leg Raise Test to Predict Hypotension in Patients Undergoing Urological Procedures Under Spinal Anesthesia
    Abdullah MW, et al., J Anesth Clin Care 2017, 4: 021 DOI: 10.24966/ACC-8879/100021 HSOA Journal of Anesthesia and Clinical Care Clinical Perspective these outcomes were not related to an individual’s cardiac output The Use of Passive Leg Raise response to the PLR test before spinal anesthesia. Conclusion: The use of PLR test to predict the occurrence of hy- Test to Predict Hypotension in potension in patients undergoing urological procedures under spinal anesthesia was not useful. Patients Undergoing Urolog- Keywords: Passive leg raise; Spinal anesthesia; Spinal hypoten- ical Procedures under Spinal sion; Urologic procedures Introduction Anesthesia Transurethral surgeries are common surgical procedures that can Mai Wedad Abdullah, Mona Hossam EL Din Abdelhamid*, Nor- be performed under general or spinal anesthesia [1], spinal anesthesia han Abdel Aleim Ali and Atef Galal Abdel Moula has proved to be an excellent choice for such surgeries [2]. Hypoten- sion after spinal anesthesia remains a common and potentially seri- Department of Anesthesia and Pain Management, Faculty of Medicine, Cairo University, Egypt ous complication, despite the use of prophylactic ephedrine and fluid loading with crystalloids [3]. Hypotension during spinal anesthesia is due to sympathetic blockade which leads to vasodilatation with a reduction of systemic vascular resistance. Extensive block may lead to decreased venous return which is the main determinant of hypoten- Abstract sion during central neuraxial blockade [4]. Aim of study: A prospective observational study to examine wheth- Most patients scheduled for endoscopic urological surgery are el- er Passive Leg Raise Test (PLR) administered with non invasive car- derly and frequently suffered from cardiopulmonary, endocrine, or diac output monitoring by the electrical Cardiometry could be used other co morbidities [5].
    [Show full text]
  • Comparison of the Accuracy of Monitoring Devices in Prediction of Fluid Responsiveness in Severe Sepsis and Septic Shock
    IRB# 15-21 COMPARISON OF THE ACCURACY OF MONITORING DEVICES IN PREDICTION OF FLUID RESPONSIVENESS IN SEVERE SEPSIS AND SEPTIC SHOCK PRINCIPAL INVESTIGATOR: JEFFREY C. FRIED, MD DATE OF PROTOCOL: 12/29/2016 VERSION 3 BACKGROUND One of the most challenging problems in critical care is determination of whether patients have adequate intravascular volume, and whether they would benefit from additional intravenous fluids. Giving too much fluid to patients with adequate intravascular volume could lead to fluid overload, congestive heart failure and subsequent respiratory failure. Not giving enough fluid to 1 IRB# 15-21 patients, risks leaving them under-resuscitated and worsening their shock state, leading to organ failures, such as kidney failure. Clinically, it is very difficult to determine this “intravascular volume status”, and predict which patients would benefit from more fluid. One of the ways we currently determine this, is to measure cardiac output and one of its main components, stroke volume (how much blood is pumped by the heart each beat) and see whether these increase in response to a passive leg raise (PLR) maneuver1. The maneuver is simple, quick, with essentially no risk. The maneuver involves measuring baseline cardiac output and stroke volume with the patient’s head up at 45 degrees and legs flat for 3 minutes. Subsequently, the head is placed flat and the legs are raised to 45 degrees for 3 minutes. If the cardiac output and stroke volume increase in response to this maneuver, there is a high probability that the patient will have a good response to giving intravenous fluid. Currently there are multiple FDA approved devices which can be used to measure cardiac output and stroke volume, ranging from very invasive (pulmonary artery catheter), to minimally invasive (requiring arterial catheter +/- central venous catheter- Flotrac, PICCO)3,4 to a newer, completely non- invasive device, called the NICOM (Cheetah).
