Thread by @POCUSClub

Patient in Janus Jeneral Hospital with neutropenic septic shock. 3ml/hr of single strength noradrenaline - MAP 65, FiO2 30%, Lactate 7. CVP 5. UO 50ml/hr. CTPA negative for PE. AP4C on arrival. #vexus #echo #shock #FOAMed @GUH_ICU_Anaesth @IrishEMtrainees @ICSIreland

Has already had 3L of crystalloid pre admit to crit care.

RVSP = TR Max PG (18.4) + CVP (5) = 23mmHg

Overnight, lacto-bolo reflex sets in & gets 'maintenance' plus multiple boli of IV crystalloid b/c of high lactate.

In the am, increasing shocked state. On norad 20ml/hr SS, vasopressin max, adrenaline 5ml/hr to maintain MAP > 60.

RV & RA acutely dilated on focused US.

Oliguric now. FiO2 requirements now 60%. +5L balance in 24 hours. CVP now 18. Lactate now 12.

RVSP = TR Max (28.8) + CVP (18) = 46.8mmHg

Renal vein doppler shows only diastolic flow in renal vein.

Increasing CVP/Venous pressure beyond physiologic norms has the same effect as clamping of the renal vein thereby decreasing perfusion across the glomerular vasculature = no urine output #vexus

Patient is commenced on stat 80mg furosemide with a furosemide infusion at 20mg/hr with the effect of -3L total balance in 5 hours.

Shocked state improves, now only on single agent norad 5 hours later.

Repeat renal vein doppler now shows some flow albeit not normal.

1) Patients with undifferentiated shock need a focused assessment with US to diagnose the cause of shock

2) Beware & resist the lacto bolo, creato-bolo reflex.

3) If lactate climbs during your volume resus think again

4) Sometimes a lasix infusion IS the resus fluid of choice