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sábado, 31 de octubre de 2015

Respuesta a fluidos

St.Emlyn’sOctober 30, 2015 by Richard Carden
...So what can we do in the ED to gauge responsiveness to a fluid bolus?
The passive leg raise (PLR) is commonly cited means of assessing fluid responsiveness, as depicted below:
The PLR is a fantastic way of assessing fluid responsiveness, however it really does require a measure of cardiac output or stroke volume. As described in a systematic review by Cavallaro et al. PLR whilst monitoring cardiac output is much more sensitive and accurate than by measuring arterial pulse pressure. A simple measure that has been proposed is pleth variability index (PVI), which aims to detect changes in stroke volume by using pulse oximetry waveform amplitude. This sounds great for the ED! Everyone gets a sats probe and boom there we go. However, the majority of studies at present find that PVI is poor predictor of fluid responsiveness.
So heart rate, blood pressure, PVI and PLR may not give us any idea of fluid responsiveness in the ED?! PLR seems like the best option but we must measure this effect in real time with some form of stroke volume or cardiac output monitoring.
Ultrasound assessment of stroke volume may be an answer, and emergency physicians are certainly becoming more adept with this technique.
What we do know is that a positive fluid balance in sepsis is an independent predictor of mortality in sepsis and is an important factor in 28-mortality in patients with AKI.
I am declaring myself as somewhat of a Marik-phile, and I recommend reading this paper for a more comprehensive review of fluid responsiveness.
What next?
We need better studies to determine the most accurate way to assess fluid responsiveness in the emergency department. I am hoping to be involved in such a study in the coming year so watch this space!
For more information, check out these awesome links from EMCrit, LITFL and CrashingPatient."
http://stemlynsblog.org/maestrini-frank-starling-guyton-and-fluids/