Fluid therapy in critically ill patients: perspectives from the right heart

Abstract

As right heart function can affect outcome in the critically ill patient, a thorough understanding of factors determining right heart performance in health and disease is pivotal for the critical care physician. This review focuses on fluid therapy, which remains controversial in the setting of impending or overt right heart failure. In this context, we will attempt to elucidate which patients are likely to benefit from fluid administration and for which patients fluid therapy would likely be harmful. Following a general discussion of right heart function and failure, we specifically focus on important causes of right heart failure in the critically ill, i.e. sepsis induced myocardial dysfunction, the acute respiratory distress syndrome, acute pulmonary embolism and the effects of positive pressure ventilation. It is argued that fluid therapy should always be cautiously administered with the right heart in mind, which calls for close multimodal monitoring.

The role of point-of-care ultrasound in intra-abdominal hypertension management

“…According to the 2013 WSACS guidelines, IAH is defined as a sustained increase in IAP equal to, or above 12 mm Hg, that is frequently associated with abdominal (as well as extra-abdominal) pathology and complications [1,5]. A missed IAH diagnosis can lead to longer ICU length of stay, prolonged ventilation, and higher incidence of ventilator-associated pneumonia, amongst other indirect consequences impairing patient recovery [2,6]. Therefore, it is paramount that ICU doctors and nurses are aware of the importance of IAH and ACS in both adults and children [7,8].…”

“…With the increased use of ultrasound [2] as a bedside modality in both emergency and critical care patients [3], we hypothesized that ultrasound could be used as an adjuvant point-of-care tool during IAH management. This may be particularly relevant to the first and second basic stages of the algorithm.…”

Biochemical markers for clinical monitoring of tissue perfusion

“…In clinical practice, two approaches are used to increase SV (and CO): adding volume (to increase preload based on the Frank-Starling law) and administering agents with a positive inotropic effect (i.e., inotropes) to increase cardiac contractility. However, it is well known from clinical trials that the administration of higher doses of both volume and/or inotropes is associated with worse outcomes [6][7][8][9]. There is no rigorous threshold of CO that should be reached in treating circulatory shock, and the goal is to increase CO only as much as needed to ensure adequate perfusion [1].…”