Correspondence
be proven by further studies. Beyond the financial aspect, we think that the main interest of cardiopulmonary ultrasound in the ED is to give a faster and more accurate diagnosis, thus allowing to initiate a more appropriate treatment. Sincerely yours, Emeric Gallard, MD⁎ Jean-Eudes Bourcier, MD Jean-Philippe Redonnet, MD Didier Garnier, MD Emergency, Anesthesiology, and Critical Care Department Lourdes Hospital, Lourdes, France Corresponding author at: Service d’Accueil des Urgences, CHG Lourdes 65100 Lourdes, France E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2015.01.042
471
Mustafa Tanriseven, MD Department of General Surgery, Diyarbakır Military Hospital Diyarbakır, Turkey Eyup Duran, MD Department of General Surgery, Elazıg Military Hospital, Elazıg, Turkey http://dx.doi.org/10.1016/j.ajem.2015.02.004 References [1] Sirvent JM, Ferri C, Baro A, Murcia C, Lorencio C. Fluid balance in sepsis and septic shock as a determining factor of mortality. Am J Emerg Med 2014. http://dx.doi.org/ 10.1016/j.ajem.2014.11.016. [2] Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77. [3] Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259–65. [4] Coen D, Cortellano F, Pasini S, Tombini V, Vaccaro A, Montalbetti L, et al. Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med 2014;32:563–8. [5] Marik PE, Varon J. Early goal-directed therapy: on terminal life support? Am J Emerg Med 2010;28:243–5.
Fluid necessity should be followed by central venous pressure☆ Fluid balance in sepsis: a single parameter does not provide the solution To the Editor, We intentionally read the article “Fluid balance in sepsis and septic shock as a determining factor of mortality” written by Sirvent et al [1] with interest. They concluded that a positive fluid balance in the first 4 days was associated with higher mortality in severe sepsis and patients with septic shock [1]. There is a global tissue hypoxia in severe sepsis and septic shock, which may proceed to multiorgan failure and death [2]. Too little fluid may result in tissue hypoperfusion and worsen organ dysfunction [3]. Intravenous fluids, source control, vasopressors, inotropic agents, and mechanical ventilation are a key component in the early management of septic shock [3] and used to a balance in normalized values for mixed venous oxygen saturation, arterial lactate concentration, base deficit, and pH [2]. It is necessary that early central venous catheter is placed and a central venous pressure measured as an indicator of volume responsiveness [4]. The major elements of early goal-directed therapy include fluid resuscitation to achive a central venous pressure of 8 to 12 cm of water and to maintain the central venous oxygen saturation higher than 70% [5]. We think that fluid necessity should be followed by central venous pressure. Positive fluid balance is a result of low urine output because of tissue hypoperfusion and renal failure. There is a positive correlation between mortality and renal failure induced by tissue hypoperfusion. For this reason, creatinine and lactate levels should be monitored closely initially and after. Hakan Sarlak, MD Department of Internal Medicine, Diyarbakır Military Hospital Diyarbakır, Turkey Corresponding author. Department of Internal Medicine, Diyarbakır Military Hospital, Seref Inaloz St, 21100 Yenisehir,Diyarbakır, Turkey Tel.: +90 412 2288 225; fax: +90 412 2236 732 E-mail address: [email protected]
☆ There is no conflict of interests.
To the Editor, We have read with attention the letter by Hakan Sarlak with the title “Fluid necessity should be followed by central venous pressure” (CVP) about our recent study published in The American Journal of Emergency Medicine [1]. We agree that the CVP provides valuable information about the interaction of pump function of the heart and venous return when we consider simultaneously your changes and cardiac output. However, the analysis is complex in critically ill patients because, in addition to a technically adequate measurement, the interpretation requires consideration of multiple factors affecting the cardiac pressures [2] (hence, the importance to avoid inadequate venous return in the initial resuscitation of critically ill). What choice do we have, in practice, to ensure that we have sufficient venous return, with a fast and simple measure (CVP), applicable to any intensive care unit and emergency department? In addition to ultrasound techniques, we think that the initial evaluation of septic patients should evaluate the clinical examination and measure the CVP. The recommendation for a CVP, while recognizing its limitations, in the initial resuscitation of septic patient, we think it is a guarantor measure at an initial time of resuscitation in which the priority is to ensure sufficient venous return [2]. Obviously, in our observational study, all patients had a central venous catheter inserted, and CVP and central venous saturation were measured at baseline and at 6 hours. However, several studies have emphasized the reduced clinical value of static hemodynamic parameters, such as CVP [3] and pulmonary artery occluding pressure, as compared with dynamic parameters in predicting fluid responsiveness. Such dynamic indicators include passive leg raising, which induced changes in cardiac output [4] and ultrasound to evaluate the variations of both superior and inferior vena cava diameter and distensibility [5]. The mechanisms by which positive fluid balance can adversely influence outcomes remain unknown. Nevertheless, hypervolemia might exacerbate capillary leak in septic shock patient, thus contributing to pulmonary edema. Positive fluid balance could also result in intraabdominal hypertension, thus contributing to organ hypoperfusion and subsequent organ failure [6].
