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Purpose Echocardiography is a common tool for cardiac and hemodynamic assessments in critical care research. However, interpretation (and applications) of results and between-study comparisons are often difficult due to the lack of certain important details in the studies. PRICES (Preferred Reporting Items for Critical care Echocardiography Studies) is a project endorsed by the European Society of Intensive Care Medicine and conducted by the Echocardiography Working Group, aiming at producing recommendations for standardized reporting of critical care echocardiography (CCE) research studies. Methods The PRICE panel identified lists of clinical and echocardiographic parameters (the “items”) deemed important in four main areas of CCE research: left ventricular systolic and diastolic functions, right ventricular function and fluid management. Each item was graded using a critical index (CI) that combined the relative importance of each item and the fraction of studies that did not report it, also taking experts’ opinion into account. Results A list of items in each area that deemed essential for the proper interpretation and application of research results is recommended. Additional items which aid interpretation were also proposed. Conclusion The PRICES recommendations reported in this document, as a checklist, represent an international consensus of experts as to which parameters and information should be included in the design of echocardiography research studies. PRICES recommendations provide guidance to scientists in the field of CCE with the objective of providing a recommended framework for reporting of CCE methodology and results.

Objectives: Septic shock, defined as sepsis with hypotension not responding to fluid resuscitation or requiring vasopressor support, results in the worst outcomes in sepsis patients. This subtype of the patient is often difficult to detect. The shock index (SI) has demonstrated the potential for predicting hemodynamic compromise and collapse and predicting patient outcomes in multiple medical and surgical settings. In our study, we assessed the utility of the SI as a hemodynamic screening tool to identify patients likely to fail to respond to fluids and ultimately to be diagnosed with septic shock. Methodology: A single-center cross-sectional analysis of patients presenting with hypotension and septicemia over 1 year. The study was conducted using the electronic medical records of the emergency department patients presenting to King Saud University Medical City. The charts were reviewed from 2 May 2015 to 24 April 2016 using the local medical registry. The study was approved by the hospital institutional review board (IRB). Data extraction was performed using a standardized form. Results: The area under the curve was 0.77 (P < 0.001) for the prediction of hemodynamic collapse. An initial SI ≥0.875 had a sensitivity of 81% and a specificity of 72% for the identification of patients in whom fluid resuscitation would fail. Conclusions: Based on our findings, we found that the SI was a reliable screening tool for the identification of hypotensive patients with sepsis who would ultimately be diagnosed with septic shock.

Fluid challenge is a common diagnostic method to help the physician detennine fluid responsiveness, which is an important component of fluid management in critically ill patients）H Raising legs of a patient induces the transfer of a variable amount of blood （approximately 200-300 ml） contained in the venous reservoir from the limb to central venous compartment. According to Franck-Starling curve, this transient increase of preload might lead to an increase in cardiac output （CO） in thture responders resulting from their preload-reserve status. Many clinical studies have validated passive leg raising （PLR）, and the advantage of PLR is attractive in Intensive Care Unit （ICU）. Recently, PER has been suggested as a simple and potential method to predict fluid responsiveness, which is similar to an ＂auto-fluid challenge＂ without a drop of fluid. However, one study revealed poor application of PLR in the real world, We acknowledged that the lack of education on PLR would result in the current practice. On the other hand, the application of PLR might be not simple in clinical practice, and the holy grail of fluid responsiveness still needs to be discovered. The standard of PLR has not been established, and some questions of PLR merit discussion.

Background and Aims: Pulse pressure variation (ΔPP) is considered as one of the best predictors of fluid responsiveness in patients under mechanical ventilation. Pleth Variability Index (PVI) has been proposed as a noninvasive alternative. However, pneumoperitoneum has been recently suggested as a limitation to their interpretation. The aim of this study was to compare changes in ΔPP and PVI related to autotransfusion associated with a Trendelenburg maneuver before and during pneumoperitoneum. Methods: 50 patients undergoing elective abdominal laparoscopic surgery were enrolled in this prospective observational study. All patients were equipped with an invasive radial artery catheter and a PVI probe. After obtaining a stable signal with both ΔPP and PVI, baseline values were recorded, before and after head-down tilts of 10°, with or without abdominal insufflation (10-12 mmHg). All measurements were made before any fluid challenge under standardized anaesthesia, while patients were paralyzed and mechanically ventilated with 8 mL/kg tidal volume. Results: Changes in ΔPP and PVI associated with the Trendelenburg maneuver before and after insufflation of the pneumoperitoneum were significantly different (P < 0.001). In baseline conditions, the Trendelenburg maneuver was associated with a significant decrease in heart rate while mean arterial pressure remained unchanged. Both ΔPP and PVI decreased. After insufflation of the pneumoperitoneum, the Trendelenburg maneuver was associated with a significant decrease in heart rate and ΔPP and an increase in mean arterial pressure while PVI remained unchanged. Conclusion: Pneumoperitoneum did not alter the response of ΔPP to autotransfusion associated with the Trendelenburg maneuver, which was not the case for the PVI. This latter decreased during Trendelenburg maneuver performed alone and remained unchanged during Trendelenburg maneuver performed after insufflation of the pneumoperitoneum.

