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#Hemodynamics

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Romain Barthélémy

The previous consensus on circulatory shock and hemodynamic monitoring was brilliant. I have a talk for the residents of our ICU which is almost entirely based on this paper.

link.springer.com/article/10.1

SpringerLinkConsensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine - Intensive Care MedicineObjective Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock. Methods The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575–590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock? Four types of statements were used: definition, recommendation, best practice and statement of fact. Results Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring. Conclusions This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock.
#Hemodynamics#Monitoring#CriticalCare
Romain Barthélémy

Nice paper for the fans of #physiology of the mechanisms of #hypoxemia

annalsofintensivecare.springer

SpringerOpenEffects of CPAP and FiO2 on respiratory effort and lung stress in early COVID-19 pneumonia: a randomized, crossover study - Annals of Intensive CareBackground in COVID-19 acute respiratory failure, the effects of CPAP and FiO2 on respiratory effort and lung stress are unclear. We hypothesize that, in the compliant lungs of early Sars-CoV-2 pneumonia, the application of positive pressure through Helmet-CPAP may not decrease respiratory effort, and rather worsen lung stress and oxygenation when compared to higher FiO2 delivered via oxygen masks. Methods In this single-center (S.Luigi Gonzaga University-Hospital, Turin, Italy), randomized, crossover study, we included patients receiving Helmet-CPAP for early (< 48 h) COVID-19 pneumonia without additional cardiac or respiratory disease. Healthy subjects were included as controls. Participants were equipped with an esophageal catheter, a non-invasive cardiac output monitor, and an arterial catheter. The protocol consisted of a random sequence of non-rebreather mask (NRB), Helmet-CPAP (with variable positive pressure and FiO2) and Venturi mask (FiO2 0.5), each delivered for 20 min. Study outcomes were changes in respiratory effort (esophageal swing), total lung stress (dynamic + static transpulmonary pressure), gas-exchange and hemodynamics. Results We enrolled 28 COVID-19 patients and 7 healthy controls. In all patients, respiratory effort increased from NRB to Helmet-CPAP (5.0 ± 3.7 vs 8.3 ± 3.9 cmH2O, p < 0.01). However, Helmet’s pressure decreased by a comparable amount during inspiration (− 3.1 ± 1.0 cmH2O, p = 0.16), therefore dynamic stress remained stable (p = 0.97). Changes in static and total lung stress from NRB to Helmet-CPAP were overall not significant (p = 0.07 and p = 0.09, respectively), but showed high interpatient variability, ranging from − 4.5 to + 6.1 cmH2O, and from − 5.8 to + 5.7 cmH2O, respectively. All findings were confirmed in healthy subjects, except for an increase in dynamic stress (p < 0.01). PaO2 decreased from NRB to Helmet-CPAP with FiO2 0.5 (107 ± 55 vs 86 ± 30 mmHg, p < 0.01), irrespective of positive pressure levels (p = 0.64). Conversely, with Helmet’s FiO2 0.9, PaO2 increased (p < 0.01), but oxygen delivery remained stable (p = 0.48) as cardiac output decreased (p = 0.02). When PaO2 fell below 60 mmHg with VM, respiratory effort increased proportionally (p < 0.01, r = 0.81). Conclusions In early COVID-19 pneumonia, Helmet-CPAP increases respiratory effort without altering dynamic stress, while the effects upon static and total stress are variable, requiring individual assessment. Oxygen masks with higher FiO2 provide better oxygenation with lower respiratory effort. Trial registration Retrospectively registered (13-May-2021): clinicaltrials.gov (NCT04885517), https://clinicaltrials.gov/ct2/show/NCT04885517 .
#AIC#CriticalCare#FOAMcc
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Romain Barthélémy

#Albumin Should Be Remembered When Patients With #SepticShock Are Resuscitated

“Although no significant difference in 28-day mortality rate or 90-day mortality rate was observed between the use of albumin and #crystalloids, #colloids appeared to be more effective than crystalloids in stabilizing hemodynamic end points”

I couldn't agree more. Sometimes you have to find what to do at the moment. It is safe and may help.

journal.chestnet.org/article/S

#FOAMcc#CHEST#CriticalCare
Romain Barthélémy

Nice work by Jon-Emile Kenny et. al emphasizing that a significant amount of fluid challenge in ED are ineffective to improve flow, therefore can’t have any positive effect at all.

jintensivecare.biomedcentral.c

BioMed CentralThe time cost of physiologically ineffective intravenous fluids in the emergency department: an observational pilot study employing wearable Doppler ultrasound - Journal of Intensive CareBackground Little data exist on the time spent by emergency department (ED) personnel providing intravenous (IV) fluid to ‘responsive’ versus ‘unresponsive’ patients. Methods A prospective, convenience sample of adult ED patients was studied; patients were enrolled if preload expansion was indicated for any reason. Using a novel, wireless, wearable ultrasound, carotid artery Doppler was obtained before and throughout a preload challenge (PC) prior to each bag of ordered IV fluid. The treating clinician was blinded to the results of the ultrasound. IV fluid was deemed ‘effective’ or ‘ineffective’ based on the greatest change in carotid artery corrected flow time (ccFT∆) during the PC. The duration, in minutes, of each bag of IV fluid administered was recorded. Results 53 patients were recruited and 2 excluded for Doppler artifact. There were 86 total PCs included in the investigation comprising 81.7 L of administered IV fluid. 19,667 carotid Doppler cardiac cycles were analyzed. Using ccFT∆ ≥  + 7 ms to discriminate ‘physiologically effective’ from ‘ineffective’ IV fluid, we observed that 54 PCs (63%) were ‘effective’, comprising 51.7 L of IV fluid, whereas, 32 (37%) were ‘ineffective’ comprising 30 L of IV fluid. 29.75 total hours across all 51 patients were spent in the ED providing IV fluids categorized as ‘ineffective.’ Conclusions We report the largest-known carotid artery Doppler analysis (i.e., roughly 20,000 cardiac cycles) in ED patients requiring IV fluid expansion. A clinically significant amount of time was spent providing physiologically ineffective IV fluid. This may represent an avenue to improve ED care efficiency.
#JIntensiveCare#FOAMcc#CriticalCare
Clément Brunner

Time for an

Hi 🐘, I’m Clément, FWO post-doc fellow at NERF - NeuroElectronics Research Flanders - in Dr. Alan Urban lab. My research combines the development of the functional ultrasound imaging modality aka for diverse preclinical applications 🐭🐷🐵 and its use for whole-brain imaging of awake rodents : , mapping, sensory functions.

Stay up-to-date on (v)fUSI R&D (past&future) here: @fUSI

Continued thread
Artinis NIRS

All cells in all organs of the body have a constant but variable need for #oxygen. However, the body stores for oxygen are minimal. A constant and adequate supply of oxygen to the tissues through the circulation is essential. Any interference with tissue oxygenation will lead very rapidly to irreversible damage.

Optical oximetry, and near infrared spectroscopy (#NIRS) in particular, is a tool for assessing of the #oxygenation status and #hemodynamics of various organs, e.g. #muscle and #brain.

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