472
Correspondence
From there, I agree that the initial fluid reanimation in sepsis requires a finer analysis, considering the complexity of the critically ill patient and avoidance of falling into an overly simplistic view of the problem looking for a single parameter that provides us the “solution.” Josep-Maria Sirvent, MD, PhD⁎ Cristina Murcia, MD Carolina Lorencio, MD Department of Intensive Care (ICU), University Hospital of Girona Doctor Josep Trueta, IDIBGI, CIBERES, Girona, Spain ⁎Corresponding author at: Department of Intensive Care (ICU) University Hospital of Girona Doctor Josep Trueta, Avda. de França s/n E-17007 Girona, Spain. Tel.: +34 972 940 288; fax: +34 972 940 296 E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2015.02.003
References [1] Sirvent JM, Ferri C, Baro A, Murcia C, Lorencio C. Fluid balance in sepsis and septic shock as a determining factor of mortality. Am J Emerg Med 2014. http://dx.doi.org/ 10.1016/j.ajem.2014.11.016. [2] Henderson WR, Griesdale DE, Walley KR, Sheel AW. Clinical review: Guyton—the role of mean circulatory filling pressure and right atrial pressure in controlling cardiac output. Crit Care 2010;14:243–5. [3] Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41:1774–81. [4] Cavallaro F, Sandroni C, Marano C, La Torre G, Mannocci A, De Waure C, et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. Intensive Care Med 2010; 36:1475–83. [5] Guarracino F, Ferro B, Forfori F, Bertini P, Magliacane L, Pinsky MR. Jugular vein distensibility predicts fluid responsiveness in septic patients. Crit Care 2014;18:647–52. [6] Myburgh JA. Fluid resuscitation in acute illness—time to reappraise the basics. N Engl J Med 2011;364:2543–4.
be proven by further studies. Beyond the financial aspect, we think that the main interest of cardiopulmonary ultrasound in the ED is to give a faster and more accurate diagnosis, thus allowing to initiate a more appropriate treatment. Sincerely yours, Emeric Gallard, MD⁎ Jean-Eudes Bourcier, MD Jean-Philippe Redonnet, MD Didier Garnier, MD Emergency, Anesthesiology, and Critical Care Department Lourdes Hospital, Lourdes, France Corresponding author at: Service d’Accueil des Urgences, CHG Lourdes 65100 Lourdes, France E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2015.01.042
471
Mustafa Tanriseven, MD Department of General Surgery, Diyarbakır Military Hospital Diyarbakır, Turkey Eyup Duran, MD Department of General Surgery, Elazıg Military Hospital, Elazıg, Turkey http://dx.doi.org/10.1016/j.ajem.2015.02.004 References [1] Sirvent JM, Ferri C, Baro A, Murcia C, Lorencio C. Fluid balance in sepsis and septic shock as a determining factor of mortality. Am J Emerg Med 2014. http://dx.doi.org/ 10.1016/j.ajem.2014.11.016. [2] Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77. [3] Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259–65. [4] Coen D, Cortellano F, Pasini S, Tombini V, Vaccaro A, Montalbetti L, et al. Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med 2014;32:563–8. [5] Marik PE, Varon J. Early goal-directed therapy: on terminal life support? Am J Emerg Med 2010;28:243–5.
