My friend Chad Meyers is an ED Intensivist from NYC. He gave this lecture at ALLNYCEM 2012, but the video sucked. He rerecorded it for the EMCritters.
I will be bringing Roger Harris, MD of SMACC and Sydney ICU fame on the show in the very near future to debate this very issue.
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Scott Weingart
An ED Intensivist from NY. No conflicts of interest (coi).
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wow, great lecture ! (as always)
I’ll let Chad know, thanks.
Hallo! This is also a good article that you probably allready have seen.
http://www.cardiovascularultrasound.com/content/10/1/49
Regards
/Mats
That’s a very good reference:
Cardiovascular Ultrasound 2012;10:49
Thanks for some very practical advice to guide luid therapy in ER. most useful!
Thanks for the clarification on fluid responsive versus fluid tolerant. I agree that although cvp doesn’t represent fluid responsiveness as that is a cardiac output and starling curve dependent process, it is still an important measure for guiding resus in very sick septic patients.
Just to be clear, from my perspective, CVP brings nothing to the table over IVC ultrasound. And it doesn’t require a central line. However if you already have a line in, why not add CVP as clinical data.
While I agree with Scott that information obtained from IVC evaluation or CVP monitoring is likely interchangeable, the one advantage of CVP monitoring is that it is continuous. I don’t think the advantage merits the placement of central line for the sole purpose of obtaining CVP measurements, but if I have a line in place, I’ll definitely transduce it. It’s just easier to glance at the monitor periodically and order another fluid bolus as opposed to repeating an IVC evaluation intermittently.
Scott and Chad,
What are your thoughts on the use of continuous ScVO2 monitoring with the Edwards catheter? Our intensivists want us to place them in the ED, and feel they are essential to optimal resuscitation. I agree that the information provided is useful, but the catheters are expensive and would require additional training for our nurses to learn how to calibrate them. Our department is already pretty strapped for new equipment and is staffed by many traveling nurses, making training for a new technology challenging. Is it worth pushing my department on this?
Thanks
Hi Scott, thanks for posting up the lecture. I’m an Anaesthetics trainee in Australia who is particularly intrigued by this lecture and the concept of fluid tolerance, as I have an interest in IVC ultrasound. Would you (or Chad) say that the concept of “fluid tolerance” is a relatively new concept? Apart from Lichtenstein’s article in 2009, there hasn’t been much written on the idea of fluid tolerance since Chad’s lecture in 2012. Perhaps I’m looking in the wrong places but would you know if there are any current studies relating to fluid tolerance? And in your view (or Chad’s), do you think there is a place for the peri-operative management of fluids as guided by fluid tolerance (i.e. not necessarily in the septic patient)?
Thanks heaps!
Have not seen any studies to this effect. It is a tough sell; we all do it clinically, but convincing people it is ok is hard–doing a study is even harder.
Thanks for the swift reply. One would think that if we can use a non-invasive tool like the IVC ultrasound to guide fluid management peri-operatively, surely it would be safer for patients, especially those with existing cardiac or renal impairment. I’m currently pitching a study to our local ethics committee about using fluid tolerance as a guide for fluid replacement- we shall see if anything materialises. I can keep you posted if you’re interested.
there is a host of anesthesia literature you can find under goal-directed therapy, especially for colo-rectal cases.
Thanks Scott. My understanding is that most of the studies done were looking at fluid responsiveness rather than fluid tolerance, and that most methods were invasive rather than non-invasive. I think there is room to explore and expand the use of fluid tolerance in other aspects of patient care, and I really hope this concept takes off.
[…] The Holy Grail of Fluid Resuscitation is just a Tin Cup – Where are we at? Chad Meyers drowns out some of the dogma, and lets us know were we should be heading when giving fluids to our sickest patients. […]