Couple of good reviews to be read
1. The issue of fluid management in ARDS is increasingly being spoken about.
Tagami et al have reviewed this topic well in the current issue of Current opinion in Critical Care. An excellent diagnostic framework has been posted.
2. A two series guideline has been published on Takatsubo Cardiomyopathy in the European Heart Journal
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ReplyDeleteSir , ards article is very informative, can we grade severity of ards based on PVPI? Can we decide on proning or ECMO depends on PVPI
ReplyDeleteRajyalakshmi, the main role of PVPI is to avoid volume overload
DeleteThanks for the good review sir..I feel it has given good opinion about only the positive aspect of measuring PVPI and EVLWI..this article has given less information regarding the limitations of them and I have few comments sir..
ReplyDelete1. Can we use them in Conditions like where the actual thoracic volumes less specially in post lung surgery or some intra thoracic vascular occlusions in which we may not use all these indices perfectly...if we are allowed to use them to what extent we can..?
2. My concern is can we use all the indices in diseases like COPD with ARDS where actually have relatively damaged alveolar capillary endothelial membrane and increased permeability
3. It is not very uncommon to have a synpneumonic effusion with ARDS..so can we actually use them in such a situation and if yes to what extent of pleural effusion..
Rajesh, contrary to popular belief, it is increasingly being recognised that EVLW methods using thermodilution actually underestimate EVLW in conditions of lobectomy and effusion. Personally I prefer a combo of LUSG and EVLW in ARDS
DeleteThanks for the link Dr Srinivas. A few comments if I may.
ReplyDelete1. I am not sure how PVPI would change management of anyone coming with pulmonary edema whether cardiogenic or non cardiogenic, as both groups would recieve a restrictive fluid strategy, lung protective ventilation as per ARDSnet.ECHO may help in diagnosis in many cases And as for prognostication it would show up with improvement in P:f ratio.
2. I feel the real use for transpulmonary thermodilution is in complex shock situations where EVLW would give an idea as to when the fluid we are giving is causing more ahrm than good. eg: if SVV and GEDV were showing fluid responsiveness but giving a fluid bolus causes increase in EVLW then we probably need to go up on vasopressors rather than pumping fluid. Just my 2 cents.
Dr Srinivas if I may ask when would you insert PiCCO or Volume view in ARDS patients ?
Pavan, thanks for the comment. Agreed that both conditions need fluid moderation. However in sepsis preventing vol overload is crucial to avoid ARDS as well as AKI
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