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Clinical Cases 122: Feast, Fast or Flood Fluid Freesome

This is a “what would Weingart do?” trio of cases.  If you haven’t been keeping up with ‘the Man’s podcast then you would have missed the last few episodes where he has re-explored the modern paradigm of fluid resuscitation in Critical Care.  We have seen a whole tsunami of potential answers, techniques and a few really odd ways of measuring that enigmatic thing called “fluid responsiveness” in the last few years.  It can be really confusing – and technically challenging at times.  So I did like Scott’s simplification of the subject into 2 simple questions in his recent podcast (Emcrit Podcast 162).  Weingart boils it down to 2 simple questions:

  1. Can the RV take more volume?
  2. Can the LV use more volume?

Now of course those are simple questions which have rather complex answers.  But it is a simple way of thinking about the things that we do in order to assess volume responsiveness – most of our techniques try and answer one or both of these.

So instead of trying to explain it to you, I am going to suggest that you go over to Emcrit and listen to his excellent dissection of the state-of-the-art in fluid therapy and then come back here and try and manage these 3 tricky fluid cases.  Each one is a conundrum – should we give more volume?  Lets dive right into you next shift in Broome ED!

As you arrive for night shift you note that there seems to be a buzz of activity in what you were hoping was going to be a quiet ED.  There are multiple patients attached to multiple monitors and a whole pile of paperwork covering the desktop in the fishbowl.  This is not good…

Your exhausted-looking colleague, Dave [75% of my colleagues are named Dave ] prepares to deliver the handover (Ed: thats “sign out” for the Americans ).  There are 3 patients in the department whom he is worried about, all are on their way to a better place…  the HDU.  But being Broome – you are the only doctor in the building, so that is really just a quirk of geography – they are all yours.

Dave tells you that he has been struggling to work out what to do with the fluids of these 3 sick folk.  He is keen to get a second opinion, a fresh head and decide what to do with their fluids in the coming hours.

Here is the handover:

Case 122a:

Albert is a 67 yo man with severe emphysema.  He has been worked over by the tertiary Respiratory team and they have diagnosed him with severe pulmonary hypertension with RVSP off the chart.  He is on home oxygen for this and has been using oral Viagra with some success in the last few months.  He usually runs a low BP of around 100 systolic.  He also has bad diabetes with nasty leg ulcers and mild renal impairment.  The good news is that his left heart is in pretty good nick.

Albert has MRSA growing in his cellulitic legs and has dropped his bundle a bit this arvo – he has no other clear source, is covered with appropriate ABs but remains hypotensive, MAP now 60mmHg with poor mentation despite 2500ml of crystalloid.  His urine output has tailed off since arriving in ED.

His lungs look abnormal ( but this in unsurprising) on US – but not clearly wet.  His IVC is plump with minimal respiratory variation.  His ECHO is wildly abnormal – it takes a moment to realise that it is the correct orientation – the big chunky ventricle is actually the RV with a smaller, under-filled LV flopping away with a high ejection fraction.

What is your strategy here?

Case 122b:

Beryl is a 56 yo woman who has been on haemodialysis for 7 years.  She has diabetic nephropathy and ischemic heart disease.  She has had 3 “major coronary events” in the last year.  Prior to this she was always hypertensive on 3 meds, but now runs a BP of 110 post dialysis at ideal weight.  She has become difficult to dialyse with many sessions being cut short for hypotension.  In the last week she has only spent about half her usual hours “in the chair” and was becoming hypertensive with a BP of 170/110 yesterday. She is about 6kg over her “dry weight”.

When she arrived at the dialysis unit this morning she was feeling crook.  Her BP was 90/65, she was febrile with rigors and the dialysis nurses found her fistula to be hot, tender and red.  They declined her dialysis and have sent her in for ABs and admission.  Oh – and the next available “chair” is more than 48 hours away.  Dr Dave was reluctant to give too much fluid as her closest acute HD option is 2000 km away!

Her Sono-findings show: a small number of bibasal B-lines, though only in the bases.  Her IVC is 2 cm, with about 50% collapse, her ECHO is abnormal with her chronic LV hypertrophy, old apical wall hypokinesis.  A quick Diastology study shows impaired relaxation with a pseudo normal pattern. (Check out echobasics.de if you want a basic run through what this means.)

