Cite this post as:
Scott Weingart, MD FCCM. EMCrit Wee – Advanced Ultrasound Assessment of Volume Status. EMCrit Blog. Published on December 15, 2017. Accessed on April 27th 2024. Available at [https://emcrit.org/emcrit/emcrit-wee-advanced-ultrasound-assessment-volume-status/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: December 15, 2017
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Thanks for putting together a great discussion. At one point Phillipe mentioned he did not think much of echocardiographic measurements of the left heart with regard to volume assessment, giving the example of LVOT VTI. I am curious how others feel about using E/e’ as a measure of left sided filling pressures, as a piece of the puzzle of fluid tolerance. There is not much data that I could find with this in the EM/Critical Care world, and what is out there is mixed. Intuitively, knowing when the left atrial pressure is too high would help in knowing when back… Read more »
I think the main problem with using E/e’ ratios to guide fluid resuscitation is that it doesn’t take into account that the pulmonary vessels are often leaky during shock states, especially septic shock. Leaky pulmonary vessels will result in extravascular lung water accumulation at lower left atrial pressures than we would normally predict, so I think this decreases the utility of using this in fluid resuscitations. That being said, I actually do use it as a stop point in my fluid resuscitation strategy to avoid wet lungs. As an additional measure, I look for an increase in B-lines as well.… Read more »
Yup, that was the basis of Daniel Lichtenstein’s (THE GODFATHER of POCUS and the originator of Lung US) FALLS Protocol in the mid 2000’s, but I agree with you, gotta try to stop before.
Hi Michael and thanks for listening and contributing. I think diastology is a murky topic at best, and that we have to look at organ-local measures of fluid tolerance, and as Korbin states, the leak may happen with completely normal pressures as well. Having said that, if I note abnormal diastolic parameters in someone without organ congestion, I will be more wary to give fluids, whereas with normal parameters and nor organ signs of congestion I will feel comfortable. I think keeping a cardiocentric view of pressures/volumes doesn’t help us as much as looking at the rest, provided we can… Read more »
I tend to agree with Philippe and Korbin. An ultrasonographic assessment of left-sided filling pressures may not be the optimal method to assess fluid tolerance. From my perspective we have to move away from left ventricular-centric, fluid forward, oxygen delivery, measurements as they have consistently failed us in the past. Rather than identifying measures that tell us when to administer fluid, we have to identify measures that inform us when to stop. Both portal and hepatic vein flow abnormalities are promising methods of assessing fluid tolerance and since our conversation I have been using them daily when assessing fluid tolerance.… Read more »
Philippe and Rory, I think we are all on the same page here. I want to bring up a few thoughts that we haven’t discussed, but I think are relevant to this discussion (you probably have thought about this as well, but I can’t resist bringing it up anyway). First, I would want to state that in general, I’m speaking to the resuscitation of a patient with a systemic inflammatory condition and hemodynamic derangements along any various points of a spectrum, but perhaps could be applied to shock states in general. When speaking of hyperdynamic cardiac function and low SVR… Read more »
very cool discussions here , and the ” portal veins and pocus” link.
any sugesstions, anyone, for the best site for a common er doc to learn ER POCUS for portal veins, and pulsatility? had trouble finding one.
Well, we are actually having a workshop run by Andre Denault himself as part of a conference in April. You’re welcome to join in! https://wp.me/p1avUV-ps
Sorry, I’m quite late to the party here. Thanks for giving me a shout-out above. I’m tickled to read that the CVP is coming back in fashion – not as a marker of fluid responsiveness or status [that’s just silly] but as a marker of fluid tolerance. With respect to the first comment – using tissue Doppler to estimate left atrial pressure is reasonable, just as using *pulmonary venous velocity waveform analysis as an estimate of left atrial pressure is reasonable … as a back pressure to the lungs. These [tissue doppler, venous velocimetry] are surrogates for left heart congestion.… Read more »
So as a little follow up, Rory and I discuss a clinical case where these principles were elegantly applied by @EMnerd_ : https://wp.me/p1avUV-qK
Cheers!
Philippe
As a little follow up, Rory and I discussed a clinical case illustrating the application of these principles: https://wp.me/p1avUV-qK