SCCM Pod-516: Bedside Practices in Hemodynamic Management

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While advanced monitoring technology can provide valuable information, the importance of clinical judgment and examination should not be minimized. Host Ludwig H. Lin, MD, is joined by Maurizio Cecconi, MD, to discuss the integration of clinical judgment with technology when assessing hemodynamic instability and shock. They emphasize the importance of fluid challenges tailored to individual patient characteristics, along with standardized approaches. Dr. Cecconi explores the role of big data and artificial intelligence (AI) in treatment refinement and advocates for global access to care. He highlights fluid responsiveness dynamics and the interaction between fluids and vasopressors, urging a cautious approach to fluid administration due to its drug-like effects. 

Dr. Cecconi is an anesthesiologist and intensive care specialist and chair of the Department of Anesthesia and Intensive Care at Humanitas Research Hospital and University in Milan, Italy. This podcast is sponsored by Baxter Healthcare.

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Transcript:

Announcer: This podcast is sponsored by Baxter Healthcare. Baxter’s Starling Fluid Management Monitoring System provides continuous, accurate, noninvasive and personalized hemodynamic monitoring to support individualized fluid management. The Starling system empowers you to make patient-specific fluid management decisions wherever your patient is in the hospital, helping to deliver the right therapy to your patient every time. Visit starling.baxter.com to learn more. This device is prescription-only use. For safe and proper use of the product mentioned herein, please refer to the appropriate operator’s manual or instructions for use.

Dr. Lin: Hello and welcome to the 2024 Congress edition of the Society of Critical Care Medicine Podcast. I’m your host, Dr. Ludwig Lin. Today, I’m joined by Dr. Maurizio Cecconi, MD, to discuss this year’s Max Harry Weil Honorary Lecture on the topic of fluid resuscitation. Professor Cecconi is an anesthesiologist and intensive care specialist and chair of the Department of Anesthesia and Intensive Care at Humanitas Research Hospital and University in Milan, Italy. Dr. Cecconi, welcome and thank you so much for agreeing to do this podcast. Before we start, do you have any disclosures that we should report?

Dr. Cecconi: Hello, Ludwig. Great to be here to talk about this very interesting topic and a passion of my research for many years. The disclosure that I have, I’ve done research in collaboration with a series of hemodynamic monitoring companies. Probably the biggest conflict that I have is that I do believe that, in complex patients, having data on advanced monitoring can provide useful information to treat our patients.

Dr. Lin: Great. There are so many different ways for us to approach a conversation about hemodynamics and monitoring and ways of altering that. So maybe what we can do is, I’ll just ask you about your philosophy in that we have a lot of data that we can get. We have more and more technology that we can use to obtain new types of data. There are things that we all talk about, vasopressors and fluids, to hopefully achieve a particular hemodynamic goal with the outcome of a positive one for our critically ill patients. Maybe what I can do is just get you to share with us your philosophy of how you approach this topic.

Dr. Cecconi: It’s a great question, probably also because if people read my research, they will see that a lot of the research is on advanced monitoring and how to give fluids or how we look at the response to fluids with our patients. But the reality, at the end of the day, I’m a big advocate of clinical judgment and clinical examinations, first of all. You can do a lot with that.

My students and my trainees sometimes make fun of me, saying that I ask them to touch the temperature of the patient or to do a capillary refill time even on mannequins in the simulation center. But that’s something that I really believe is important, always not to forget that the diagnosis of hemodynamic instability, diagnosis of a patient in shock, is not something that you have to do with a monitor or with technology, something that you can really do with your clinical examination. Most of the time, just with your hands, your eyesight, and by really examining the patient you have in front of you.

It does not mean that we don’t need technology. It means that when we have diagnosed that the patient needs some attention and some treatment, and we are talking about fluids today, and fluids are, of course, one of the cornerstones to stabilize a patient with hemodynamic instability or shock. Then there are some situations where you want maybe to use technology to get some extra information because our clinical examination may be blind to what happens to blood flow.

