Fluid loading guided by cardiac and lung ultrasound for patients with sepsis in the emergency department: proof-of-concept study

Bastard, Quentin Le; Javaudin, François; Montassier, Emmanuel; Pès, Philippe; Arnaudet, Idriss; Conte, Philippe Le

doi:10.1097/mej.0000000000000678

Cited by 4 publications

(3 citation statements)

References 7 publications

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“…B-lines indicate the presence of interstitial lung edema, but quantification is not always easy. Lung echography can also be performed in sequential manner to detect the development of lung edema by counting the number of B-lines during fluid administration [ 35 ] or weaning from mechanical ventilation [ 36 ].…”

Section: Monitoring Techniquesmentioning

confidence: 99%

How can assessing hemodynamics help to assess volume status?

et al. 2022

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In critically ill patients, fluid infusion is aimed at increasing cardiac output and tissue perfusion. However, it may contribute to fluid overload which may be harmful. Thus, volume status, risks and potential efficacy of fluid administration and/or removal should be carefully evaluated, and monitoring techniques help for this purpose. Central venous pressure is a marker of right ventricular preload. Very low values indicate hypovolemia, while extremely high values suggest fluid harmfulness. The pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile and is particularly useful for indicating the risk of pulmonary oedema through the pulmonary artery occlusion pressure. Besides cardiac output and preload, transpulmonary thermodilution measures extravascular lung water, which reflects the extent of lung flooding and assesses the risk of fluid infusion. Echocardiography estimates the volume status through intravascular volumes and pressures. Finally, lung ultrasound estimates lung edema. Guided by these variables, the decision to infuse fluid should first consider specific triggers, such as signs of tissue hypoperfusion. Second, benefits and risks of fluid infusion should be weighted. Thereafter, fluid responsiveness should be assessed. Monitoring techniques help for this purpose, especially by providing real time and precise measurements of cardiac output. When decided, fluid resuscitation should be performed through fluid challenges, the effects of which should be assessed through critical endpoints including cardiac output. This comprehensive evaluation of the risk, benefits and efficacy of fluid infusion helps to individualize fluid management, which should be preferred over a fixed restrictive or liberal strategy. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06808-9.

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Section: Monitoring Techniquesmentioning

confidence: 99%

How can assessing hemodynamics help to assess volume status?

et al. 2022

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“…While there appears to be a lack of studies that specifically quantify volume resuscitation in the setting of POCUS use, there exists some literature with mixed findings on this topic. In a proof-of-concept study by Le Bastard et al, patients with sepsis who received POCUS to assess volume status received less than the recommended 30 ml/kg of crystalloid over 3 hours [ 34 ], indicating the potential for POCUS use to decrease fluid administration. A randomized controlled trial showed significantly decreased fluid administration in the POCUS group with septic shock as follows: 36 ml/kg in the POCUS group compared to 48 ml/kg in the non-POCUS group [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review

Ablordeppey,

Zhao,

Ruggeri

et al. 2024

Emergency Medicine International

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Background. Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when unguided by point-of-care ultrasound (POCUS). The primary study objective was to evaluate whether total IVF volume differs for emergency department (ED) septic shock patients receiving POCUS versus no POCUS. Methods. We conducted a retrospective observational cohort study from 7/1/2018 to 8/31/2021 of atraumatic adult ED patients with septic shock. We agreed upon a priori variables and defined septic shock as lactate ≥4 and hypotension (SBP <90 or MAP <65). A sample size of 300 patients would provide 85% power to detect an IVF difference of 500 milliliters between POCUS and non-POCUS cohorts. Data are reported as frequencies, median (IQR), and associations from bivariate logistic models. Results. 304 patients met criteria and 26% (78/304) underwent POCUS. Cardiac POCUS demonstrated reduced ejection fraction in 15.4% of patients. Lung ultrasound showed normal findings in 53% of patients. The POCUS vs. non-POCUS cohorts had statistically significant differences for the following variables: higher median lactate (6.7 [IQR 5.2–8.7] vs. 5.6], p=0.003), lower systolic blood pressure (77.5 [IQR 61–86] vs. 85.0, p<0.001), more vasopressor use (51% vs. 34%, p=0.006), and more positive pressure ventilation (38% vs. 24%, p=0.017). However, there were no statistically significant differences between POCUS and non-POCUS cohorts in total IVF volume ml/kg (33.02 vs. 32.1, p=0.47), new oxygen requirement (68% vs. 59%, p=0.16), ED death (3% vs. 4%, p=0.15), or hospital death (31% vs. 27%, p=0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure. Conclusions. Among ED patients with septic shock, POCUS was more likely to be used in sicker patients. Patients who had POCUS were given similar volume of crystalloids although these patients were more critically ill. There were no differences in new oxygen requirement or mortality in the POCUS group compared to the non-POCUS group.

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“…Focused cardiac ultrasound (US) (FoCUS) is a noninvasive tool widely used in the ED by example to diagnose acute cardiac failure [6] or to monitor fluid loading in sepsis [7]. FoCUS could also be used to differentiate aetiologies of shock.…”

Section: Introductionmentioning

confidence: 99%

Goal-directed ultrasound protocol in patients with nontraumatic undifferentiated shock in the emergency department: prospective dual centre study

Leroux¹,

Javaudin

Bastard

et al. 2021

European Journal of Emergency Medicine

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Background and ImportanceEarly identification of the cause of shock is associated with better prognosis.Objective The aim of this study was to explore the performances of an ultrasound protocol (echoSHOCK) to diagnose the cause of shock in the emergency department (ED). Design, settings and participantsThis was a prospective study performed in two EDs. Included patients were older than 18 years admitted with shock. After routine workup strategy, the suspected cause of shock and the planned treatment were reported. The echoSHOCK protocol, using only B mode, was then performed. After performing echoSHOCK, the investigator reported the same two items.Intervention echoSHOCK protocol that assessed: compressive pericardial effusion (tamponade), right ventricle dilatation and flattening of the septum, left ventricle dimension and systolic function, indices of hypovolemia. Outcomes measure and analysisWe defined four different causes for shock (tamponade, acute cor pulmonale, cardiogenic and hypovolemia). The primary endpoint was the degree of agreement of the routine workup and echoSHOCK with an expert panel. Main Results85 patients [mean age of 73 ( 14) years] were included. Kappa coefficients between routine strategy and echoSHOCK for the cause of shock, with the expert panel were 0.33 (95% CI, 0.26-0.4) and 0.88 (95% CI, 0.83-0.93), respectively. Likewise, for the planned treatment, kappa were 0.21 (95% CI, 0.14-0.28) and 0.9 (95% CI, 0.85-0.94), respectively. The physician's confidence increased from 3.9 (2.1) before echoSHOCK to 9.3 (1.1) after, (P < 0.001). ConclusionThis study suggested that echoSHOCK significantly increased the ability to determine the cause of undifferentiated shock in the ED.

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Fluid loading guided by cardiac and lung ultrasound for patients with sepsis in the emergency department: proof-of-concept study

Cited by 4 publications

References 7 publications

How can assessing hemodynamics help to assess volume status?

How can assessing hemodynamics help to assess volume status?

Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review

Goal-directed ultrasound protocol in patients with nontraumatic undifferentiated shock in the emergency department: prospective dual centre study

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