“Question re fluid resuscitation and heart failure in ear and procedure”
Hello, looking for the protocol for someone elderly in the er that’s receiving fluid resuscitation for sepsis , hypotension, bradycardia and hypothermia Prior to er transfer md was concerned with fluid overload possibility ordering lasix 20 mg. I’m seeking to find the monitoring after fluids are given with a patient with above dx with the concerns of respiratory distress in relation to existing heart failure and the normal protocol when the patient starts to progressively have a loose productive cough to gurgling obvious from fluids given. Thank you in advance and this is hypothetical in question as a discussion with classmates is occurring and we do not meet in class for another week. Thanks
Male | 87 years old
Complaint duration: 1
Medications: None
Conditions: Heart failure with hypoxia, AKD, hx asbestos, htn
2 Answers
This is a tricky question and patient. Sepsis protocols say treat with fluids and intubate to protect the airway. If the ER doc is great at POCUS (beside ultrasound), they can look at the lungs for B lines to see if they are fluid overloaded or the size of the IVC to determine fluid status. CVP can also be used to help determine if they are hyper/hypo/or euvolemic..
A few things you need to take into account. 1) what’s the patients ejection fraction. 2) is the patient volume depleted (intravascular) 3) is the patient fluid responsive? Point 1 will be answered with a recent echo. Assuming compensated heart failure with a normal ejection fraction and no evidence of moderate/severe aortic stenosis then that’s a plus. Point 2 can be established quickly in the er based on clinical exam but my favorite method is use of ultrasound to see if IVC is collapsing or not. Collapsing ivc usually indicates the need for fluids. The third point can be established with the Cheetah/nicom device. This will help you realize if stroke volume is increasing with fluids and thus patient is fluid responsive. Once you know these three parameters you can establish how much (volume)/aggressive (rate)you can hydrate your patient. Typically in the er if we see a heart failure patient that needs fluids, for example someone with sepsis, then we will start with a 250cc bolus and check the following parameters mentioned above. In your question you mention hypotension, bradycardia, hypothermia. This can be an indication of sepsis with end organ damage but other issues such as myxedema coma must also be ruled out (screen tsh), as the treatment will additionally require more than just fluids and antibiotics including stress dose steroids and thyroid hormone replacement. Best of luck with school!
