An intensivist on a learning frenzy. Caring for the critically ill using evidence-based medicine.
In this post, I will discuss an article titled "Direct assessment of microcirculation in shock: a randomized-controlled multicenter study" (DAMIS trial) published in 'Intensive Care Medicine.' Shock is a life-threatening condition defined by a critical mismatch between oxygen supply and demand at the tissue level. In clinical settings, especially in ICUs, understanding and managing shock …
Continue reading Microcirculation Assessment in Shock Patients: The DAMIS Trial
Fluid responsiveness is defined as "as the ability of the left ventricle to increase its stroke volume (SV) in response to fluid administration". There are multiple strategies to define fluid responsiveness in patients who are on mechanical ventilation such as PPV, SVV, EEOP. Positive end-expiratory pressure (PEEP) can decrease cardiac output in mechanically ventilated patients. …
Continue reading PEEP-Test for Fluid/Volume Responsiveness in Resuscitation
Today, we're going to be reviewing what some might consider to be a landmark study: the CLOVERS trial. The first thing most clinicians do when a patient is hypotensive is provide IV fluids. The surviving sepsis guidelines recommend 30cc/kg in patients who are in septic shock. It often bears reminding that the objective of providing …
Continue reading More Fluids vs. Vasopressors in the First 24h of Septic Shock (CLOVERS Trial)
When I was completing my fellowship I dabbled a bit at performing transesophageal echocardiograms in the CCU/CVICU. I did not receive any formal training at it, though. I've been in practice out of fellowship for 5 years now and have made it a point to add the skill to my arsenal. On this page, I …
Continue reading Transesophageal Echocardiography (TEE): Adding to the Skill Set
As much as I am not a huge fan of bombarding septic shock patients with IV fluids, I understand there is a role for fluid resuscitation.When our patients get better, though, it is time to get rid of these fluids.That is what we call deresuscitation.It is part of the 4 D's in fluid therapy: drug, …
Continue reading How Strong Is Your Deresuscitation Game in Sepsis Patients?
We often overload our septic shock patients with IV fluids.The CLASSIC trial looked at the fluids we give in the ICU after resuscitation in the ED.This is not medical advice. Read the article for yourself.Almost 1600 patients were enrolled in either the standard or restrictive IV fluid group.Before arriving to the ICU, these patients received …
Continue reading CLASSIC Trial: IV Fluids for Septic Shock in the ICU
A common scenario that occurs daily, heck even perhaps hourly, in most emergency departments or intensive care units around the world including providing patient with IV fluids rapidly via fluid bolus to resuscitate hypotensive patients or those who are in shock. In order to mitigate said hypotension/shock, the most common response by clinicians is to …
Continue reading Fluid Bolus in Resuscitation: Pressure Bag vs. 999ml/hr on the IV Pump
There are numerous methodologies that we can utilize to determine fluid responsiveness in our critically ill patients in the emergency department or in the intensive care unit. In this post, I will be taking a deep dive into pulse pressure variation, PPV as the shorthand. For details about the other methods for determining fluid responsiveness, …
Continue reading Pulse Pressure Variation (PPV) for Fluid/Volume Responsiveness
What is end-expiratory occlusion testing? It is a method we can use at the bedside to determine whether a patient is fluid-responsive. We have actually known about this since 2009 when Monnet et al. explored this concept in a not-free article. The full description of the heart-lung interaction that allows this to work is beyond …
Continue reading End-Expiratory Occlusion for Fluid/Volume Responsiveness
This is a work-in-progress blog post for my lecture "Resuscitation and Fluid Responsiveness." In the lecture, I discuss fluid resuscitation in sepsis and volume responsiveness. After all, only 50% of critically ill patients are fluid responsive, and 66% of patients in septic shock are volume overloaded on hospital day 1 (Douglas et al.). Those are …
Continue reading Resuscitation in Sepsis using Fluid/Volume Responsiveness