Fluids or inotrophes in undifferentiated shock-Review of Case series
Introduction
There is a long-standing debate as to the most accurate method of determining the
volume status of a critically ill patient,as well as the physiological ability to respond
to fluid therapy. In the assessment of a critically ill patient receiving volume
replacement, a wide variability of assessment options are available; however, the
current literature has yet to determine which method is the best. This case series shows the how difficult is to assess the accurate fluid status in undifferentiated shock in critically ill patients and to predict the fluid responsiveness.
Case-1
A wife has brought a 67-year-old man to the ED with confusion and reduced urine output. She also stating that he was sick for previous several days with flu and febrile.
The blood pressure of the patient on admission was 85/45 mmHg. Other vitals were, respiratory rate 25 /min, pulse rate 132/min, temperature 1010F and Oxygen saturation was 93% with face mask. An ECG does not show any specific changes except sinus tachycardia. As the patient deteriorate further transferred to the ICU. Resuscitation according to early goal directed therapy was
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initiated. Patient parameters were improved with treatment and Blood pressure start to drop again after 12 hours. Central venous pressure around 10 cm h2o.Noradrenaline infusion was titrated to MAP of 65 mmHg. Whether to give further fluid or not was raised and assessing the patient's fluid status was a real challenge. Case-2 A 7 year old girl was admitted to a paediatric ward following fever for 5 days and positive serology for Dengue antigen test. As the platelet count drops to 140000cm2 and hematocrit raised child was transferred to ICU for monitoring. On admission to ICU child was afebrile PR-110/min,BP-80/50mmHg and urine output more than 0.5ml/kg.During next 24 hours child deteriorate and Plt count drops from 100000 to 11000.Hematocrit raised to 50% and urine output was varied but less than0.5 ml/kg. IV fluid therapy with normal saline and IV Dextran boluses given according to the Dengu critical phase management protocol .CVP line was not inserted initially as high risk of bleeding .As child condition deteriorated further right femoral central venous access was obtained under Ultrasound guidance. Uss assessment of inferior venacava and echocardigrafic views of right ventricle shows fluid depleted status correlate with blood pressure drop. Case-3 A 72 yrs old female admitted to the coronary care unit following generalize weakness, faintishness, nausea, vomiting and loss of appetite for last 3 days. She was a known lady with chronic biventricular failure and followed up at cardiology clinic. Her ejection fraction was 25% which was done 3 months back. On admission to the ccu,her vitals were,BP 80/50mmHg,PR 110/min,RR 26/min with cold extremities. Within few hours of admission patient was further deteriorate and collapsed. She was intubated strated on dobutamine infusion and admit to ICU for further care. When arrival to the ICU her BP was 85/50mmHg,PR 120/min, with cold clammy extremities. Central venous line was inserted and reading was 11 cm H2o.Bed side 2Decho shows hypokinetic heart with almost empty right ventricles. Intravenous fluid bolus of 250ml normal saline was given and re-evaluate the heart chambers. Discussion In all three cases patients were presents with shock.