But again, when we have done a therapy, whether it’s a fluid challenge or we started a vasopressor or a combination of both, this technology helps me guide the treatment. But at the end of the day, I always want to go back to the clinical examination and to the assessment of the adequacy of perfusion in my patient, which again, we don’t do with this technology that we use to monitor. But the monitor is very useful to try to give the right amount of fluids without giving too much, without giving too little.

Dr. Lin: I love that. I feel like really, really good critical care medicine is really just being a good intern. You have to really pay attention to all the details and also not to be too proud. I don’t know if you know what I mean, but I think we all have our suspicions of what some patient might have. Going down one road immediately sometimes precludes us from exploring the other possibilities on the differential diagnosis. So you really have to have both. You really have to have the physical exam and then look for data, whether it’s technology or lab data or whatever, to really corroborate and confirm that diagnosis. Do you know what I’m saying?

Dr. Cecconi: I kind of agree with you. In a way, it’s been one of the reasons why with my research groups, first in the UK and now in Italy, we really try to study as much as possible something that seems so simple to say, like a fluid challenge. But, you know, we all have our own biases, we all have our own ways to define what a fluid challenge is or should be, so there is still really a lot of research that we have to do to understand how we can really talk to each other with different colleagues, different clinicians, and try to find maybe a common way to understand how fluids work, and we decide the therapy together at the bedside.

Dr. Lin: Let’s talk about fluid challenges more. When you’re thinking about fluid challenges, are there particular subtypes of patients in shock that you were thinking about, or is that something that’s applicable to all types of shock?

Dr. Cecconi: That’s a great question. To be fair, I think there is still a bit of confusion there. FENICE was one of the largest observational studies. It was Fluid Challenges in Intensive Care, the acronym stands for that. We conducted a study with Daniel De Backer and others with the European Society of Intensive Care Medicine about 10 years ago now. We were finding some very interesting findings there.

For instance, the variability of what people call a fluid challenge is huge. You go from 500 mL, which is the average, and I suspect this is a very pragmatic average just because there are 500-mL bags that are easier to open and to give to patients. Everything was going from 200 mL to a liter. The speed, so the rate of administration, was going from 250 mL an hour to 1 liter per hour or maybe a bit more. I suspect, again, that’s not a lot of thinking there, probably just what is the maximum speed of your pump at the bedside. So, lots of those things prompted us to look at this issue as an opportunity to do research and maybe to do some quality improvement at the bedside.

Back to your question on what is a fluid challenge. A fluid challenge, in my view, should not be confused with fluid administration. It is part of fluid administration. But when you decide to give a fluid challenge, I’m sure we will discuss a bit today about when we can predict whether the patient will respond or not to fluids, but when you have decided that fluid administration could be an option for this patient, I don’t think it matters too much if this patient is in cardiogenic shock or septic shock as long as it is decided that fluids could be an option.

I think, when you want to test that hypothesis, why don’t you take the opportunity to do it in a controlled way? This is what I call a fluid challenge, which probably we can summarize as a definition of a small bolus of fluid that is useful to do therapy but at the same time to inform about the physiologic response and the physiologic status of the patient in response to the fluid that I’m giving.

Dr. Lin: I like it. So, for you, is there a starting volume that you think about?

Dr. Cecconi: Another great question. We have done a series of papers on this. If I can go back for a moment, let’s talk about what are the components of a fluid challenge. I think about the type of fluids that we are giving. For simplicity today, I think we should just focus on crystalloids and not dwell too much on the others, especially because if we give fluids in a short period of time, we can kind of assume that during that short period of time, there is not really a lot of redistribution outside of the intravascular space.

But maybe we can discuss these nuances as well. There is the volume of fluid. The volume of fluid, you can think about a fixed volume, you can think about volume per kilogram of our patients. Then when I give fluids, of course, there is the time in which I’m giving these fluids. To give it in 5 minutes, in 10 minutes, or in 20 minutes, you may be surprised or not, you can find very different answers.