Background: Passive leg raising (PLR) represents a \"self-volume expansion (VE)\" that could predict fluid responsiveness, but the influence of systolic cardiac function on PLR has seldom been reported. This study aimed to investigate whether systolic cardiac function, estimated by the global ejection fraction (GEF) from transpulmonary-thermodilution, could influence the diagnostic value of PLR. Methods: This prospective, observational study was carried out in the surgical Intensive Care Unit of the First Affiliated Hospital of Sun Yat-sen University from December 2013 to July 2015. Seventy-eight mechanically ventilated patients considered for VE were prospectively included and divided into a low-GEF (<20%) and a near-normal-GEF (≥20%) group. Within each group, baseline hemodynamics, after PLR and after VE (250 ml 5% albumin over 30 min), were recorded. PLR-induced hemodynamic changes (PLR-Δ) were calculated. Fluid responders were defined by a 15% increase of stroke volume (SV) after VE. Results: Twenty-five out of 38 patients were responders in the GEF <20% group, compared to 26 out of 40 patients in the GEF ≥20% group. The thresholds of PLR-ΔSV and PLR-Δ cardiac output (PLR-ΔCO) for predicting fluid responsiveness were higher in the GEF ≥20% group than in the GEF <20% group (ΔSV: 12% vs. 8%; ΔCO: 7% vs. 6%), with increased sensitivity (ΔSV: 92% vs. 92%; ΔCO: 81% vs. 80%) and specificity (ΔSV: 86% vs. 70%; ΔCO: 86% vs. 77%), respectively. PLR-Δ heart rate could predict fluid responsiveness in the GEF ≥20% group with a threshold value of −5% (sensitivity 65%, specificity 93%) but could not in the GEF <20% group. The pressure index changes were poor predictors. Conclusions: In the critically ill patients on mechanical ventilation, the diagnostic value of PLR for predicting fluid responsiveness depends on cardiac systolic function. Thus, cardiac systolic function must be considered when using PLR. Trial Registration: Chinese Clinical Trial Register, ChiCTR-OCH-13004027; http://www.chictr.org.cn/showproj.aspx?proj=5540.

Abstract Introduction Fluid challenges are widely adopted in critically ill patients to reverse haemodynamic instability. We reviewed the literature to appraise fluid challenge characteristics in intensive care unit (ICU) patients receiving haemodynamic monitoring and considered two decades: 2000–2010 and 2011–2021. Methods We assessed research studies and collected data regarding study setting, patient population, fluid challenge characteristics, and monitoring. MEDLINE, Embase, and Cochrane search engines were used. A fluid challenge was defined as an infusion of a definite quantity of fluid (expressed as a volume in mL or ml/kg) in a fixed time (expressed in minutes), whose outcome was defined as a change in predefined haemodynamic variables above a predetermined threshold. Results We included 124 studies, 32 (25.8%) published in 2000–2010 and 92 (74.2%) in 2011–2021, overall enrolling 6,086 patients, who presented sepsis/septic shock in 50.6% of cases. The fluid challenge usually consisted of 500 mL (76.6%) of crystalloids (56.6%) infused with a rate of 25 mL/min. Fluid responsiveness was usually defined by a cardiac output/index (CO/CI) increase ≥ 15% (70.9%). The infusion time was quicker (15 min vs 30 min), and crystalloids were more frequent in the 2011–2021 compared to the 2000–2010 period. Conclusions In the literature, fluid challenges are usually performed by infusing 500 mL of crystalloids bolus in less than 20 min. A positive fluid challenge response, reported in 52% of ICU patients, is generally defined by a CO/CI increase ≥ 15%. Compared to the 2000–2010 decade, in 2011–2021 the infusion time of the fluid challenge was shorter, and crystalloids were more frequently used.

Fluid resuscitation is a core component of emergency and critical care medicine. While the focus of clinicians has largely been on detecting patients who would respond to fluid therapy, relatively little work has been done on assessing patients' tolerance to this therapy. In this article we seek to review the concept of fluid tolerance, propose a working definition, and introduce relevant clinical signals by which physicians can assess fluid tolerance, hopefully becoming a starting point for further research.

