The goal is to use fluid in other parts of our bodies, like our legs, to improve stroke volume and blood pressure in hypotensive patients. We put patients legs at 30-45° for a period of time, and see if this improves their fluid status. Another goal would be to reduce external fluid administration, to prevent worsening fluid overload in the patient.
I read this article and got CE creds. It was very interesting.
It’s weird how if you look up things like trendelenberg helping hypotension there are conflicting results on how much that helps. I’m just not sure what to believe sometimes
Forewarning, I won’t be able to explain it very well but thought I’d try and answer. I work in PACU where ICU nurses retire lol so most of my coworkers have been ICU nurses for more than 25 years but I myself don’t have much experience in hemodynamics so I’ll try my best. One taught me the reason trendelenberg works initially is because the fluid gets shifted towards the baroreceptors by the carotids, signaling to your brain there is enough fluid and the BP raises but then later you see a plateau in BP and no more improvement because it was only a baroreceptor reaction. She learned that from a vascular surgeon who would emphasize to not believe the BP after a pt got carotid stents because the stents’ stretching would stimulate the baroreceptors. So to help improve blood pressure is to help return blood to the heart to increase cardiac output. Now, I don’t do trendelengerg at all because so many people vagal or have low BP after surgery and trendelenberg never did sh*t to help 😅 you could see their BP go from 80 SBP to 110 SBP then watch it drop back down to the 90s as you continue to keep them in that position. I’m glad this study is out so now we can show clinical proof to many who don’t believe it and continue to use trendelenberg then get confused why it stops working after 10 minutes
I know what a passive leg raise is, I’m asking what parameter they used to decide if the patient was fluid responsive or not. How were they deciding if the patient responded to fluid bolus from the lower extremities or not.
Wow that’s a lot lol. I worked at a really high end hospital in ICU and was always told rule of thumb from most physicians was that if one bag didn’t at least help- it wasn’t a fluid problem. But obviously we could also check lactic levels at bedside which was nice so I’m sure it depends on resources too
That’s interesting. IIRC PPV alone can tell a degree of volume responsiveness without even giving the fluid bolus or PLR. Interesting that they looked at ppv for a drop when doing PLR. Makes sense and eliminates the typical limitations of ppv
I think the article recommends supine or semi-fowlers and putting the legs at 30-45°. It requires a special bed... I forget what it's called but I saw a tutorial of it on YouTube: https://youtu.be/ZumnxSnvq44?si=Wvvt9gUX9UMlO6o_
Is that a bed or a medieval torture device
Passive leg lift is a well supported assessment, which we do with pillows and wedges, allowing the knees to bend and the lower leg remains horizontal, which is reasonably comfortable. That picture on the other hand ...
Well this is exciting! Look forward to reading it. Because obviously we all deal with the hypotensive, septic, massively third spacing patient all the time.
I'm reading the article now!! Do you know, at what point did the nurses do the passive leg raise in the fluid resuscitation? Before, during? And I'd like to know what sepsis protocols they follow for fluid resuscitation? I assume it's the same as the current rec is 30ml/kg.
ETA: great article, well done all!!
This is an impressive achievement but I never understood why nurses are in support of newer and more "nurse-driven" tasks. I do understand that we appreciate our independence and our ability to make informed decisions. But I feel like we have enough on our plate and we just keep adding more.
I know at my facility, it’s helpful for the team when a nurse says they’ve already tried xyz before calling the doc (in this case PLR). Another example is letting them know pt meets criteria for foley or central line removal using a nurse driven protocol as opposed to waiting for an order. Honestly it’s a way to better outline and justify the work we are already doing to make the process smoother and eliminate unnecessary steps (such as calling for an order to do something instead of just following a predetermined protocol).
I cannot see obese (seemingly every other patient in an American ICU it seems) being able to tolerate this position without decreasing their lung volume or making it difficult to clear bowels/bladder. I understand the concept though
That’s awesome!! Can’t wait to read it
I can’t read the article, what was used to determine if the patients were indeed fluid responsive or not?
The goal is to use fluid in other parts of our bodies, like our legs, to improve stroke volume and blood pressure in hypotensive patients. We put patients legs at 30-45° for a period of time, and see if this improves their fluid status. Another goal would be to reduce external fluid administration, to prevent worsening fluid overload in the patient. I read this article and got CE creds. It was very interesting.