So – she looks septic, we know she is overweight / volume…. and her BP at handover time is 80/45 with her non-fistula hand feeling cool.  What do you want to do Doc?

Case 122c:

Hank is a 70 yo chap with a history of dilated cardiomyopathy of uncertain aetiology.  He has had intermittent AF over the years and takes a bunch of meds, (including 3 diuretics!) for his NYHA 3 failure.  Today he has presented feeling syncopal and weak after spending the day clearing the garden for the oncoming cyclone season.  It is 107 F and 98% humidity out there!! He took his BP with his home monitor and it kept reading “ERROR” – because his AF was back and too erratic.  On the monitor he is going at 140 in AF with lots of ventricular ectopics.  His peripheral pulse is extremely variable volume – the SpO2 probe is giving his pulse rate as 35/min intermittently. [i.e a quarter of the beats are reaching his fingertips!]  The best BP we can get is 85/40 laying and he drops to 70/40 when upright with immediate syncopal symptoms.

His US-interrogation shows:  wet lungs with B-lines up to the scapulae and small bilateral effusions.  His IVC is plump and there is a small, pericardial effusion with no pressure effect on the RA or RV. His ECHO is tricky as he is going fast and lots of irregular beats.  He has a massive heart, big LA and significant mitral regurgitation.  His last ECHO estimated an EF of 20% and with the eyeball this seems about the same tonight.

Should we give him some volume?  What else can we do?

Dr Dave is handing over and walking out the door!  He wishes you well and leaves you with your trusty US machine, a VBG machine and your awesome nurses.  The night may be a long one.  You sit for a moment and think….   “What would Weingart DO?”

OK crew.  Plenty of fluid for thought there!

I would love to hear your comments. I really hope to learn a few things here.

Casey

PS:  Second last chance  to get SMACC DUB tickets tomorrow.  Get online at smacc.net.au to find out how to register.  And put your name down for a workshop – the ECHO guys are superstars and can show you how to do all the stuff I mentioned in the cases above!

 

Comments

  1. Kirsty Challen says:

    Ermmm….is phone a friend an option?!

    Can I start with Hank? DC cardioversion please +/- drugs to keep him in sinus (which ones would depend on what he is already taking). Hopefully restoring sinus would better enable him to cope with some rehydration? (Being a Brit I don’t understand 107F but I think it’s hot).

    Albert seems to need to get some fluid from his RV to his LV so it would seem sensible to attempt to treat his pulmonary hypertension. Now I’m no expert at this but more Viagra?

    Beryl looks really tricky -- I don’t think I’d want to try to predict her potential to improve with fluid, so can I try a passive leg raise while watching the echo please?

    Looking forward to thoughts from brighter minds than mine!

  2. John Wayne says:

    Albert:
    I hope Albert is satisfied with his achievements so far in life.

    Betty:
    Her initial BP gives a map in the seventies so this is OK. Dave was probably right to withhold fluids at that point.
    Her echo shows moderate diastolic dysfunction only.
    Her IVC filling and pulmonary ultrasound indicate that she does have some extra fluid on board but could probably tolerate more in a pinch.
    These findings, and the history of frequent hypotensive episodes on dialysis may indicate that her dry weight needs to be increased, but that is someone else’s problem for a later day (hopefully).
    I think she is at point where a pressor should be started and I would start with Norad.
    Also, if in doubt, I think it is important to treat the sepsis that we see now rather than worry about pulmonary oedema that we may see in the future. If this develops, we can support her lungs and transfer her to a centre with haemodialysis. Hypotensive arrest is more difficult to reverse.

    Hank:
    AF at 140 with normal myocardium is usually not the cause of any hypotension, but in Hank’s case his heart is unlikely to be able to compensate for even minor insults. Sinus rhythm would definitely be an improvement.
    Echo shows severe left, probably biventricular failure with backflow into the lungs and vena cava. Neither ventricle will benefit from further fluid.
    He need diuresis, ionotropes and cardioversion.
    Dobutamine is the ionotrope of choice however can exacerbate AF.
    I would start a small dose of dobutamine with caution.
    Betablockers are contra-indicated in cardiogenic shock.
    If he is already taking a calcium channel blocker I would trial a further or IV dose under very close monitoring.
    If he is taking a beta blocker, or there is no change, I would electrically cardiovert him using a dissociative dose of Ketamine.

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