Ultrasound and NICOM in the assessment of fluid responsiveness in patients with mild sepsis in the emergency department: a pilot study

OBJECTIVE We investigated whether combining the caval index, assessment of the global contractility of the heart and measurement of stroke volume with Noninvasive Cardiac Output Monitoring (NICOM) can aid in fluid management in the emergency department (ED) in patients with sepsis. SETTING A prospective observational single-centre pilot study in a tertiary care centre. PRIMARY AND SECONDARY OUTCOMES Ultrasound was used to assess the caval index, heart contractility and presence of B-lines in the lungs. Cardiac output and stroke volume were monitored with NICOM. Primary outcome was increase in stroke volume after a fluid bolus of 500 mL, while secondary outcome included signs of fluid overload. RESULTS We included 37 patients with sepsis who received fluid resuscitation of at least 500 mL saline. The population was divided into patients with a high (>36.5%, n=24) and a low caval index (<36.5%, n=13). We observed a significant increase (p=0.022) in stroke volume after 1000 mL fluid in the high caval index group in contrast to the low caval index group but not after 500 mL of fluid. We did not find a significant association between global contractility of the left ventricle and the response on fluid therapy (p=0.086). No patient showed signs of fluid overload. CONCLUSIONS Our small pilot study suggests that at least 1000 mL saline is needed to induce a significant response in stroke volume in patients with sepsis and a high caval index. This amount seems to be safe, not leading to the development of fluid overload. Therefore, combining ultrasound and NICOM is feasible and may be valuable tools in the treatment of patients with sepsis in the ED. A larger trial is needed to confirm these results.