The first case patient 's hypotension indicate severe physiological compromise as he was a longstanding hypertensive patient. Patient was respond to the initial fluid resuscitation and cause for the second blood pressure drop was not obvious and CVP was inconclusive. Bed side USS shows minimal IVC collapsibility and almost full right ventricle means further fluid boluses would be detrimental. Second case is clear that child was in dengue shock due to fluid leakage. But the question arise was usual leaking phase was over and why the patient is still having signs of shock .furthermore fluid quota suppose to be given within the critical phase was exceeded. insertion of central line was debated due to bleeding
risk. In the management of critically ill dengue patients assessment of fluid status is mainly by clinical parameters,PR,pulse pressure,blood pressure,capiilary refilling ,urine output and hematcrit.CVP is rarely used as there is high risk of bleeding and not much of experience with regard to USS guided fluid therapy.USS is mainly diploid for the identification of fluid leaking in dengue patient. There is a potential for the USS guided fluid in dengue and area is widely open for the research work. Third case ,obvious cause for the shock was acute on chronic heart failure, but did not responds to the inotrophes effectively.CVP was unreliable here and bed side 2decho was a useful tool to identify the fluid deficit and guide the fluid therapy to optimize preload of the patient. Rapid Ultrasound in SHock (RUSH) protocol is a valuable tool for the evaluating a patient with undifferentiated shock should be applied in step by step manner to diagnosis and management. Three major component of RUSH protocol are[10,11,12]. PUMP (i.e. the heart): Look at the heart for pericardial effusion (cardiac tamponade), contractility of the left ventricle (ischemia), and relative size of right and left ventricles (right heart strain in PE) TANK (i.e. intravascular volume assessment): IVC assessment (size, collapsibility) and ‘tank compromise 'in tension pneumothorax PIPES (i.e. major arteries and veins): Assessment for AAA or dissection flap, and DVT in legs . From Perera et al. The RUSH Exam: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill. Ultrasound Clinics N Am 28 (2010) 29–56. Traditional way of assessing fluid status by CVP monitoring is criticized. In 1960s clinician started to measure central venous pressure as a surrogate measure of right ventricular volume which invariably represent the amount of blood return to the heart. The CVP is an approximation of the right atrial pressure and is an indicator of RV preload, which is a major determinant of RV filling pressure. Both RV preload and RV filling pressure correlate with intravascular volume. Lower CVP may occur with vasodilation or hypovolemia, which decreases the volume returning to the right atrium. This volume depletion creates a need for fluid replacement. Up until the 1980s, it was believed that maintenance of normal hemodynamic parameters was the key to resuscitation of critically ill patients. Land mark study by rivers et al in 1993 showed the marked reduction of mortality by 21% from early goal directed therapy(EGDT) with CVP monitoring[5].This study supports the use of CVP in critically ill patients. Since then 'bundle care 'with EGDT in resuscitating septic shock patients were debated. In 2014 and 2015 triad of trials namely, Protocol-based Care for Early Septic Shock (PROCESS)6, Protocolised Management in Sepsis(PROMISE )8and Australasian Resuscitation in Sepsis Evaluation(ARISE)7 challenged the EGDT in sepsis and shows there is no mortality or morbidity befits when comparing with standard care.CVP is a static measure and can be affected by various physiological and anatomical factors like right heart failure, valvular heart disease, poor lung compliance or arrhythmias. Meta analysis by Mark et al in 2013 concluded that CVP should not be used as a guide to fluid therapy in critically ill patients[9].However the 'standard of care by the treating physician' describe by the above mentioned investigators may not be the same in low resource settings ,especially in he ED's without emergency physicians. Therefore practicing EGDT in Sri Lankan setting is not unwise as it did not show any increase in morbidity or mortality. Preload assessment and fluid responsiveness of patients with a critical or sub-critical hemodynamic status have been addressed in various research studies, both in Intensive Care Unit patients [1,2,3,4,] and during major operations .Different predictors of fluid responsiveness have been identified, basically belonging to five different categories: a) pressure-based parameters like right atrial pressure (RAP) , mean pulmonary arterial pressure (MPAP) and pulmonary artery occlusion pressure (PAOP) [3] b) areas and volumes like left ventricular end diastolic area (LVEDA) [1], right ventricular end diastolic volume (RVEDV), and