The threshold that defines my response. Who is a patient who is a responder? Is it a patient who increases cardiac output and stroke volume by 10%, by 15%? You understand when we talk to each other, there are so many variables here that actually the same clinical problem can be tackled probably in slightly different ways.

But it’s important to think about these things, and at the bedside, I think particularly within your team, within your ICU, probably you should have a way to try to have a standard approach to this test when you give it to your patient. I’m not sure we have found the perfect recipe yet. Maybe there isn’t a perfect recipe yet. The type of patient, of course, matters. If my patient is very vasodilated, maybe I will need to give a bit more volume to increase the stress volumes according to the Guytonian theories and therefore to increase the mean systemic filling pressures and the gradient for the venous return.

Maybe in a surgical patient with a vascular tone that is intact, we can give a bit less fluids. But again, the overall message is that it does not matter so much if the shock is due to one reason or another, you can still use this technique. The important thing is that, of course, you think about the patient in front of your eyes and that may change a little bit what you do. But I still like to use this approach in the moment that I’ve decided that I want to give fluids to this patient because I’m thinking that fluids may improve the clinical situation of this patient. To test this hypothesis, yes, I usually do it with a small bolus of fluid, and I see what happened to the initial response and whether this response is sustained or not and so on.

Dr. Lin: I see. I think, to summarize what you’re saying is, the idea of a fluid challenge is the most important concept, really, when you’re by the bedside. Think about doing it and then one and one’s team need to reach some consensus about what the definition of the response would be to that fluid challenge, and maybe one can actually tailor the volume involved and the speed involved, depending on the patient’s comorbidities or the disease process that’s happening. Is that about right?

Dr. Cecconi: Yes, and let’s make a practical example with some of my research with some of my groups. I remember when I was in London, we started to look at pharmacokinetics and pharmacodynamics of fluid administration exactly because we saw that there was so much variability in what people were defining as a fluid challenge around the world. We thought, let’s go back to basics. We gave a small bolus. We looked at the total response in terms of increases in cardiac output and we wanted to see when there was the maximum response. Was it immediately after the end of the fluid challenge? Was it a bit later?

We looked at this maximum response and then we followed this for a few minutes to see how long this effect was sustained. When we did that, we basically found out that, for instance, even in surgical patients, who in theory should have kind of a tone that is still intact, responders and nonresponders were separated by the degree of increasing cardiac output. That’s easy to understand. But then both responders and nonresponders in that study, we found that, actually, after 10 minutes, they had completely dissipated the effect of that fluid challenge.

Why is this important? Because I should give fluids, first of all, when I think there is a clinical problem. Can I improve the perfusion of my patient? If I can predict, even before giving fluids, whether this patient will have an increase in cardiac output or not by giving these fluids, probably I should use these techniques. Whether this is pulse pressure variation, stroke volume variation, there are many of those.

Nevertheless, there comes a moment where you, with all the information that you have for our patient, with the seriousness of the situation at the time, whether I’m treating this patient in A&E or two days later in intensive care, that also changes a bit. When I have all this information and I decide, yes, I think fluids could be an option here to improve the situation, then yes, I think, with my team, I like to have a kind of a standard approach on how I give this fluid. Because we are taking care of patients 24/7, a patient now may be different at 10:00 at night, and actually exchanging this information between teams is very important.

It’s also very important that you find a way in which you trust the test, both when it’s positive but also when it’s negative. If you don’t trust the test, if you don’t trust the test that your colleague has made, you run the risk then to bring your conscious or unconscious bias. You were talking about being proud before. So we run the risk maybe to just follow our initial idea without being informed by the physiologic response of what we see in front of our eyes.

Dr. Lin: Right. Let’s talk about that. I think it’s nice when talking with colleagues to have a common language, and I think in medicine, that common language winds up being about data. Are there ways of using monitors or using data to gauge the responsiveness, and, if yes, what are the ones that you like?

