This lecture reviews the fundamental concepts regarding fluid administration and hemodynamic monitoring in the critically ill
The viewer may also be interested in the lecture on the utility of the CVP
Paul Marik
Intensivist, Researcher, Myth-Buster, Status Quo Destabilizer
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18 Comments on "iSepsis – Fluid Management and Hemodynamic Assessement"
Grant:
Good questions. Sepsis is a very complicated disease, and our understanding continues to evolve. I think these patients are best treated at a tertiary care center with full time intensivists who have the resources to care for these very sick patients.
In terms of fluids during transit. I would always establish a “good” peripheral line. I would then evaluate the patients’ vital signs. If the vitals are “normal” don’t give fluids. If the patient is hypotensive (MAP 105) i would give a 500 cc bolus of NaCl. . However, MOST IMPORTANT is to monitor the response of the fluid bolus on the MAP, HR and resp rate. If no improvement and/or increase in respiratory rate STOP fluids. If the patient appeared to benefit from the first 500cc bolus I would cautiously give a second bolus (of 500cc). Never EVER give a rapid 30cc/kg bolus of fluid; this is a dangerous strategy. When you transfer the patient at the receiving hospital it would be important to convey this information to the receiving team.
Hope this helps.
Paul Marik.
Dr. Marik…It helps enormously. It gives me a set of “protocols” I can understand, appreciate in that they make sense, and have the equipment and knowledge to use in those first 45 or so minutes. I can do my “likely sepsis” patients good, and that’s what I strive to do.
Thank you very much. I will be passing your articles on to our new medical director as soon as she takes over, and working to get our existing protocols reviewed and hopefully changed. Thank you for the time you took to write a reply that applies so incredibly well to what I, as a paramedic/critical care paramedic, need to know. I will actually try to get your reply starting with “Sepsis is a very complicated disease…” and ending with “…this information to the receiving team” put into our sepsis protocols verbatim.
Respectfully,
Grant Jonsson, MS, critical care paramedic
A MAP <105 is hypotensive?! – how hypertensive are American patients usually?
Benjamin; Thanks for pointing out this obvious error. Should have been MAP < 65 mmHg. Paul
OOps that should be MAP < 65 mmHg. Sorry about that typo.
Elegant discussion!
Major gratitude for sharing your expertise & time!
Thanks you for this great talk!
What I still can’t get my head around is when to actually give fluids.
With PLR or a bolus you determine whether the patient is fluid responsive or not. But then you add that being fluid responsive doesn’t mean you actually need fluids. So how do I determine the need for fluids is this concept?
Chris…Read the second paragraph of Dr. Marik’s reply to my question. It starts “In terms of fluids during transit.” This might help. I think Dr. Marik’s answer, contained in this paragraph, makes the whole thing much more clear to me….Grant Jonsson, MS, CCP
Dr. Marik can you comment on the recent article in JICM?
J Intensive Care Med. 2017 Jan 1:885066617711882. doi: 10.1177/0885066617711882. [Epub ahead of print]
Karl…I will be very interested in hearing Dr. Marik’s response to your question. It’s a conundrum!
In our team we yesterday asked ourselves:
Is it less harmful or even more useful to applicate/increase enteral fluids after (or even while) first stabilisation of your septic patient and further evidence of intravasal volume depletion in Sepsis under the condition that gastric and bowel function is not obviously impaired?
Corinna: I would not use the GUT as a route of fluid resuscitation in the ICU. This is a generally auseful approach in patients with diarrhea. However, in ICU patients who have a water deficit (not volume deficit) it is appropriate to increase the amount of “free water” provided enterally.
Dr. Marik,
How do you assess a patient’s perfusion status? Do you only look at MAP or do you use markers others use such as warm/cool extremities, UOP, lactate, etc.
Brian:
Good question. The most important and first goal of resuscitation is a MAP of at least 65mmHg. Thereafter you want to check peripheral perfusion (esp. temp of knee), heart rate (< 100bpm), UO (not a good sign in septic patient), mentation, etc. Lactate is not a sign or indicator of organ perfusion.