intra-thoracic blood volume (ITBV) [9]; c) transmitral valve flow doppler parameters . d) dynamic parameters like inspiratory decrease in RAP,Stroke volume variation(SVV), expiratory decrease in arterial systolic pressure, respiratory changes in pulse pressure, and respiratory changes in aortic blood velocity (ABV) [1,2 ,4 ]. e) USS based inferior vena caval measurements ,IVC collapsibility and caval index Out of all above mentioned methods ultra sound based measurements of IVC ,stroke volume variation and respiratory changes in aortic blood velocity by thransthorasic echo are most feasible in the emergency department. This is well applied especially to a low resource settings like Sri Lanka. Conclusion These cases highlight the role of resuscitative ultrasound and the RUSH protocol in guiding the care of the patient in shock. Due to the noninvasive nature of ultrasound and its ability to provide repeated assessment of physiology during resuscitation, this modality has moved to the front line of emergency care and this must be the high time to consider the routine use of ultrasound in critical care and emergency setting in Sri Lanka. Three major recent studies(PROCESS,PROMISE,ARISE) does not support the routine practice of EGDT in sepsis. however all these trials were done in high resource settings in developed countries(UK,USA and Australia) .It is still applicable in Sri Lankan ED's where we might not able to give the 'standard of care by a treating physician ' until emergency physicians are available. References 1.Tavernier B, Makhotine O, Lebuffe G. et al. Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced ypotension. Anesthesiology. 1998;89:1313–1321. [PubMed] 2.Michard F, Boussat S, Chemla D. et al. Relation 29 between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162:134–138. [PubMed] 3.Tousignant CP, Walsh F, Mazer CD. The use of transesophageal echocardiography for preload assessment in critically ill patients. Anesth Analg. 2000;90:351–355. [PubMed] 4.Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients. Chest. 2002;121:2000–2008. [PubMed] 5. Rivers E, Nguyen B, Havstad S, et al; Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377 6. ProCESS Investigators, Yealy DM, Kellum JA,Huang DT, et al. A randomized trial of Protocolbased care for Early Septic Shock. N Engl J Med.2014;370(18):1683-1693. 7. Peake SL, Delaney A, Bellomo R; ARISE Investigators.Goal-directed resuscitation in septic shock. N Engl J Med. 2015; 372(2):190-191. 8. Mouncey PR, Osborn TM, Power GS, et al; ProMISe Trial Investigators. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med.2015;372(14):1301-1311 9. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41(7):1774-1781. 10. Arntfield RT, Millington SJ. Point of care cardiac ultrasound applications in the emergency department and intensive care unit–a review. Curr Cardiol Rev. 012;8(2):98-108. 11.Akilli B, Bayir A et al. Inferior vena cava diameter as a marker of early hemorrhagic shock: a comparative study. Ulus Travma Acil Cerrahi Derg 2010;16(2):113-8. 12. Perera et al. The RUSH Exam: Rapid Ultrasound in Shock in the Evaluation of the Critic 13F. Sebat, A. A. Musthafa, D. Johnson et al., “Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years,” Critical Care Medicine, vol. 35, no. 11, pp. 2568–2575, 2007. 14. A. E. Jones, V. S. Tayal, D. M. Sullivan, and J. A. Kline, “Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients,” Critical Care Medicine, vol. 32, no. 8, pp. 1703–1708, 2004. 15. P. R. T. Atkinson, D. J. McAuley, R. J. Kendall et al., “Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension,” Emergency Medicine Journal, vol. 26, no. 2, pp. 87–91, 2009.
We can organize information regarding this case study by using the Four Topics Method beginning with the Medical Indications. Maria, a 20-year-old female, has been involved in a motor vehicle accident. She has a history of Sickle Cell disease and is currently twenty-five weeks pregnant with her first child. Initially Maria presents with somewhat stable vital signs. She displays tachypnea, and complains of severe abdominal cramping as well as weakness, light-headedness and left shoulder pain. She is neurologically intact with lung sounds that are within defined parameters. Maria’s condition changes and she begins to display signs and symptoms of internal bleeding. This is a life threatening condition. The problem is critical and can be reversed with a transfusion and surgery. The goal of transfusion would be to replace blood loss and restore vascular volume and the goal of surgery would be to repair the bleed. If the bleed is corrected in a timely manner and without complication, the probabilities of success are somewhat high. There is no plan in place to account for therapeutic failure. Medical care in this instance could not only save the life of this patient but also that of her unborn child. Further harm to Maria and her baby could be avoided if she would agree to the treatment.
