Justin Bowra gave a fantastic lecture on the use of IVC ultrasound at SMACC.
Here is the audio, if you want to hear the original lecture:
There was a post on Life in the Fast Lane by Justin as well.
His slides from the talk are here:
Now let's get to the SMACCing back…
I agree with 90% of Justin's talk, but as to the other 10%:
D-Dimer????
Mech Ventilated Patients
Collapse???
Diagnosis of Undifferentiated Shock
Quick look at size and collapsibility gives huge amounts of information
Fluid Responsiveness
Need a strategy for Spontaneously Breathing Patients
- Go bronze and give a bunch of fluid until you feel slightly uncomfortable
- Then go for the silver and resus until IVC starts to lose easily discernible collapse (20-30%)
- If you want to be really cool, at this point go for the gold-use some marker of stroke volume to see if additional fluid will be of benefit (either with empiric add. bolus or passive leg raise). If you want to be lazy, just put them on some norepi at this point.
Now if you use this strategy, you need to look at the operator receiver thingy-me-bobs [sic]
Spont. breathing IVC-CI trials fail due to the misfounded desire for dichotomy.
Lanspa
(Lanspa M et al. Shock 2013. 39(2). pp. 155-160)
Muller
(Muller L et al. Critical Care 2012, 16:R188)
This makes sense as respiratory-dynamic CVP demonstrates the same thing (Shock 2006;26(2):140)
Confounders:
Splint IVC open-Tamponade, Tension PTX, Massive PE, Status Asthmaticus, Right heart disease
Don't sniff test, don't tell the pt to do weird abdominal yoga breathing
Fluid Tolerance
IVCCI 15% had good accuracy (92% sens/84% spec) for CHF (Blehar et al. The American Journal of Emergency Medicine 2009;27(1):71)
and (Miller at al. Am J Emerg Med 2012;30:778) showed similar text characteristics.
by all means add in the Lichtenstein Lung Ultrasound, but only if negative when you start
We need more and better Studies
- Get a bunch of sick patients
- Do an IVCCI with a cut off of something like 30%
- Give fluid (500-1000 ml crystalloid)
- See if there was a 15% increase in SVi with a REAL cardiac output monitor or skilled evaluation of LV VTI
- AND
- see if there was a >5 mm Hg increase in arterial line MAP
and now on to the SMACC Down…
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Scott Weingart
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Hi Scott, Fantastic podcast and SMACC back! I absolutely love your approach which is a great way to apply evidence in physiological and clinical fashion, and the bronze/silver/gold approach is fantastic. I can’t agree more on how sadly close minded some physicians can be, so meticulous in packing that poo box, while not offering anything substantial – or physiological – instead, opting for the passive “watchful waiting” mode until someone (likely a big name in ED/CC) comes up with “the perfect resuscitation recipe” which will fit all patients (NOT!). I follow a highly similar approach to undifferentiated shock, because I fundamentally believe it is biologically impossible for a single recipe to work for all. It may work for most, but we don’t treat 1000, 100 or even 10 at a time, we treat 1. Therapy without individualizing to the patient is nonsensical to me. With your permission, I’m inserting a portion of a chapter on shock from a book I’mworking on, on integrating bedside ultrasound to clinical practice (due end 2013) which I think you will relate to: the patient in shock The principle of assessing shock reflects simple physiology. After all, there are only a few mechanisms by which… Read more »
[…] IVC fluid responsiveness remains a bit of a controversial area – though I am a fan of looking at IVCs and deciding if they are “appropriate for the clinical scenario”. Check out Dr Justin Bowra’s demolition and Dr Weingart’s defense of the humble IVC HERE at EMCrit […]
Hi Scott!
4-6 liters of fluids???!!!
What about when Paul Marik says that Vasodilatory shock is not a fluid depleted state so if you administer more than 2-2.5 liters of fluids, you’re actually overdistending the heart causing your ANP’s to damage the glycocalyx and worsening the interstitial edema. And, that whatever you give is all going to end up in the interstitial space anyway within a few minutes-hours.
I think he might be waaaay to conservative about fluids, but your 4-6 liters without any assesment makes me think that it’s waaaay to liberal.
What do you think? Please lemme know!
PS : I’m a big fan of yours btw. Keep up the good work of spreading knowledge.