Fluid necessity should be followed by central venous pressure☆ Fluid balance in sepsis: a single parameter does not provide the solution To the Editor, We intentionally read the article “Fluid balance in sepsis and septic shock as a determining factor of mortality” written by Sirvent et al [1] with interest. They concluded that a positive fluid balance in the first 4 days was associated with higher mortality in severe sepsis and patients with septic shock [1]. There is a global tissue hypoxia in severe sepsis and septic shock, which may proceed to multiorgan failure and death [2]. Too little fluid may result in tissue hypoperfusion and worsen organ dysfunction [3]. Intravenous fluids, source control, vasopressors, inotropic agents, and mechanical ventilation are a key component in the early management of septic shock [3] and used to a balance in normalized values for mixed venous oxygen saturation, arterial lactate concentration, base deficit, and pH [2]. It is necessary that early central venous catheter is placed and a central venous pressure measured as an indicator of volume responsiveness [4]. The major elements of early goal-directed therapy include fluid resuscitation to achive a central venous pressure of 8 to 12 cm of water and to maintain the central venous oxygen saturation higher than 70% [5]. We think that fluid necessity should be followed by central venous pressure. Positive fluid balance is a result of low urine output because of tissue hypoperfusion and renal failure. There is a positive correlation between mortality and renal failure induced by tissue hypoperfusion. For this reason, creatinine and lactate levels should be monitored closely initially and after. Hakan Sarlak, MD Department of Internal Medicine, Diyarbakır Military Hospital Diyarbakır, Turkey Corresponding author. Department of Internal Medicine, Diyarbakır Military Hospital, Seref Inaloz St, 21100 Yenisehir,Diyarbakır, Turkey Tel.: +90 412 2288 225; fax: +90 412 2236 732 E-mail address: [email protected]
☆ There is no conflict of interests.
To the Editor, We have read with attention the letter by Hakan Sarlak with the title “Fluid necessity should be followed by central venous pressure” (CVP) about our recent study published in The American Journal of Emergency Medicine [1]. We agree that the CVP provides valuable information about the interaction of pump function of the heart and venous return when we consider simultaneously your changes and cardiac output. However, the analysis is complex in critically ill patients because, in addition to a technically adequate measurement, the interpretation requires consideration of multiple factors affecting the cardiac pressures [2] (hence, the importance to avoid inadequate venous return in the initial resuscitation of critically ill). What choice do we have, in practice, to ensure that we have sufficient venous return, with a fast and simple measure (CVP), applicable to any intensive care unit and emergency department? In addition to ultrasound techniques, we think that the initial evaluation of septic patients should evaluate the clinical examination and measure the CVP. The recommendation for a CVP, while recognizing its limitations, in the initial resuscitation of septic patient, we think it is a guarantor measure at an initial time of resuscitation in which the priority is to ensure sufficient venous return [2]. Obviously, in our observational study, all patients had a central venous catheter inserted, and CVP and central venous saturation were measured at baseline and at 6 hours. However, several studies have emphasized the reduced clinical value of static hemodynamic parameters, such as CVP [3] and pulmonary artery occluding pressure, as compared with dynamic parameters in predicting fluid responsiveness. Such dynamic indicators include passive leg raising, which induced changes in cardiac output [4] and ultrasound to evaluate the variations of both superior and inferior vena cava diameter and distensibility [5]. The mechanisms by which positive fluid balance can adversely influence outcomes remain unknown. Nevertheless, hypervolemia might exacerbate capillary leak in septic shock patient, thus contributing to pulmonary edema. Positive fluid balance could also result in intraabdominal hypertension, thus contributing to organ hypoperfusion and subsequent organ failure [6].
472
Correspondence
From there, I agree that the initial fluid reanimation in sepsis requires a finer analysis, considering the complexity of the critically ill patient and avoidance of falling into an overly simplistic view of the problem looking for a single parameter that provides us the “solution.” Josep-Maria Sirvent, MD, PhD⁎ Cristina Murcia, MD Carolina Lorencio, MD Department of Intensive Care (ICU), University Hospital of Girona Doctor Josep Trueta, IDIBGI, CIBERES, Girona, Spain ⁎Corresponding author at: Department of Intensive Care (ICU) University Hospital of Girona Doctor Josep Trueta, Avda. de França s/n E-17007 Girona, Spain. Tel.: +34 972 940 288; fax: +34 972 940 296 E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2015.02.003
References [1] Sirvent JM, Ferri C, Baro A, Murcia C, Lorencio C. Fluid balance in sepsis and septic shock as a determining factor of mortality. Am J Emerg Med 2014. http://dx.doi.org/ 10.1016/j.ajem.2014.11.016. [2] Henderson WR, Griesdale DE, Walley KR, Sheel AW. Clinical review: Guyton—the role of mean circulatory filling pressure and right atrial pressure in controlling cardiac output. Crit Care 2010;14:243–5. [3] Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41:1774–81. [4] Cavallaro F, Sandroni C, Marano C, La Torre G, Mannocci A, De Waure C, et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. Intensive Care Med 2010; 36:1475–83. [5] Guarracino F, Ferro B, Forfori F, Bertini P, Magliacane L, Pinsky MR. Jugular vein distensibility predicts fluid responsiveness in septic patients. Crit Care 2014;18:647–52. [6] Myburgh JA. Fluid resuscitation in acute illness—time to reappraise the basics. N Engl J Med 2011;364:2543–4.