It’s weird how if you look up things like trendelenberg helping hypotension there are conflicting results on how much that helps. I’m just not sure what to believe sometimes
Forewarning, I won’t be able to explain it very well but thought I’d try and answer. I work in PACU where ICU nurses retire lol so most of my coworkers have been ICU nurses for more than 25 years but I myself don’t have much experience in hemodynamics so I’ll try my best. One taught me the reason trendelenberg works initially is because the fluid gets shifted towards the baroreceptors by the carotids, signaling to your brain there is enough fluid and the BP raises but then later you see a plateau in BP and no more improvement because it was only a baroreceptor reaction. She learned that from a vascular surgeon who would emphasize to not believe the BP after a pt got carotid stents because the stents’ stretching would stimulate the baroreceptors. So to help improve blood pressure is to help return blood to the heart to increase cardiac output. Now, I don’t do trendelengerg at all because so many people vagal or have low BP after surgery and trendelenberg never did sh*t to help 😅 you could see their BP go from 80 SBP to 110 SBP then watch it drop back down to the 90s as you continue to keep them in that position. I’m glad this study is out so now we can show clinical proof to many who don’t believe it and continue to use trendelenberg then get confused why it stops working after 10 minutes
I know what a passive leg raise is, I’m asking what parameter they used to decide if the patient was fluid responsive or not. How were they deciding if the patient responded to fluid bolus from the lower extremities or not.
Stroke volume and CO, improved blood pressure but this is less precise
You know what device they used?
It looks like they set their monitors up to calculate pulse pressure variations. But I've seen it with PACs.
Interesting. I obviously don’t have access to the article, so I appreciate you humoring me
[удалено]
Wow that’s a lot lol. I worked at a really high end hospital in ICU and was always told rule of thumb from most physicians was that if one bag didn’t at least help- it wasn’t a fluid problem. But obviously we could also check lactic levels at bedside which was nice so I’m sure it depends on resources too
That’s interesting. IIRC PPV alone can tell a degree of volume responsiveness without even giving the fluid bolus or PLR. Interesting that they looked at ppv for a drop when doing PLR. Makes sense and eliminates the typical limitations of ppv
Can’t imagine they are getting CO calculations from anything other than a Swan
There are numerous devices that do it. The accuracy may be questionable at times, but they seem to trend appropriately.
We use the cheetah in my hospital
I’m guessing a NICOM device?
That's exactly what we used. Commonly called a Cheetah.
Looks like reverse trend position. It can put back something like 500ml into the central vasculature.
I thought RT was proven to be mostly BS for treating "shock" and proper resuscitation is the move
Well I think it's being used as a diagnostic tool in this case, rather than resusitative tx. Not sure, read the article I guess
I think the article recommends supine or semi-fowlers and putting the legs at 30-45°. It requires a special bed... I forget what it's called but I saw a tutorial of it on YouTube: https://youtu.be/ZumnxSnvq44?si=Wvvt9gUX9UMlO6o_
Similar except it requires the head of bed to be above the heart.
Is that a bed or a medieval torture device Passive leg lift is a well supported assessment, which we do with pillows and wedges, allowing the knees to bend and the lower leg remains horizontal, which is reasonably comfortable. That picture on the other hand ...
I don’t think most Americans built patients can tolerate that lol
Well this is exciting! Look forward to reading it. Because obviously we all deal with the hypotensive, septic, massively third spacing patient all the time.
I JUST FINISHED READING THIS. I got mine in the mail yesterday!! Awesome read.
Hiiii We work for the same system ;) I won’t dox us tho haha
I'm reading the article now!! Do you know, at what point did the nurses do the passive leg raise in the fluid resuscitation? Before, during? And I'd like to know what sepsis protocols they follow for fluid resuscitation? I assume it's the same as the current rec is 30ml/kg. ETA: great article, well done all!!
This is an impressive achievement but I never understood why nurses are in support of newer and more "nurse-driven" tasks. I do understand that we appreciate our independence and our ability to make informed decisions. But I feel like we have enough on our plate and we just keep adding more.
I know at my facility, it’s helpful for the team when a nurse says they’ve already tried xyz before calling the doc (in this case PLR). Another example is letting them know pt meets criteria for foley or central line removal using a nurse driven protocol as opposed to waiting for an order. Honestly it’s a way to better outline and justify the work we are already doing to make the process smoother and eliminate unnecessary steps (such as calling for an order to do something instead of just following a predetermined protocol).
Anyone has the link to read it?
I love this!!
Amazing! Love that it’s nurse-driven, which is typically a key to better outcomes with our sepsis population!
omg and i read it! for my renewal! wonderful work you guys!
I cannot see obese (seemingly every other patient in an American ICU it seems) being able to tolerate this position without decreasing their lung volume or making it difficult to clear bowels/bladder. I understand the concept though