Dr. Cecconi: Yes, there are ways, and I think we have a lot of technology and monitors at the bedside and not necessarily do we always need to have very advanced monitors. A standard blood pressure monitor and heart rate monitor in a patient who responds to fluids is already giving us a lot of information. I think the important thing is to realize that when you’re doing a test like this, exactly because you’re testing the system, you need to put yourself almost into an experimental condition.

In this moment, I like my patient to be calm and not to have any maneuvers, no aspirations, no changes in bed positioning. Everything needs to stay as still as possible. I give my fluids and when I give my fluids, I want to see how the heart rate is changing, how the blood pressure is changing. If I see that the heart rate comes down and blood pressure goes up, I don’t need a fancy cardiac output monitor to tell me that the patient responded to fluids with an increase in cardiac output. I’m seeing the proxy of that with the increase in blood pressure, with the decrease in heart rate.

The problem we have is when, despite giving our fluids and our therapies, because these concepts apply to many things that we do in intensive care, we don’t see any response. And when we don’t see any response with basic monitoring, if my patient is not improving clinically, as I was telling you before, I always like to go back every time I do a treatment to do a quick examination of my patient.

In that situation, if the patient is not improving, maybe it’s getting worse, and the standard monitors that I have are not informing me, they’re not showing me a response, then there are two possibilities for this lack of response. One, that there is really no response and therefore fluids are not indicated, or one, simply that I’m not seeing the response with an increase of blood flow because the changes in blood pressure, or the lack of changes in blood pressure actually, are masking this effect.

That goes back to clinical judgment. If my patient is sick and is not improving, and I don’t see any changes in the vitals, maybe in that situation, yes, that’s where I want to very quickly put an echo probe if I’ve not done it yet, look at cardiac function, make an assessment. I like to also combine technology. I’m not someone who would say you should always use echo or you should always use a cardiac output monitor. I think we’re moving away from that. We need to have a more holistic approach to more variables to try to get as much information as possible, especially in very sick patients in which variable time is a very important variable. We want to get this information in this moment because to have this extra information then can inform us whether to proceed with fluids or actually do something else.

Dr. Lin: This is a personally driven question, I guess, because when I was a medical student, I worked on this one variable. It was gastric intramucosal pH, and I feel like, throughout the history of medicine, there’s been these hopes that there is some holy grail, you know, a variable that would tell us if somebody is adequately perfusing or not. Do you have such?

Dr. Cecconi: That’s a great example because actually gastric tonometry was probably one of the most promising technologies at some point, even with some very positive data, you know, from little trials and improvement in outcomes. But we abandoned it because it was not feasible to use it practically at the bedside.

One other very important thing is that we need to look at the variability on how we give fluids but also to find technology that is feasible to use. If something is very interesting and maybe very useful, but impossible to bring to the bedside because of how cumbersome it is and because it’s impossible to make sure that 24/7 someone is able to use it, maybe it’s not the right technology.

But I like your example very much because using technology to inform us about what happens in terms of response to fluids in cardiac output is one thing, but the most important thing is going back again to the clinical examination. When I mention clinical examination, I actually mention the adequacy of perfusion. Again, a clinical examination is one part of it, but it’s not enough, especially in very sick patients.

In very sick patients, I still like to measure a venous blood gas if I have a central line, and I like to see how the central venous saturation is. We had a trial that showed that if you’re using multicenter randomized approaches, it didn’t show an improvement in mortality. Those studies, they don’t remove the physiologic signs, in my opinion, that if a patient has a low Scvo2, which is very rare now, well, that’s very useful information to have in that patient. You shouldn’t throw that information away if you have it.

So, to use adjuncts to our clinical examinations that are informing us about the adequacy of perfusion, I think is very, very important. And I do think that we’re living in an era that would be a revolution in how we practice medicine. AI was a kind of science fiction 10 years ago, up to 5 years ago. But now we start to see more and more the availability in many settings to predict what’s happening, maybe to bring more variables together. One of my hopes is that actually we will do exactly that. How can we look at the response, not just in terms of cardiac output response, but look at all the changes that we see, look at how the perfusion is changing, maybe in real time, in a short period of time, and trying to put all these things together to understand when to start and when to stop.

