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The four questions of fluid therapy (Part 1.2.)

The four questions of fluid therapy (Part 1.2.)

Part 1.2. of series on fluid therapy

Why should I bother about the ebb and flow phase of shock? An illustrative case report

Question 1

At this stage, the participants of the ISICEM and IFAD meetings were asked the first multiple choice question (MCQ1): “Taking into account the results obtained with the transthoracic cardiac ultrasound, what is your treatment of choice at this stage?” Possible answers were: 1) norepinephrine; 2) dobutamine; 3) fluid bolus; 4) diuretics or 5) other. Figure 3 shows the results of the three votings. Based on the cardiac US findings physicians at ISICEM and iFAD seemed reluctant to fill the patient (only 6 to 13% stated to give a fluid bolus) and most of them were in favour of administrating dobutamine (39 to 64%).

Fig3
Figure 3. Multiple choice question 1 (MCQ1): “Taking into account the results obtained with the transthoracic cardiac ultrasound, what is your treatment of choice at this stage?” Distribution of answers (in percentage) on MCQ1, blue squares denote the voting results of the ISICEM 2012 meeting, red squares show the results of the iFAD 2012 meeting, and green squares denote the voting results of the ISICEM 2013 meeting.

Further course

The FiO2 was increased to 100% and the PEEP was set according to the low flow pressure-volume (PV) loop (as can be automatically constructed with the Draeger Evita XL ventilator). Figure 4 shows the PV loop with detection of a lower inflection point at 16 cmH2O.

Fig4 PV loop
Figure 4. Low flow pressure volume (PV) loop showing a lower inflection point at 16 cmH2O and thus a best PEEP at 18 cmH2O.

During the PV loop, that also acted as a recruitment maneuver his systolic blood pressure decreased to 40 mmHg, so norepinephrine was started and swiftly increased to 0.4 ug/kg/min. Dobutamine was also started at 4 ug/kg/min. Saturation remained poor at 88% and he was switched to high frequency percussive ventilation (HFPV) with the VDR4 ventilator (Percussionaire Corporation, Sandpoint, Idaho, U.S.A). A transpulmonary thermodilution PiCCO catheter (Pulsion Medical Systems, Munich, Germany) was inserted in the femoral artery at this point. The evolution of the hemodynamic parameters obtained after insertion of the PiCCO catheter together with the respiratory variables are listed in Tables 2 and 3. The initial hemodynamic picture showed a normal cardiac index (CI) of 3.5 L/min.m2 (normal range 3-5), a relatively low intravascular filling status with a GEDVI of 757 ml/m2 (normal range 680-800), a very low global ejection fraction GEF of 13%  (normal range 25-35) but a very severe capillary leak with high extravascular lung water index (EVLWI) of 38 ml/kg predicted body weight (normal range 3-7). The high EVLWI was suggestive of hyper permeability edema in view of the high pulmonary vascular permeability index (PVPI) of 7.4 (normal range 1-2.5) [16].

Table 2. Evolution of hemodynamic parameters obtained with transpulmonary thermodilution (PiCCO).

