Shock Syndromes I

In the previously mentioned study, the AUC ROC for predicting fluid responsiveness was higher

for PPV than for SVV.

In one study of postoperative patients, IVC distensibility was not noninferior to PPV (noninferiority

p=0.28), considering a noninferiority margin of 15%.

However, obtaining PPV from echocardiography leads to a lower AUC ROC for predicting fluid

responsiveness (0.66–0.68) than does obtaining PPV from other methods (AUC ROC 0.94).

changes appear to be superior to IVC distensibility and PPV.

incorporating dynamic markers into a resuscitation strategy that improves patient outcomes in the ICU

is still lacking.

In a randomized controlled trial of patients with septic shock and/or acute respiratory distress

syndrome that randomized patients to treatment on the basis of pulse index continuous cardiac

output (PiCCO)-derived parameters (one of the arterial pulse pressure waveform analysis devices

described in Table 2) or control, 28-day mortality did not differ between groups.

A pilot study using protocol-guided assessments of fluid responsiveness after initial resuscitation

in patients with septic shock requiring vasopressors found this approach feasible and safe, paving

the way for larger trials using this approach.

Patient Case

Questions 2 and 3 pertain to the following case.

A 59-year-old man with a medical history of cirrhosis complicated by ascites was transferred from the ward to

the medical ICU for gross hematemesis, with an Hgb decrease from 9.2 g/dL to 7.3 g/dL, blood pressure 82/36

mm Hg, and new-onset confusion. After 2 L of lactated Ringer’s solution and 2 units of PRBCs, the patient’s

Hgb increased to 9.1 g/dL, but he remained hypotensive. The medical team placed a PAC and an arterial blood

pressure catheter, which showed the following: CVP 8 mm Hg, PCWP 14 mm Hg, CO 7.4 L/minute, and MAP

58 mm Hg.

After further resuscitation, the patient developed hypoxemia requiring intubation and mechanical ven-

tilation. A post-intubation radiograph revealed diffuse bilateral alveolar opacities. The patient remained

hypoxemic with an Fio2 of 90% and was subsequently deeply sedated and given atracurium. The patient also

remained hypotensive with low urinary output. Which best predicts that the patient will respond favorably

to a fluid bolus?