Septic Shock Fluid Therapy – Bedside Metrics
A 49 year old male patient was brought to Aster Hospital on 26th November 2017 upon feeling uneasy and passing loose stools.
Comorbids were – Hypertensive on Tab Bisoprolol 2.5 mg OD, Dyslipidemia on Tab Atorva 20 mg HS.
The patient, when brought to the ER was found to have HR-88/min, NIBP was 70/50mmHg. Despite being given fluid boluses, his BP continued to be low, vasopressor (noradrenaline) was started and the patient was shifted to ICU. He was given Empirical Antibiotics in the ER. On arrival to the ICU, the patient was cold, clammy and slightly disoriented. His vitals then were; HR- 90/min (probably due to betablockade, he was on Tab.Bisoprolol)), BP- 65/50 mmHg, RR-44/min, Desaturating. He had received multiple fluid boluses along with IV Fluid @ 200ml/hr.
Provisional ICU admission Diagnosis:
- Septic/hypovolemic shock- Acute gastroenteritis.
- Acute Pulmonary edema-Volume overload
Management: (main steps)
- Non- invasive ventilation with high Fio2 started for pulmonary edema
- Fluid boluses were continued with Passive leg raising- targeting Pulse pressure variation (PLR)
Since we do not use CVP at all, ICU nurses have been taught PLR maneuvers. Other metrics that we use for fluid resuscitation are a) IVC diameter- just look at respiratory variation or collapsibility b) Arterial Line Tracing- respiratory variation c) B-Lines and A lines.
- Antibiotics were escalated and Inj.Hydrocortisone was added (Relative Adrenal insufficiency).
The patient improved over time and was discharged successfully.
This case presentation is to highlight the bedside use of metrics for fluid therapy especially boluses during shock. In literature, we may come across many gadgets and near Gold Standard Metrics, pragmatically speaking, we must use what we have and can, at the bedside.
Most importantly, as in any critical care set-ups, the backbone is the CCM nurses. Whatever metric one may apply it should be practical and easy enough to be practiced by the ICU nurses. A gentle reminder like oxygen, IV fluid is another most commonly misused ‘drug’ by definition.
HOD Critical Care Medicine
Specialist Internal Medicine
Aster Hospital, Mankhool