Day

Time

CI

GEDVI

GEF

EVLWI

PVPI

PPV

HR

MAP

CVP

1

17:00

3,2

746

13

38

6,9

18

117

57

14

1

19:00

4,6

839

20

26

4,2

6

108

97

8

2

04:00

5,5

921

26

13

1,9

5

91

88

6

2

12:00

5

945

22

17

2,4

4

94

75

5

2

20:00

5,4

1025

23

19

2,5

6

93

79

6

3

04:00

4,8

1042

20

15

2,0

24

87

78

13

3

16:00

4,6

967

23

15

2,1

3

80

98

8

4

10:00

7

1073

24

14

1,8

5

107

103

10

4

18:00

5,9

977

26

12

1,7

4

101

85

9

5

10:00

4,6

1182

19

16

1,8

3

89

90

10

5

20:00

4,1

1060

17

13

1,7

4

80

86

14

6

04:00

3,1

893

16

14

2,1

5

79

76

9

6

11:00

3,3

972

17

14

2,0

4

80

95

6

6

17:00

3,2

900

16

12

1,8

3

84

109

5

7

06:00

3

882

20

11

1,7

10

65

72

10

7

12:00

3,8

908

21

10

1,5

17

144

100

6

7

18:00

5

829

25

12

2,0

6

88

69

4

8

05:00

4,9

1116

22

9

1,1

6

82

96

4

8

10:00

5,5

972

23

11

1,5

6

84

80

9

8

20:00

4,2

934

23

10

1,5

6

70

80

10

9

05:00

4,7

931

23

8

1,2

10

87

73

7

Abbreviations and units:
CI: cardiac index (L/min.m2)
CVP: central venous pressure (mmHg)
EVLWI: extravascular lung water index (ml/kg PBW)
GEDVI: global end diastolic volume index (ml/m2)
GEF: global ejection fraction (%)
HR: heart rate (bpm)
MAP: mean arterial pressure (mmHg)
PPV: pulse pressure variation (%)
PVPI: pulmonary vascular permeability index

Table 3. Evolution of respiratory and oxygenation parameters.

Day

Time

Vent

pO2

pCO2

P/F

lactate

pH

RR

TV

IPAP

PEEP

1

17:00

VDR4

82,5

42,8

121,3

1,82

7,25

24

442

30

6

1

19:00

VDR4

83,5

44,9

157,5

2,08

7,36

24

660

32

10

2

04:00

VDR4

86,5

32,7

192,2

3,56

7,41

16

680

32

11

2

12:00

VDR4

88,5

38,9

205,8

1,63

7,36

16

665

34

18

2

20:00

VDR4

167,6

37,8

316,2

2,44

7,48

16

670

35

20

3

04:00

VDR4

93,3

39,5

266,6

2,1

7,46

16

680

34

18

3

16:00

VDR4

103,9

35

494,8

1,79

7,48

16

710

34

16

4

10:00

EVITA

112

39,7

311,1

2,23

7,44

18

633

32

7

4

18:00

EVITA

76,8

33,8

295,4

1,45

7,48

16

899

30

6

5

10:00

EVITA

50,3

25,6

98,6

1,05

7,53

17

735

30

6

5

20:00

VDR4

102,3

28,7

292,3

1,65

7,58

17

640

32

14

6

04:00

VDR4

133,2

26,3

380,6

1,1

7,59

18

630

34

19

6

11:00

VDR4

143,2

24,6

477,3

1,04

7,59

17

630

33

14

6

17:00

VDR4

133,6

29,1

534,4

0,96

7,54

14

755

32

9

7

06:00

EVITA

92,3

41,7

355,0

0,77

7,44

12

641

30

9

7

12:00

EVITA

91,2

33,1

364,8

0,91

7,51

12

365

30

7

7

18:00

EVITA

66,7

28,2

115,0

1,58

7,55

13

850

28

7

8

05:00

EVITA

104,9

36

308,5

0,77

7,45

10

1020

28

7

8

10:00

EVITA

120,4

32,5

334,4

0,74

7,47

15

793

26

6

8

20:00

EVITA

107,6

32,2

358,7

0,59

7,44

11

900

26

6

9

05:00

EVITA

81,9

32,1

273,0

0,5

7,44

12

768

26

6

Abbreviations and units:
IPAP: inspiratory positive airway pressure (cmH2O)
PEEP: positive end expiratory pressure (cmH2O)
P/F: pO2 over FiO2 ratio
RR: respiratory rate
TV: tidal volume (ml)
VDR4: high frequency percussive ventilator
Vent: type of ventilator

At the same time however the patient seemed to be fluid responsive with a high pulse pressure variation (PPV) of 19% (normal range <10).  Heart rate was regular at 119 beats per minute with a MAP of 65 mmHg. The CVP was still 16 mmHg. His response to a passive leg raising (PLR) maneuver was positive (15% increase in CI and MAP) confirming that he was volume responsive despite the fact that he had such bad pulmonary edema (EVLWI 38) with a critical oxygenation status (P/F ratio of 57, at IPAP of 34 cmH2O and PEEP of 15 cmH2O).

Multiple choice question 2

At this stage, the participants of the ISICEM and IFAD meetings were asked the second multiple choice question (MCQ2): “Taking into account the results obtained with the transpulmonary thermodilution, what is your treatment of choice at this stage?” Possible answers were:
1) norepinephrine
2) dobutamine
3) fluid bolus
4) diuretics
5) other

 

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