    [Show full text]
  • Passive Leg Raising for Fluid Responsiveness in Children: Is It Reliable? Javed Ismail1, Arun Bansal2
    EDITORIAL Passive Leg Raising for Fluid Responsiveness in Children: Is it Reliable? Javed Ismail1, Arun Bansal2 Indian Journal of Critical Care Medicine (2020): 10.5005/jp-journals-10071-23430 Intravenous fluid administration is an integral part of management for critically ill children with impaired perfusion. Loss of more than 1Pediatric Intensive Care, NMC Royal Hospital, Abu Dhabi, United Arab 15–20% of intravascular volume impairs the preload which in turn Emirates results in decreased cardiac output, clinically manifesting with 2Department of Pediatrics, Advanced Pediatric Centre, Postgraduate signs of impaired perfusion or shock. In children, major causes Institute of Medical Education and Research, Chandigarh, India of shock, such as diarrhea, hemorrhage, sepsis, or anaphylaxis, Corresponding Author: Arun Bansal, Department of Pediatrics, result in either actual or relative intravascular hypovolemia (due to Advanced Pediatric Centre, Postgraduate Institute of Medical vasodilation). Rapid administration of fluid bolus could augment Education and Research, Chandigarh, India, Phone: +91 9815455002, preload to improve the cardiac output and, thus, can potentially e-mail: [email protected] reverse shock. However, studies demonstrate that only half of How to cite this article: Ismail J, Bansal A. Passive Leg Raising for the patients are preload responsive. In the other half, this fluid Fluid Responsiveness in Children: Is it Reliable? Indian J Crit Care Med accumulates and leaks into the interstitial space of almost all organs 2020;24(5):291–292. and can result in serious adverse effects. Fluid leak is exacerbated Source of support: Nil in inflammatory states such as sepsis; and about 95% of the given Conflict of interest: None fluid leaks out within 1 hour even among the fluid responders, thus limiting the beneficial effect.1 Hence, to identify which patient would respond to fluid bolus, tests of fluid responsiveness are recommended.
    [Show full text]
  • Shock and Awe: a Dynamic Approach to Resuscitation
    Shock and Awe: A dynamic approach to resuscitation Critical Care Symposium October 28, 2017 Anna Perrello, RPA-C, MPAS Brian Kersten, PharmD, BCCCP, BCPS Disclosures • Brian Kersten o Nothing to disclose • Anna Perrello o Nothing to disclose Objectives • Identify and explain the physiology of various shock states including distributive, cardiogenic, obstructive and hypovolemic. • Discuss advantages and limitations to static and dynamic predictors of volume responsiveness. • Recognize techniques related to visualization of basic structures and medium identification during bedside ultrasonography. • Evaluate treatment options for shock states using dynamic measures for fluid resuscitation Shock • A heterogenous syndrome best defined as circulatory failure o Originates from mismatch between oxygen delivery (DO2) and oxygen consumption (VO2) • Often becomes apparent in setting of arterial hypotension Differentiating Shock Systemic Mixed Wedge Cardiac vascular venous pressure output resistance oxygen Hypovolemic - Hemorrhage ↓ ↓ ↑ ↓ - Dehydration Cardiogenic - Myocardial infarction ↑ ↓ ↑ ↓ - Arrhythmia - Cardiomyopathy Obstructive - Pulmonary embolism ↑↔ ↓ ↑ ↓ - Tension pneumothorax - Cardiac tamponade Distributive - Septic shock - Anaphylaxis ↑↔ ↑ ↓ ↑ - Neurogenic - Myxedema coma - Post-cardiopulmonary bypass Goals of Therapy in Shock • Restore effective tissue perfusion and normalize cellular metabolism by ensuring systemic oxygen delivery by 1. Aggressive and appropriate fluid resuscitation 2. Supporting CO and MAP • Above are titrated to
    [Show full text]
  • Non-Invasive Stroke Volume Measurement and Passive Leg
    Available online http://ccforum.com/content/13/4/R111 ResearchVol 13 No 4 Open Access Non-invasive stroke volume measurement and passive leg raising predict volume responsiveness in medical ICU patients: an observational cohort study Steven W Thiel, Marin H Kollef and Warren Isakow Pulmonary and Critical Care Division, Washington University School of Medicine, Campus Box 8052, 660 South Euclid Avenue, St. Louis, MO 63110, USA Corresponding author: Warren Isakow, [email protected] Received: 19 May 2009 Revisions requested: 22 Jun 2009 Revisions received: 25 Jun 2009 Accepted: 8 Jul 2009 Published: 8 Jul 2009 Critical Care 2009, 13:R111 (doi:10.1186/cc7955) This article is online at: http://ccforum.com/content/13/4/R111 © 2009 Thiel et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Introduction The assessment of volume responsiveness and during PLR was then compared with the change in SV with the decision to administer a fluid bolus is a common dilemma volume expansion to determine the ability of PLR in conjunction facing physicians caring for critically ill patients. Static markers with SV measurement to predict volume responsiveness. of cardiac preload are poor predictors of volume responsiveness, and dynamic markers are often limited by the Results A total of 102 fluid challenges in 89 patients were presence of spontaneous respirations or cardiac arrhythmias. evaluated. In 47 of the 102 fluid challenges (46.1%), SV Passive leg raising (PLR) represents an endogenous volume increased by ≥15% after volume infusion (responders).
