Sepsis Clinical Trial
— FRESEDICUOfficial title:
Comparison of Non-Invasive Methods of Assessing Fluid Responsiveness in ED and ICU Patients
Verified date | April 2020 |
Source | Olive View-UCLA Education & Research Institute |
Contact | n/a |
Is FDA regulated | No |
Health authority | |
Study type | Observational |
Accurate assessment of fluid responsiveness (FRes) is central to guiding fluid management in
septic and critically ill patients. As evidence accumulates that both inadequate and
excessive fluid resuscitation are associated with increased morbidity and mortality, it is
simultaneously becoming increasingly clear that current widely used methods to predict FRes
are of questionable accuracy. The optimal technique to predict FRes would be a non-invasive
point-of-care test with not only a high degree of accuracy, but also one which requires
minimal training to perform correctly and may be easily performed repeatedly for serial
evaluation of FRes during the ongoing management of the critically ill patient.
To date, three major ultrasonographic modalities have emerged as viable candidates for the
bedside assessment of FRes: 1) measurement of dynamic changes in inferior vena caval diameter
(IVC-CI), 2) measurement of dynamic changes in peripheral arterial waveform derived variables
(PA Doppler), and 3) echocardiographic measurement of dynamic changes in left ventricular
outflow tract waveform derived variables (LVOT Doppler). In this study, the investigators
will perform the first direct comparison of techniques representing all three of the above
modalities in the prediction of FRes against a non-invasive bioreactance cardiac output
monitor (the Cheetah NICOM™), which has been extensively validated against gold-standard
invasive methods of cardiac output measurement. The investigators will compare the accuracy
of these modalities in both spontaneously breathing and mechanically ventilated patients
using passive leg raise testing (PLR) as a surrogate for volume challenge. In addition, the
investigators will also elicit information from the treating physician(s) on their clinical
assessment of FRes.
The investigators will recruit adult patients in the ED and ICU with sepsis, who have
received an initial bolus of 20-30 cc/kg of IV fluid, and can tolerate the PLR and US
procedures. Prior to US and NICOM measurement, investigators will ask the attending physician
managing the patient regarding their assessment of the their fluid status. Then, separate
investigators will perform US and NICOM measurements independently to ensure blinding. NICOM
data, which has been well validated in septic patients, will be shared with the attending
physician. They will then be asked if this new data will change management.
Status | Completed |
Enrollment | 50 |
Est. completion date | December 1, 2019 |
Est. primary completion date | November 1, 2019 |
Accepts healthy volunteers | No |
Gender | All |
Age group | 18 Years to 90 Years |
Eligibility |
Inclusion Criteria: - Subjects presenting to the ED will be screened in accordance with the Olive View Medical Center Sepsis Waiver, and subjects meeting two of the following four criteria will be eligible for inclusion in the study: Temperature >38/100.4 or <36/96.8, heart rate >90, respiratory rate >20 or PaCO2<32, and WBC >12K or <4K or > 10% bands (neutrophils). The clinical team will be contacted regarding patients identified based on this initial screening, and if the patient is determined to have a suspected infection and a fluid bolus is planned, the patient will be enrolled in the study if they meet the following criteria: - Adult between the age of 18 to 90 years old; - Not pregnant; - Not using non-invasive positive pressure ventilation (CPAP or BiPAP); - No history of heart, lung, and/or liver transplant; - Not determined by the clinical team to be acutely unstable requiring immediate intervention at the time of data collection, and; - No contraindications to a passive leg raise test (known or suspected cranio-cerebral or C-spine injury, venous thrombosis, orthopedic injury requiring immobilization or traction, or other contraindications as per clinical team). Exclusion Criteria: - Pregnant; - Using non-invasive positive pressure ventilation (CPAP or BiPAP); - Presence of or suspected elevated intracranial pressure; - Presence of central venous catheters or other medical devices that prevent the use of bedside ultrasound; - History of heart, lung, and/or liver transplant; - History of critical aortic stenosis or severe aortic insufficiency; - Determined by the clinical team to be acutely unstable and requiring immediate intervention at the time of study enrollment or data collection or; - Has a contraindication to passive leg raise maneuver, e.g. known cervical spinal injury, deep venous thrombosis, orthopedic injury requiring immobilization or traction. |
Country | Name | City | State |
---|---|---|---|
United States | Olive View-UCLA | Sylmar | California |
Lead Sponsor | Collaborator |
---|---|
Olive View-UCLA Education & Research Institute | University of California, Los Angeles |
United States,
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Primary | Fluid responsiveness (measured as cardiac output change, velocity time integral change, or maximal velocity change of greater than 10%, with either passive leg raise maneuver or respiratory variability). | FRes is defined as the ability to predict that subjects who receive a small bolus of 250-500 ml of intravenous fluid will have a rise in their cardiac output or stroke volume of greater than 10%. FRes is a unit-less measurement, as it reflects the percent change in either stroke volume, cardiac index/output, IVC diameter, VTI, or Vmax, as a result of either a passive leg raise or the respiratory cycle. The criterion standard for FRes in this study will be assessed with the NICOM machine. Assessments of FRes using ultrasound-based measures (LVOT, carotid, femoral, and IVC) will be compared to the NICOM-determined assessment of FRes. Analysis is directed at how well the ultrasound-based definitions of FRes perform compared to the NICOM-based assessment. | Fluid responsiveness is assessed in a three minute interval using the study gold standard, the NICOM. FRes assessment using ultrasound will be performed during this time. One set of measurements will be obtained upon subject admission to the ED or ICU. |
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