A decade of progress in critical care echocardiography: a narrative review

Increased right ventricle (RV) afterload during acute respiratory distress syndrome (ARDS) may induce acute cor pulmonale (ACP).

Background Fluid challenges (FCs) are one of the most commonly used therapies in critically ill patients and represent the cornerstone of hemodynamic management in intensive care units. There are clear benefits and harms from fluid therapy. Limited data on the indication, type, amount and rate of an FC in critically ill patients exist in the literature. The primary aim was to evaluate how physicians conduct FCs in terms of type, volume, and rate of given fluid; the secondary aim was to evaluate variables used to trigger an FC and to compare the proportion of patients receiving further fluid administration based on the response to the FC. Methods This was an observational study conducted in ICUs around the world. Each participating unit entered a maximum of 20 patients with one FC. Results 2213 patients were enrolled and analyzed in the study. The median [interquartile range] amount of fluid given during an FC was 500 ml (500–1000). The median time was 24 min (40–60 min), and the median rate of FC was 1000 [500–1333] ml/h. The main indication for FC was hypotension in 1211 (59 %, CI 57–61 %). In 43 % (CI 41–45 %) of the cases no hemodynamic variable was used. Static markers of preload were used in 785 of 2213 cases (36 %, CI 34–37 %). Dynamic indices of preload responsiveness were used in 483 of 2213 cases (22 %, CI 20–24 %). No safety variable for the FC was used in 72 % (CI 70–74 %) of the cases. There was no statistically significant difference in the proportion of patients who received further fluids after the FC between those with a positive, with an uncertain or with a negatively judged response. Conclusions The current practice and evaluation of FC in critically ill patients are highly variable. Prediction of fluid responsiveness is not used routinely, safety limits are rarely used, and information from previous failed FCs is not always taken into account. Electronic supplementary material The online version of this article (doi:10.1007/s00134-015-3850-x) contains supplementary material, which is available to authorized users.

To define competence in critical care ultrasonography (CCUS). The statement is sponsored by the Critical Care NetWork of the American College of Chest Physicians (ACCP) in partnership with La Société de Réanimation de Langue Française (SRLF). The ACCP and the SRLF selected a panel of experts to review the field of CCUS and to develop a consensus statement on competence in CCUS. CCUS may be divided into general CCUS (thoracic, abdominal, and vascular), and echocardiography (basic and advanced). For each component part, the panel defined the specific skills that the intensivist should have to be competent in that aspect of CCUS. In defining a reasonable minimum standard for CCUS, the statement serves as a guide for the intensivist to follow in achieving proficiency in the field.