Case study - Adult - Fluid Challenge Septic Shock
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A 69-year-old woman with septic shock and peritonitis underwent surgery and was intubated. She had hemodynamic instability and high lactate levels requiring vasoactive drugs. A fluid challenge using USCOM showed an increase in her stroke volume of more than 15%, indicating she was fluid responsive. Continued fluid optimization was recommended before adding additional vasoactive drugs. USCOM provided a non-invasive way to guide fluid resuscitation.
Case study - Adult - Fluid Challenge Septic Shock
- 1. Fluid challenge - Septic Shock Presentation Woman, 69 years old, admitted to ICU for septic shock due to peritonitis. Treatment She underwent surgery, requiring intubation and mechanical ventilation. She presented with hemodynamic instability with lactate levels > 4 mmol/L and requiring high levels of vasoactive drugs (norepinephrine 2.05 yg/kg/min). CVP : 16 mmHg www.uscom.com.au The Measure of Life
- 2. Fluid challenge - Septic Shock USCOM pre fluid loading (SV) 26mls (SVI) 14mls/min/m2 (CI) 1.8L/min/m2 (Typical 2.4-3.6) www.uscom.com.au The Measure of Life
- 3. Fluid challenge - Septic Shock USCOM post fluid loading (SV) 34mls (SVI) 18mls/min/m2 (CI) 2.3L/min/m2 (Typical 2.4-3.6) Result The increase is > 15% www.uscom.com.au The Measure of Life
- 4. Fluid challenge - Septic Shock Summary She is fluid responsive however fluid resuscitation is not completely achieved. Continue fluid optimization until she is no longer fluid responsive before adding another vasoactive drug (Dobutamine). Conclusion USCOM can guide us during the resuscitation, in a very rapid and safe way, without any invasive procedure (no catheter insertion: PiCCO, Swan-Ganz). www.uscom.com.au The Measure of Life
Editor's Notes
- #2: Norepinephrine is also used as a vasopressor medication (for example, brand name Levophed) for patients with critical hypotension. It is given intravenously and acts on both α1and α2 adrenergic receptors to cause vasoconstriction. Its effects are often limited to the increasing of blood pressure through agonist activity on α1 and α2 receptors, and causing a resultant increase in peripheral vascular resistance. At high doses, and especially when it is combined with other vasopressors, it can lead to limb ischemia and limb death. Norepinephrine is used mainly to treat patients in vasodilatory shock states such as septic shock and neurogenic shock, while showing fewer adverse side-effects compared to dopamine treatment.[44]http://en.wikipedia.org/wiki/Norepinephrine
- #3: Hypodynamic circulation Low SVI 14 (Typical 30-55)Low CO –3.4 (Typical 2.5-6.0)Low CI –1.8 (Typical 2.4-3.6)Vpk – 0.7 (Typical 0.9-1.3)Fluid or Contractility?
- #4: Hypodynamic circulation Low SVI - 18 (Typical 30-55)Low CO – 4.3 (Typical 2.5-6.0)Low CI – 2.3(Typical 2.4-3.6)Stroke volume (SV) 34mls
- #5: Dobutamine is used to treat acute but potentially reversible heart failure, such as which occurs during cardiac surgery or in cases of septic or cardiogenic shock, on the basis of its positive inotropic action.[2]http://en.wikipedia.org/wiki/Dobutamine