A Reader’s Question on Fluids! #FOAMed

So just got what I think is an excellent and common question from a reader, worth addressing with a mini-podcast:

Dr Rola, my name is Pedro Alvarado, i’m a Mexican critical care fellow (currently in the 2/2 training year). Been very interested in the last year on being able to answer the question: is my patient going to benefit form fluid administration? (particularly in the case of an objectively diagnosed distributive shock + ARDS, i think by the way, a very difficult to answer question in the majority of Mexican ICU´s).

To answer this question i thought, until recently, one should start by answering if the patient is fluid responsive. The concept of venous congestion and fluid tolerance seems to be the counterbalance that might complete the equaition of benefit/harm ratio of fluid administration on an already high-output state. As it is, i’ve been very interested in what you have recently been describing as the VexUs score. One question, you mention this US tool as a useful stop point for fluid administration in septic (distributive I assume) patients. I understand from your explanation that the further you document ultrasonographic sings of venous hypertension from the RA (hepatic -portal-renal vein), the worse the hypertension and possibly its consequences might be. Also you imply that the earliest you document signs of venous hypertension, the better, so that you can counterbalance benefit/harm ratio of fluid administration as soon as possible.

Understanding that the first, relatively easy measurable macrostructure to be affected by right-sided hypertension is the RA, what makes VExUS more valuable than a good,old CVP monitoring for this purpose? Far more expensive and time consuming, the US is. Also CVP absolute values and trends can be continuously measured.

So here is my answer:

cheers!
Philippe

One thought on “A Reader’s Question on Fluids! #FOAMed

  1. Korbin Haycock

    To add/reiterate what Phil said: CVP is a pressure that should be used as part of your hemodynamic assessment. But VExUS lets you see the organs and how the CVP is effecting flow through them. For example, if I have a CVP of 15 mmHg, I’m concerned. However, if two different patients have a CVP of 15 mmHg, and the first patient has a VExUS 1 or maybe 2 score, I’m somewhat less bothered than if I’m looking at a second patient with a VExUS 3.

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