Easy method to determine fluid responsiveness in septic shock patients: end-tidal CO2 - a prospective observational study.

BACKGROUND: In critically ill patients, especially those with septic shock, fluid management can be a challenging aspect of clinical care. One of the primary steps in treating patients with hemodynamic instability is optimizing intravascular volume. The Passive Leg Raising (PLR) maneuver is a reliable test for assessing fluid responsiveness, as demonstrated by numerous studies and meta-analyses. However, its use requires the measurement of cardiac output, which is often complex and may necessitate clinician experience and specialized equipment. End-Tidal Carbon Dioxide (ETCO2) measurement is relatively easy and is generally stable under steady metabolic conditions. It depends on the body's CO2 production, diffusion of CO2 from the lungs into the bloodstream, and cardiac output. If the other two parameters (metabolic conditions and minute ventilation) are constant, ETCO2 can provide information about cardiac output. The aim of the present study is to investigate the sensitivity of ETCO2 measurement in demonstrating fluid responsiveness. METHODS: All patients diagnosed with septic shock and meeting the inclusion criteria were subjected to a passive leg raising test, and cardiac outputs were measured by echocardiography. An increase in cardiac output of 15% or more was considered indicative of the fluid responder group, while patients with an increase below 15% or no increase were classified as the non-responder group. Patients' intensive care unit admission diagnoses, initial laboratory parameters, tidal volume, minute volume before and after the PLR maneuver, mean and systolic blood pressure, heart rate, Pulse Pressure Variation (PPV) values, and ETCO2 values were recorded. RESULTS: Before and after the ETCO2 test, there was no statistically significant difference between the two groups. However, the change in ETCO2 (ΔETCO2) was significantly higher in the responder group. In the non-responder group, ΔETCO2 was 2.57% (0.81), whereas it was 5.71% (2.83) in the responder group (p<0.001). Receiver Operating Characteristic (ROC) analysis was performed for ΔETCO2, baseline Stroke Volume Variation (SVV), ΔSVV, baseline Heart Rate (HR), ΔHR, baseline PPV, and ΔPPV to predict fluid responsiveness. ΔETCO2 predicted fluid responsiveness with a sensitivity of 85% and a specificity of 86% when it was 4% or higher. When ΔETCO2 was 5% or higher, it predicted fluid responsiveness with a specificity of 99.3% and a sensitivity of 75.5%, with an Area Under the Curve (AUC) of 0.89 (95% confidence interval, 0.828-0.961). CONCLUSION: This study demonstrates that in septic patients, ETCO2 during the PLR test can indicate fluid responsiveness with high sensitivity and specificity and can be used as an alternative to cardiac output measurement.

Effectiveness of Using a Gelatine-Based Model in Ultrasonography-guided Jugular Central venous Catheter Placement Training: A Randomised Clinical Trial.

OBJECTIVE: To evaluate the effectiveness of using a gelatine-based model, that can be prepared easily and at a low cost, compared to training without a model in ultrasonography (USG) guided internal jugular venous catheter placement training. STUDY DESIGN: An open-label, randomised clinical trial. PLACE AND DURATION OF STUDY: (UHS) Izmir Bozyaka Training and Research Hospital, Izmir, Turkey, from 1st to 30th July 2019. METHODOLOGY: Analysis was conducted with the data of 48 participants (resident physicians-RP). Group 1 (n: 26) received imaging training with USG on a human subject and then performed needle insertion training on the gelatine-based jugular vein model with the USG guidance. Group 2 (n: 22) received the same imaging training with USG but did not perform needle insertion training. Evaluation of the participants included successful long axis vein imaging time, successful in-plane needle imaging, number of changes in needle angles, the total number of punctures, successful vein puncture time, successful catheterization time, and catheterization success with the gelatine-based test manikin. RESULTS: Comparison of the rates of successful in-plane needle imaging (Group 1: 92.3%, Group 2: 59.1%; p = 0.006), catheterization success (Group 1: 92.3%, Group 2: 59.1%; p = 0.006), successful catheterisation time (Group 1: 77.5 sec, Group 2: 152.5 sec; p = 0.026), and total complications (Group 1: 3.8%, Group 2: 31.8%; p = 0.010) demonstrated that the model-trained RPs were significantly more successful. CONCLUSION: The study results suggest that the use of a gelatine-based model in USG-guided central jugular vein catheterisation training can be an effective method to reduce complications. KEY WORDS: Central venous catheter, Medical training, Simulation-based training, Ultrasonography.