Based on this fascinating trial and the outstanding work done by Antoine Vieillard Baron’s group, I (along with support from Pierre Kory of critcaresono.com fame) came up with the below flowsheet to guide integration of ultrasound findings in septic shock patients.
The biggest wrinkle of course is how to manage volume in patients who are triggering the vent and show features of IVC collapse. We know that all the studies to date proving volume responsiveness with mechanically ventilated patients has been done with those passive on the ventilator. It has been our experience, however, that if the IVC itself is flat (<1.5cm in a vented patient) then this is a reliable feature of volume responsiveness. More conservatively, we can say that these patients will be volume tolerant (to use Scott Weingart’s terminology). Further work needs to be done with this and certainly integrating the LV function in these patients as well as their aeration pattern on lung ultrasound (A diffuse A profile would suggest tolerance, as well – as encouraged by Lichtenstein in his FALLS protocol).
Download the pdf of the above support tool here.