Background Current recommendations support guiding fluid resuscitation through the assessment of fluid responsiveness. Recently, the concept of fluid tolerance and the prevention of venous congestion (VC) have emerged as relevant aspects to be considered to avoid potentially deleterious side effects of fluid resuscitation. However, there is paucity of data on the relationship of fluid responsiveness and VC. This study aims to compare the prevalence of venous congestion in fluid responsive and fluid unresponsive critically ill patients after intensive care (ICU) admission. Methods Multicenter, prospective cross-sectional observational study conducted in three medical–surgical ICUs in Chile. Consecutive mechanically ventilated patients that required vasopressors and admitted < 24 h to ICU were included between November 2022 and June 2023. Patients were assessed simultaneously for fluid responsiveness and VC at a single timepoint. Fluid responsiveness status, VC signals such as central venous pressure, estimation of left ventricular filling pressures, lung, and abdominal ultrasound congestion indexes and relevant clinical data were collected. Results Ninety patients were included. Median age was 63 [45–71] years old, and median SOFA score was 9 [7–11]. Thirty-eight percent of the patients were fluid responsive (FR+), while 62% were fluid unresponsive (FR−). The most prevalent diagnosis was sepsis (41%) followed by respiratory failure (22%). The prevalence of at least one VC signal was not significantly different between FR+ and FR− groups (53% vs. 57%, p  = 0.69), as well as the proportion of patients with 2 or 3 VC signals (15% vs. 21%, p  = 0.4). We found no association between fluid balance, CRT status, or diagnostic group and the presence of VC signals. Conclusions Venous congestion signals were prevalent in both fluid responsive and unresponsive critically ill patients. The presence of venous congestion was not associated with fluid balance or diagnostic group. Further studies should assess the clinical relevance of these results and their potential impact on resuscitation and monitoring practices.

The central venous pressure (CVP) is the most frequently used variable to guide fluid resuscitation in critically ill patients, although its use has been challenged. In this viewpoint, we use a question and answer format to highlight the potential advantages and limitations of using CVP measurements to guide fluid resuscitation.

Background Fluid boluses are administered to septic shock patients with the purpose of increasing cardiac output as a means to restore tissue perfusion. Unfortunately, fluid therapy has a narrow therapeutic index, and therefore, several approaches to increase safety have been proposed. Fluid responsiveness (FR) assessment might predict which patients will effectively increase cardiac output after a fluid bolus (FR+), thus preventing potentially harmful fluid administration in non-fluid responsive (FR−) patients. However, there are scarce data on the impact of assessing FR on major outcomes. The recent ANDROMEDA-SHOCK trial included systematic per-protocol assessment of FR. We performed a post hoc analysis of the study dataset with the aim of exploring the relationship between FR status at baseline, attainment of specific targets, and clinically relevant outcomes. Methods ANDROMEDA-SHOCK compared the effect of peripheral perfusion- vs. lactate-targeted resuscitation on 28-day mortality. FR was assessed before each fluid bolus and periodically thereafter. FR+ and FR− subgroups, independent of the original randomization, were compared for fluid administration, achievement of resuscitation targets, vasoactive agents use, and major outcomes such as organ dysfunction and support, length of stay, and 28-day mortality. Results FR could be determined in 348 patients at baseline. Two hundred and forty-two patients (70%) were categorized as fluid responders. Both groups achieved comparable successful resuscitation targets, although non-fluid responders received less resuscitation fluids (0 [0–500] vs. 1500 [1000–2500] mL; p 0.0001), exhibited less positive fluid balances, but received more vasopressor testing. No difference in clinically relevant outcomes between FR+ and FR− patients was found, including 24-h SOFA score (9 [5–12] vs. 8 [5–11], p  = 0.4), need for MV (78% vs. 72%, p  = 0.16), need for RRT (18% vs. 21%, p  = 0.7), ICU-LOS (6 [3–11] vs. 6 [3–16] days, p  = 0.2), and 28-day mortality (40% vs. 36%, p  = 0.5). Only thirteen patients remained fluid responsive along the intervention period. Conclusions Systematic assessment allowed determination of fluid responsiveness status in more than 80% of patients with early septic shock. Fluid boluses could be stopped in non-fluid responsive patients without any negative impact on clinical relevant outcomes. Our results suggest that fluid resuscitation might be safely guided by FR assessment in septic shock patients. Trial registration ClinicalTrials.gov identifier, NCT03078712 . Registered retrospectively on March 13, 2017.