    [Show full text]
  • Navigating Preload Assessment
    NAVIGATING PRELOAD ASSESSMENT CHOOSING THE RIGHT PATHWAY Cecilia Baylon & Sarah Neville LEARNING OBJECTIVES • Explain the relationship between preload and fluid responsiveness (FR) • Review the different methods of assessing preload and FR • Analyze the current research in regard to their use in the critical care setting O2 demand CARDIAC OUTPUT Respiratory Lung Muscle Compliance Patient’s Venous Vessel Diameter Function Pre-existing Alveoli Return (Peripheral Medical Perfused? Vascular Condition Blood Work of Resistance) Viscosity Breathing Total Alveoli Thickness of Circulating Ventilated? Alveolar-Capillary Membrane Volume Aortic Physical Tidal Volume etc Impedence Activity Respiratory Vital Capacity Rate Functional Resid. Capac V/Q Emotional Diffusion pH, PC02 Matching Contractility Preload Temperature Stress 2,3 DPG Afterload Ventilation ie: pain PaCO2 Oxygen ALVEOLAR Hgb Hgb Level GAS EXCHANGE Affinity METABOLIC STROKE HEART RATE DEMANDS Pa02 Oxygen VOLUME ARTERIAL OXYGEN transported SATURATION in blood Sa02 ARTERIAL OXYGEN CARDIAC OUTPUT CONTENT OXYGEN OXYGEN SUPPLY DEMAND BALANCE End organ perfusion OXYGEN SUPPLY & DEMAND (HEMODYNAMIC) FRAMEWORK CONTRACTILITY PRELOAD AFTERLOAD STROKE VOLUME X HEART RATE CARDIAC OUTPUT EOP FRANK-STARLING’S LAW FRANK-STARLING’S LAW • “the force of ventricular ejection is directly related to…” VOLUME IN THE VENTRICLE AT END-DIASTOLE (PRELOAD) AMOUNT OF MYOCARDIAL STRETCH PLACED ON THE VENTRICLE AS A RESULT Urden, Stacy, Lough (2018), p. 214 Ejection Phase Hyperinotropy Contractility Norminotropy
    [Show full text]
  • Passive Leg Raise (PLR) Test As a Predictor of Tolerence to Lower Body Negative Pressure (LBNP) Presenting Author: Aymen Alian
    Passive Leg Raise (PLR) Test as a Predictor of Tolerence to Lower Body Negative Pressure (LBNP) Presenting Author: Aymen Alian, MD, Yale University, department of Anesthesiology. Co-Authors: Hesham Ezz, MBChB, Yale University, department of Anesthesiology, Jose Chavez, MD, Yale University, department of Anesthesiology, Nadeem Elbetebsi, MBChB, Yale University, department of Anesthesiology, Sophisa Sophonphattana, MD, Yale University, department of Anesthesiology, Kirk Shelley, MD, PhD, Yale University, department of Anesthesiology. Introduction: Fluid responsiveness (FR) is reported to be the ability to increase stroke volume (SV) in response to fluid administration1. Passive leg raising (PLR) creates a transient increase in biventricular preload and has shown the capability to predict fluid responsiveness2. LBNP creates a reversible hypovolemic state by sequestrating blood in the lower extremities3. This study sought to examine the ability of stroke volume percent change during (PLR) to predict the extent of tolerance to hypovolemia during Lower body negative pressure (LBNP). Methods: With IRB approval 12 subjects underwent PLR at 45° angle for 2 min followed by progressive LBNP protocol at -15 mmHg, -30 mmHg, -45 mmHg, -60 mmHg, -75 mmHg and -85 mmHg. Each patient was monitored for heart rate (HR), continuous noninvasive arterial blood pressure (CNAP) (CNSystems, Austria), Noninvasive CO monitor (NICOM) (Cheetah medical, MA, USA) streaming stroke volume (SV), cardiac index (CI) noninvasively at 8s intervals. These parameters were measured at baseline, during LRT and during progressive LBNP, Subjects were classified as high tolerance (HT) and low tolerance (LT) based upon the development of symptoms of hypovolemia such as lightheadedness, nausea, diaphoresis and shortness of breath at LBNP -75 mmHg or earlier.