Dr. Lin: Interesting. I want to follow up on that because I feel like you’ve touched on the two ends of the forefront of critical care, which is, on the one hand, using big data and using rigorous studies to guide our efforts. But on the other, it’s about that one patient, and sometimes it’s that very rare esoteric patient who might fall outside what a clinical trial shows we should do for most people, because that one patient is not most people. So, how do you think we could use AI and big data to help that one rare patient?

Dr. Cecconi: That’s another great question, and in a way, in your question, we already have the answer, in the sense that there are huge limitations in going just for physiology because physiology may miss the picture of the important outcomes at the end of the ICU stay or of hospital survival and so on. But at the same time, trials in intensive care are very difficult to do. We mix very heterogeneous patients together for a treatment that then is the same and then very often we don’t find anything.

About 8 to 9 times out of 10, our studies are negative. I like to do both trials and physiologic studies, but I like to do both because I think they are informing us about a new way to do research. Everyone talks now about phenotypes, and now we can stratify better probably within the group of patients, those patients who maybe would benefit from this approach and others who would not benefit from this approach.

When I refer to this with these developments, I like to say it is when big data meets big trials, so probably we still need big numbers. I still think we need to randomize, but rather than randomizing very heterogeneous populations, probably what we will do is stratify very similar groups of patients in terms of possible responses to our treatment. This is an example from hemodynamics in our chat today, but this can apply to anything in medicine and in critical care.

When big data meets big trials, we will have smaller trials for a very homogeneous group of patients here where probably we can test our hypotheses still with randomization, which I think is important to correct even for factors that maybe you’re not seeing or you don’t measure, and then we will really progress. The pandemic has shown us that we can do big studies together. Of course, that was an advantage, if we may say, of having a single disease, but we have to find this approach in which we put a lot of data together, in which we randomize patients, but we find that specific phenotype in which my hypothesis really makes sense.

If I mix patients who are so different, I’m diluting maybe an effect and maybe I will then prevent in the future a therapy, which maybe was very useful for this group of patients and maybe causing harm in another one.

Dr. Lin: Right. I like that. It’s like one size does not fit all, but we could find maybe multiple patterns that could explain the 3 or 4 different subtypes, and that would be very useful.

Dr. Cecconi: Yeah. I think it’s an exciting time for research and for our clinical practice and our specialty. I think we have to watch this space because I’m sure that the speed of changing how we do research is changing very fast.

Dr. Lin: Let me try to go on a tangent here and ask you a little bit about the future of this, because I know that you yourself are very aware and advocating for the sustainability of critical care as a science. Some of this is expensive. Some of this is the purview of very developed and financially able countries. How do we provide care to the rest of the globe where, for example, personalized medicine is not possible, and really strive for equity? How do you feel about that?

Dr. Cecconi: I feel that it’s very important that, especially us, that we have the privilege to work in places and some of us even have positions in scientific societies where we can advocate for some of these changes and for equity. I really think it’s important that we do that, first of all, and we advocate for this. The fact that we cannot do something in lower-middle-income country settings does not mean that we should not carry on progressing our knowledge with more advanced technology in our setting.

At the same time, a lot of these topics, about fluids, for instance, they really apply with basic monitoring. I do think that, in the majority of patients, you don’t need an advanced monitor. You just need this approach that we discussed before, clinical examination, and that you can do everywhere, trying to give fluids and, again, informing if this has caused an improvement or a deterioration in the clinical situation of our patient. That you can do in many places.

For that, probably the most important technology is education and sharing knowledge and I think bringing and exchanging knowledge with our colleagues who are maybe working in other parts of the world. But if we look at history, technology has always evolved and helped us to be better as a society and to stay better, to have better outcomes. I don’t think it’s far away, the moment where maybe we will have applications on our mobile phones that we can have also in lower-middle-income countries and maybe offer a way through a mobile phone to get some of the advanced data that in the past you were getting only with invasive monitors and so on.