Sepsis is defined as an exaggerated, overwhelming and uncontrolled systemic inflammatory response to an initially localised infection or tissue injury, which may lead to severe sepsis and septic shock if left untreated (Daniels, 2009; Robson & Daniels, 2013; Dellinger et al, 2013; Perman, Goyal & Gaieski, 2012; Vanzant & Schmelzer, 2011). Septic shock can be classified by acute circulatory failure as a result of massive vasodilation, increased capillary permeability and decreased vascular resistance in the body, causing refractory hypotension despite adequate fluid resuscitation. This leads to irreversible tissue ischaemia, end organ failure and ultimately, death (McClelland & Moxon, 2014; Sagy, Al-Qaqaa & Kim, 2013, Dellinger et al, 2013).
Noticeable indications of deterioration have been shown in numerous patients few hours prior to a critical condition (Jeroen Ludikhuize, et al.2012). Critical condition can be prevented by recognizing and responding to early indications of clinical and physiological deterioration ( kyriacosu, jelsma,&jordan (2011). According to NPSA (2007) delay in responding to deteriorating vital signs have been defined as an complication resulting in prolonged length of stay, disability or death, not attributed to the patient's underlying illness procedure along but by their health-care management ( Baba-Akbari Sari et al. 2006; Helling, Martin, Martin, & Mitchell, 2014). A number of studies demonstrate that changes or alterations in a patient’s
If Cardiac Output is compromised than you will have low tissue/organ perfusion. Causing the patient to go into cardiac shock.
normal saline, lactated Ringer solution, etc), volume expanders (e.g. albumin and others), antibiotics (e.g. cefotaxime, metronidazole, ciprofloxacin, cefepime, etc), and corticosteroids (e.g. hydrocortisone, dexamethasone, etc).Medications and surgery are often the most effective and most definitive treatments that a doctor or certified medical professional can give to a septic shock patient. However most of those treatments are administered in a hospital setting. Prehospital treatment and management for septic shock would include proper management of ABC’s (Airway, Breathing, Circulation), identifying the source of infection and treat accordingly if possible, and monitoring of the patient's vital signs. Not much definitively can be done in a prehospital setting but prehospital management is vital for patient survivability.Some complications that can occur as a result of septic shock include acute respiratory distress syndrome (ARDS), respiratory failure, heart failure, renal failure or injury, and abnormal blood clotting. Sepsis is listed by The Agency for Healthcare Research and Quality as the most expensive condition treated in the U.S. with an overall cost of more than $20 billion in 2011. Sepsis and sepsis
Sayar S.,Turgut, S., Dogan, H., Ekici, A., Yurtsever, S., Dermirkan, F., Doruk, N., Tsdelen, B. (2009) Incidence of pressure ulcers in intensive care unit patients at risk according to the Waterlow scale and factors influencing the development of pressure ulcers. Journal of Clinical Nursing 18, 765-774.
An electrocardiogram (ECG) is one of the primary assessments concluded on patients who are believed to be suffering from cardiac complications. It involves a series of leads attached to the patient which measure the electrical activity of the heart and can be used to detect abnormalities in the heart function. The ECG is virtually always permanently abnormal after an acute myocardial infarction (Julian, Cowan & Mclenachan, 2005). Julies ECG showed an ST segment elevation which is the earliest indication that a myocardial infarction had in fact taken place. The Resuscitation Council (2006) recommends that clinical staff use a systematic approach when assessing and treating an acutely ill patient. Therefore the ABCDE framework would be used to assess Julie. This stands for airways, breathing, circulation, disability and elimination. On admission to A&E staff introduced themselves to Julie and asked her a series of questions about what had happened to which she responded. As she was able to communicate effectively this indicates that her airways are patent. Julie looked extremely pale and short of breath and frequently complained about a feeling of heaviness which radiated from her chest to her left arm. The nurses sat Julie in an upright in order to assess her breathing. The rate of respiration will vary with age and gender. For a healthy adult, respiratory rate of 12-18 breaths per minute is considered to be normal (Blows, 2001). High rates, and especially increasing rates, are markers of illness and a warning that the patient may suddenly deteriorate. Julie’s respiratory rates were recorded to be 21 breaths per minute and regular which can be described as tachypnoea. Julies chest wall appeared to expand equally and symmetrical on each side with each breath taken. Julies SP02 levels which are an estimation of oxygen
J.P., a 58 year old female, presents to the Emergency Room on March 18th. She has a past medical history of cervical cancer, atheroembolism of the left lower extremity, fistula of the vagina, peripheral vascular disease, neuropathy, glaucoma, GERD, depression, hypertension, chronic kidney disease, and sickle cell anemia. She complains of right lower extremity pain accompanied by fatigue, a decreased appetite, increased work of breathing, burning urination, and decreased urine output for three days. Upon admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings.