    [Show full text]
  • 100% NON-INVASIVE FLUID MANAGEMENT Proper Fluid Management May Improve Clinical Outcomes, Potentially Saving Millions in Operating Costs1,2
    100% NON-INVASIVE FLUID MANAGEMENT Proper Fluid Management May Improve Clinical Outcomes, Potentially Saving Millions in Operating Costs1,2 The Starling fluid management monitoring system provides a full hemodynamic profile within seconds. The effect of fluids can be monitored at any time and treatment modified accordingly, across the continuum of care: ED > ICU > OR > RRT In a retrospective, matched, single-center study of nearly 200 patients, researchers from the University of Kansas Health System evaluated stroke volume (SV) guided resuscitation in 100 ICU patients with severe sepsis and septic shock and found1: Initiation of Acute % ICU Length of Stay -2.89 DAYS Dialysis Therapy -13.25 Save an estimated Risk of Mechanical % $14,498 per Ventilation -51 treated patient3 $14K Starling - Over 80% of hospitalized patients receive IV fluids.4 Yet studies show that giving too little or too much fluid can lead to serious complications and contribute to rising healthcare costs.5,6 - Studies also show that only ~50% of hemodynamically unstable patients will respond to IV fluid by increasing cardiac output and perfusion. Assessing whether fluid may help or harm a patient is a critical step in optimizing treatment.7 - Using only blood pressure, urine output and heart rate to measure fluid responsiveness may provide limited and inconclusive information.7 TAKE THE GUESSWORK OUT OF YOUR FLUID ASSESSMENT WITH STARLING - Provides a dynamic assessment of fluid responsiveness — accurately, precisely and 100% non-invasively. - Supports individualized fluid therapy without requiring an invasive arterial or central line, potentially reducing the risk of hospital-acquired infections and other complications.8 - Independently validated vs.
    [Show full text]
  • The Practical Solution for Managing Perfusion Smart
    The practical solution for managing perfusion Smart. Innovation. MAP SV CI SVR FloTrac system FloTrac system: 4.5 million patients, 86 countries and 10+ years.* Trusted Worldwide Literature Chosen to monitor over 86 Countries. Used by clinicians Referenced in over 270+ 4.5 Million Patients worldwide for minimally-invasive clinical studies spanning volume management the OR and ICU *Data on file FloTrac system algorithm Compensating for patient-to-patient differences in vasculature, Provides a clear hemodynamic picture real-time changes in vascular tone and differing arterial sites. across various patient conditions and surgical procedures The FloTrac system algorithm is based on the principle that aortic pulse pressure (PP) is proportional to stroke volume (SV) and inversely related to aortic compliance. The algorithm compensates for the effects of compliance on PP based on age, gender, and body surface area (BSA). The FloTrac system enables proactive clinical decision support. The minimally-invasive FloTrac system is a reliable solution for advanced hemodynamic monitoring that automatically calculates key flow parameters every 20 seconds. The FloTrac sensor attaches to an existing arterial line and monitors advanced hemodynamic parameters: • Stroke volume (SV) • Stroke volume variation (SVV) • Mean arterial pressure (MAP) • Cardiac output (CO) • Systemic vascular resistance (SVR) Proactive decision support offered by the FloTrac system helps guide individualized treatment decisions for your moderate- to high-risk surgery patients, and can be utilized perioperatively to proactively manage your patients. The FloTrac system can also be utilized to manage physiological status in rapidly changing clinical situations in acute care settings. With the FloTrac sensor and HemoSphere monitor, you can see your patient’s physiologic status and analyze trends with exceptional clarity allowing you to intuitively navigate with a simple-to-use touchscreen.
    [Show full text]