Everything is really changing very fast. But I agree with you, we should advocate for the progress also to proceed in less privileged parts of the world. Recent history has shown that we’ve not been very good with that. If you look at the pandemic and COVID and vaccinations, I don’t think that was good enough, what we’ve seen there. In this moment, I think we have the responsibility to bring some of the progress to help our colleagues in more difficult settings to do research, to get the knowledge and, again, to get patients better there also.

Dr. Lin: I really like your point that a lot of the goals in hemodynamic manipulation are actually just in the physiology. It’s not about the technology. The technology could be very simple. And we do need to remember that, and that education, that knowledge is power, that empowering all of us with the ability to analyze these complex situations, that’s really what’s going to help. I think that’s a really good concept.

Dr. Cecconi: I like to think there’s a way but I know that I’m biased because I absolutely love physiology. But I think if you come and work in intensive care, you must love physiology.

Dr. Lin: Exactly.

Dr. Cecconi: And I think that, in the near future, we will need more technology because we will have fewer healthcare workers compared with the proportion of patients who will require intensive care. So technology is going to help us. We need the technology. But the understanding of physiology and the understanding of the mechanism is something that we need to keep, we need to preserve, and we need to make sure that the younger generation does not lose this drive to understand this physiology and then to use technology to be informed about it and to better treat our patients.

Dr. Lin: Great. I have a random question for you. Well, it’s not that random. It doesn’t really follow this train of thought but, fluid responsiveness, is that characteristic of a patient? Do you see that as a predictor of survival or is it a treatable parameter that alters somebody’s outcome?

Dr. Cecconi: I would challenge the concept that is a characteristic of that patient, I would say it’s a characteristic of the physiology of the patient in the specific moment. You and I, we can be fluid responsive now, nonresponsive in 15 minutes, and vice versa. This is normal that it’s going to change. That’s why we need to look at physiologic changes within the same patient when we talk about these concepts.

But when we discuss, I think, and study fluid responsiveness, which, if we want to give a definition so far is the response in terms of an increase in cardiac output or stroke volume when I give fluids to a patient. I think maybe we have made it a little bit oversimplistic in the sense, to me, the response to fluids cannot be looked at just in terms of response in cardiac output. The response to me is if my patient gets better. So we need to start to bring more nuances to this concept, I think. And for that, again, we probably need to review a little bit what we’re doing.

Of course, at the end of the day, we need to look at the literature that we have, and the literature that we have is still very much focusing on this response to a cardiac output increase of 10% to 15%. But as we were discussing just a few minutes ago, there are so many different ways in which I can give fluids. For instance, in one of the studies that we did, we randomized patients to receive from 1, 2, 3, or 4 milliliters per kilogram, same baseline characteristics. We kept the infusion time at 10 minutes.

What we found, probably not surprising, was that if you randomized patients to just 1 milliliter per kilogram, only a small proportion of the patients had an increase in cardiac output. The ones who had 4 milliliters per kilogram had a much higher proportion. But if you think about it, you would have got very different responses to the same clinical question for that patient.

That’s why I think we still have some research to do really to try to understand how to test the response in one patient in that specific moment. Also, if I may, sometimes we confuse fluid responsiveness with the prediction of fluid responsiveness. Fluid responsiveness is my response to fluids. The prediction of fluid responsiveness is the concept in which I can predict if there will be an increase in cardiac output even before giving fluids. Again, we have many tests now, and we should use these tests because, if I think that my patient may improve with an increase in cardiac output thanks to fluids, and if I can predict before giving these fluids whether this is going to occur or not, I may spare unnecessary fluids to my patients.

So, this is important, but today I don’t think we have time to talk about all of this. There are so many other things that we don’t consider normally when we talk about this. We focus sometimes too much on 200 mL given in this moment when maybe we are giving 100 mL an hour as a background infusion to these patients. Of course, that is also building up as positive fluid balance at the end of the day. Again, all this variability is a huge opportunity for improvement and for research. I would be happy to work with many groups to try to find more answers to all these questions.

