View Abstract

A3272 - Ultrasound and Clinical Hemodynamic Assessment of the Critically Ill Patient
Author Block: V. Sharma1, R. Gueret1, J. Bailitz2, A. Tulaimat3; 1Division of Pulmonary and Critical Care, John H Stroger Hospital of Cook County, Chicago, IL, United States, 2Department of Emergency Medicine, Northwestern Medical Center, Chicago, IL, United States, 3Pulmonary, Critical Care, and Sleep Medicine, Cook County Health and Hospitals System, Chicago, IL, United States.
Introduction/Rationale:
Fluid therapy of previously resuscitated patients in the intensive care unit (ICU) requires simultaneous assessment of disparate clinical / laboratory parameters. Assessment of the Inferior Vena Cava (IVC) and heart / lungs may inform decision making with regards to ongoing fluid therapy. Capillary refill time (CRT) > 2.4 seconds predicts mortality in patients with septic shock, and a warm peripheral temperature may imply need for more fluid resuscitation. A comprehensive snapshot of previously resuscitated septic patients that includes ultrasound assessment does not exist.
Methods:
A convenience sample of 70 critically ill patients receiving fluids (40 with sepsis/septic shock) admitted to the ICU was studied. Two intensivists with formal training in critical care ultrasound performed all clinical and ultrasound assessments the morning of admission to ICU. Peripheral temperature, CRT, IVC collapsibility (IVCc), LV function and pulmonary edema as defined by presence of B+ lines in the chest (Volpicelli et al) were assessed. Fluid therapy was defined as active resuscitation ( ≥ 200 ml of fluid administered or patients being actively bolused) or not.
Results:
Mean age was 53 ± 2 years. 31% were female, mean Charlson Comorbidity Index was 3±2.5, and the mean SAPS score was 37 ± 2. 13/70 (19%) had ultrasound determined pulmonary edema, 8/13 (22%) were being actively resuscitated. Mean IVCc for the entire cohort was 29 ± 3. For patients spontaneously breathing (n= 54) IVCc was 30 ± 3; for mechanically ventilated patients (n=12), IVCc was 29 ± 6; for those with acute circulatory failure (n=28) IVCc was 26 ± 4%. An equivalent proportion (p= 0.39) of patients receiving active resuscitation (14% 5/37) and those not receiving active resuscitation (19% 6/32) had depressed or severely depressed LV function. There was no difference in IVCc between patients with capillary refill time of ≥3 versus ≤ 2 seconds. Patients with warm peripheral skin temperature were more likely to have a higher IVCc (34± 3 vs 18 ± 5 p=0.012). Pedal edema was not associated with reduced LV function, presence of pulmonary edema, small IVCc or long CRT.
Conclusions:
Ultrasound assessment of the heart and lungs identifies a substantial minority of patients where additional fluid may be deemed harmful. Previously resuscitated patients with acute circulatory failure may be under-resuscitated and those with warm skin temperature may be targeted for IVC assessment to determine further fluid needs. Pedal edema should not influence decision making with respect to fluid therapy.