The most important elements of the guidelines are organized into two “bundles” of care (Angus, 2013). The first “bundle” is for within the first 3 hours sepsis is suspected. The first thing you would do is measure the lactate level. The second thing is obtaining blood cultures prior to administration of prescribed antibiotics. You administer broad spectrum antibiotics in patients with septic shock. The risk of dying increases by approximately 10% for every hour of delay in receiving antibiotics. The last thing you would do for the 3 hr “bundle” is fluid resuscitation: administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4mmol/L (Subtle Signs of Sepsis, 2017). The second “bundle” is for within the first 6 hours sepsis is suspected. The nurse would do the same protocol for suspected sepsis within 3 hours and continue for more advanced treatment. The next thing you would do is administer vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP ≥ 65 mmHg. For persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥ 4 mmol/L (36 mg/dL), reassess volume status and tissue perfusion and document findings. After initial fluid resuscitation, repeat focused exam, including pulse, capillary refills, vital signs, cardiopulmonary assessment, and skin (Subtle Signs of Sepsis,
Journal of Critical Care, 503.) The leading causes of most errors among stress and interruption are other factors such as: wrong dosage, dose omissi...
According to doctor’s order, repeat CBC at 1600hr and if the HB is less than 80 transfuse two units of PRBC and lasix 40 mg in between the transfusion. I visited each patients room and around 4PM I entered Mr.Govanni’s room and I noticed that he was doing something with his mobile and I greeted him but he replied without looking at me by shaking his head and said, oh!.. yes, and he continued what he was doing....
Sepsis is defined as a systemic inflammatory response caused by an infective process such as viral, bacterial or fungal (Holling, 2011). Assessment on a patient and starting treatment for sepsis is based on identifying several factors including the infective source, antibiotic administration and fluid replacement (Bailey, 2013). Because time is critical any delay in identifying patients with sepsis will have a negatively affect the patients’ outcome. Many studies have concluded every hour in delay of treatment mortality is increased by 7% (Bailey, 2013). Within this assignment I will briefly discuss the previous practice and the recent practice including the study based on sepsis. I will show what enabled practice to change and I will use the two comparisons of current practice and best practice.
D. standing near her room, breathing sharply. While asked what has just happened, she answered, ‘I feel dizzy and can faint!’ Mrs. D. then explained that she rose up from her chair in the television room and felt lightheaded. I decided to bring her to the room hoping she would feel less dizziness if she could sit. After consultation with my mentor and third year unit nursing student, I decided to perform measurement of her vital signs. Since only electronic sphygmomanometer was available for me that time, I had to use it for my procedure. Gladly, I discovered that I have already used such equipment in my previous nursing practice. Using the standard sized calf, I found that her blood pressure was 135/85, respirations were 16, and her pulse was 96 beats per minute (bpm). However, I decided to recheck the pulse manually, founding that it was irregular (78 bpm). The patient stated that she felt better after rest. Immediately after the incident I made a decision to explore carefully the medical chart of Mrs. D., along with her nursing care plan. That helped me to discover multiple medical diagnoses influencing her
A 41-year-old manwith a history of DM was brought to emergency department (ED)due to difficulty in breathing. It was associated with fever, severe sore throat and muffled voice for 2 days duration. He visited a...
The patient has high temperature-sign of fever, a very fast pulse rate (tachycardia), and chest wheezing when listened to using a stethoscope (Harries, Maher, & Graham, 2004, p.