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
Latest posts by Paul Marik (see all)
- iSepsis- SEP-1: Conspiracy Theories and Fake News! - March 3, 2018
- iSepsis – Sepsis 3.0- Flogging a dead horse! - February 23, 2018
- iSepsis – Patients with sepsis have SCURVY - February 4, 2018
Doctors…A little help please for a simple critical care paramedic. I watched Dr. Marik’s presentation and found it very interesting. I certainly do not profess to know everything he talked about, but I got the gist of it. OK, so the intricacies are not really my concern. Those belong to the intensivists. I hope they are abreast of Dr. Marik’s concerns about the Surviving Sepsis Campaign and EGDT. I only have the patient under two circumstances. If it is a 911 paramedic call I likely have the patient for 30-40 minutes or so if I decide to take said patient directly to a tertiary care center. If it is a critical care paramedic call I have the patient for approximately the same time, from our local hospital to the tertiary care center. I will have more latitude in the former situation and would appreciate advice on what I should do fluid-wise with said patient exhibiting signs and symptoms of sepsis. I DON’T HAVE any fancy diagnostic tools, but I can certainly determine temperature, mental status, RR, HR, and BP. I can auscultate lung fields and likely get enough of a history to determine if there is a likely underlying infection.… Read more »
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!
Thank you Dr. Marik for posting these useful lectures. I am an intensivist/neurointensivist at a medium sized community hospital in California. I have a few questions. (1) You mention that PLR or fluid bolus followed by an assessment of change in SV are currently the gold standards in assessment of fluid responsiveness. As your slide mentions, these require a tool to measure SV (NICOM,,USCOM or special a-lines) and in community hospitals, these tools are often not available in the ER or even the ICU. So this makes the PLR a less practical tool to assess pre-load responsiveness. In practice, I believe that many clinicians look at end points after a bolus or PLR such as decrease in heart rate or increase in BP which are intuitive but not necessarily validated. What is your thought on this and which technologies do you use at the bedside in your ICU to measure stroke volume? (2) In addition to a quick assessment of LV fxn/RV function with bedside U/S, I believe that the presence or absence of a B-line pattern lung U/S is extremely useful in determining fluid tolerance. B-lines are a good marker of EVLW, correlate with wedge pressure and are more… Read more »
Cyrus: Good questions,. No simple answers. I summarize my thoughts below: q1.In a resource limited setting one has to rely on ones clinical skills and the tools available. While the change in MAP or heart rate is an inadequate measure of the change in SV, close observation of the patient after a 500cc bolus is a key in determining if this was the right intervention and what to do next. A key factor is understanding the patients pathology and what you are trying to achieve. There is no technology that answers all ones clinical questions. We rely on bedside ECHO, as well as NICOM and PiCCO (when appropriate). However, as clinical medicine moves out of the dark ages, i believe that if a hospital has an ICU is should have the equipment necessary to safely manage these patients. q2 and q3. I agree, B lines have been shown to correlate well with EVLWI. See also my revised post on vena-caval ultrasonography – Dynamic Changes in Carotid Doppler flow is a simple method to assess fluid responsiveness. q4. The concept of the “third space” has been abandoned… it is a space that does not exist.., except in the imagination of the… Read more »
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!
Studies such as those by Herran-Monge et al[1] are frequently published in the literature with the sole purpose of trying to justify the resources and effort involved in instituting the Surviving Sepsis Campaign (SSC) Guidelines. There is no credible high level scientific data that the institution of the SSC Guidelines has specifically and directly reduced the mortality of patients with severe sepsis or septic shock. The study by Herran-Monge et al in particular has a number of fatal flaws which should have precluded publication. The two populations differ significantly in disease severity and it makes it extremely difficult to make direct comparisons. The authors report that intra-abdominal infection was the commonest source of infection. This finding differs from almost all published sepsis studies, where pneumonia is by far the most common source of infection (approx. 50%). This is particularly relevant as the timing and methods of source control become the most important factor influencing outcome in patients with intra-abdominal infection, and it is likely that this has changed over the 9 year study period. It is extremely important to emphasize that numerous changes have occurred in the management of ICU patients generally and sepsis patients in particular over the last… Read more »
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.
Hello, thank you for your data and interpretation. I agree with much of what you reveal. I have a tiny factoid known by many nurses. Often inaccurate CVP numbers get recorded in electronic charts. Stems from the manner in which the documentation is ‘pulled’ in. I have regularly found documentation of numbers for the CVP that could not have been from a recently zero’d or the transducer was inappropriately located thereby making the reading defunct. (CVP was 322) Nursing often concentrates on the HR & BP when verifying numbers to chart and the ‘screen’ from which you ‘verify’ the vitals may have numbers not seen on screen. This is on my list regarding the future use of electronic documentation for data extraction. It will not be a true reflection of reality. Not saying it is ok, just saying it exists on a large scale.
Often charting is done based on the ‘standard expectation of nursing care’ like turning every two, It is just charted that way but may not have actually happened-could be more or less.