Dr. Lin: Oh, that is such a good point that we really have to be conscious of every single detail. I like that. There is so much more to talk about in terms of this, Maurizio, and I really wish we could spend more time, but we do need to wrap up the podcast. So let me ask you if there was anything that we didn’t cover that you really wanted to make sure that the audience will take away from this conversation?

Dr. Cecconi: No, I think we talked about a lot of points. Maybe just one point that we didn’t touch on is the concept that you can test the response to fluid or you can get the response in volume even without giving volume from the outside. Let me just be very specific and clear about this. The interaction between fluids and vasopressors, I think is another very important topic.

I come from the generation where I was told that if a patient is hypotensive or in shock, first you give fluids, maybe a liter, maybe 30 milliliters per kilogram, and then you start the vasopressor if there has been no response there. I don’t think that’s very physiologic. I think if you are very vasodilated and therefore you have the redistribution of fluids from the stressed volume in the unstressed volume, we can give fluids in that situation. But probably it’s a physiologic approach also to try to restore some vascular tone and to recruit some unstressed volume into the stressed volume.

So I think a combination of vasopressors and fluids is something that, to gain time, something that probably we should consider now more and more in our practice. But I have to say that, speaking with colleagues and seeing data, this is becoming more and more practice on this.

Then just some very pragmatic messages maybe is that, remember that fluids are drugs. We are not used to thinking about this sometimes in intensive care. Everyone gets a drip with some fluids. Everyone gets at least a face mask. But both fluids and oxygen are drugs. As with any drugs, I think there are some positive effects you’re seeking, but there are also some side effects. So always think, does my patient have a problem? First of all, is there a problem with the perfusion of this patient? Do I think that increasing cardiac output will improve the perfusion? Do I think that fluids may be useful to increase the cardiac output?

When I answer these 3 questions, then probably I can start to go then to, can I predict if my patient will respond to fluids or not? Then if I decide to give fluids again, try to do it in a controlled way. Try to do it with a small bolus of fluids. You can repeat this. So a small bolus of fluids, 4 meters per kilogram. In 10 minutes, most of the time, this is sufficient to see a response or not. Look at the initial response, but also look if the response is sustained or not. If this is immediately dissipated, is that because you are thinking of some capillary leak? Or is it just because we are distributing these fluids?

Again, as I just said just a few minutes ago, consider the combination of fluids and vasopressors together. Also that, no matter what technology we are going to use to be informed more about what’s happening or what can happen to our patient is clinical judgement, is the clinical examination with the adjunct of probably blood gases to see adequacy of perfusion. That’s what leads the way in therapy and in our diagnosis and in our treatment.

Dr. Lin: That is a perfect way to summarize what we just talked about. Thank you. That was beautiful. I really enjoyed this conversation. I think it’s very thought provoking and hopefully the audience will feel the same. Thank you, Dr. Cecconi, for taking the time. I really appreciate it. This is going to conclude another episode of the Society of Critical Care Medicine Podcast series. Please do like and subscribe on your favorite podcast platform. This is Dr. Ludwig Lin. Thank you.

Announcer: This podcast is sponsored by Baxter Healthcare. Baxter’s Starling Fluid Management Monitoring System provides continuous, accurate, noninvasive and personalized hemodynamic monitoring to support individualized fluid management. The Starling system empowers you to make patient-specific fluid management decisions wherever your patient is in the hospital, helping to deliver the right therapy to your patient every time. Visit starling.baxter.com to learn more. This device is prescription-only use. For safe and proper use of the product mentioned herein, please refer to the appropriate operator’s manual or instructions for use.

Ludwig H. Lin, MD, is an intensivist and anesthesiologist at Sutter Hospitals in northern California and a consulting professor at Stanford University School of Medicine, where he teaches a seminar on the psychosocial and economic ramifications of critical illness.

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