Plurad David S, Chiu William, Raja Ali S, Galvagno Samuel M, Khan Uzer, Kim Dennis Y, Tisherman Samuel A, Ward Jeremy, Hamill Mark E, Bennett Vicki, Williams Brian, Robinson Bryce
From the Department of Surgery (D.S.P., D.Y.K.), Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California; Department of Surgery (W.C., S.A.T.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Emergency Medicine (A.S.R.), Harvard School of Medicine, Boston, Massachusetts; Department of Anesthesiology (S.M.G.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (U.K.), West Virginia University School of Medicine, Morgantown, West Virginia; Department of Surgery (J.W.), Baylor College of Medicine, Houston, Texas; Department of Surgery (M.A.H.), Carilion Clinic, Roanoke, Virginia; Banner Health (V.B.), Phoenix, Arizona; Department of Surgery (B.W.), University of Texas Southwestern, Dallas, Texas; and Department of Surgery (B.R.), University of Washington, Seattle, Washington.
J Trauma Acute Care Surg. 2018 Jan;84(1):37-49. doi: 10.1097/TA.0000000000001719.
Fluid administration in critically ill surgical patients must be closely monitored to avoid complications. Resuscitation guided by invasive methods are not consistently associated with improved outcomes. As such, there has been increased use of focused ultrasound and Arterial Pulse Waveform Analysis (APWA) to monitor and aid resuscitation. An assessment of these methods using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework is presented.
A subsection of the Surgical Critical Care Task Force of the Practice Management Guideline Committee of EAST conducted two systematic reviews to address the use of focused ultrasound and APWA in surgical patients being evaluated for shock. Six population, intervention, comparator, and outcome (PICO) questions were generated. Critical outcomes were prediction of fluid responsiveness, reductions in organ failures or complications and mortality. Forest plots were generated for summary data and GRADE methodology was used to assess for quality of the evidence. Reviews are registered in PROSPERO, the International Prospective Register of Systematic Reviews (42015032402 and 42015032530).
Twelve focused ultrasound studies and 20 APWA investigations met inclusion criteria. The appropriateness of focused ultrasound or APWA-based protocols to predict fluid responsiveness varied widely by study groups. Results were mixed in the one focused ultrasound study and 9 APWA studies addressing reductions in organ failures or complications. There was no mortality advantage of either modality versus standard care. Quality of the evidence was considered very low to low across all PICO questions.
Focused ultrasound and APWA compare favorably to standard methods of evaluation but only in specific clinical settings. Therefore, conditional recommendations are made for the use of these modalities in surgical patients being evaluated for shock.
Systematic Review, level II.
