Kita adalah Klinisi, bukan Sekedar Penghobi Ultrasonografi: Keterbatasan Ultrasonografi Point-Of-Care Jantung dalam Memandu Resusitasi Cairan

Abstract

Pemeriksaan penunjang ultrasonografi point-of-care (POCUS) jantung sangat berguna dalam memandu resusitasi pasien kritis dengan penyakit penyerta jantung. Namun, POCUS jantung memiliki keterbatasan dan harus tetap dipandu pemeriksaan fisis klinis. Seorang perempuan berusia 84 tahun, mendapatkan perawatan di ruang intensif atas indikasi hemodinamik tidak stabil pascaperdarahan akut gastrointestinal bawah. Pasien tampak somnolen, takipnea, hipotensi disertai distensi vena jugularis. Pemeriksaan laboratorium hanya menunjukkan tanda anemia akut, sedangkan pada rontgen toraks didapatkan kardiomegali dan pacu jantung-tanam. Pasien ditemukan di bangsal dalam kondisi hipotensi dan diberikan bolus cairan. Evaluasi pascabolus cairan, pasien menunjukkan tanda hemodinamik stabil yang transien akibat perdarahan yang terus menerus. Dengan kecurigaan awal bahwa terdapat gangguan fungsi jantung maka ekokardiografi digunakan untuk memandu resusitasi cairan. Pada pemeriksaan tidak didapatkan variasi left ventricular outflow tract velocity time integral (VTi) disertai regurgitasi aorta (AR) moderat dan parameter lain yang membatasi fungsi ultrasonografi POCUS jantung dalam memandu uji responsivitas cairan. Penulis akhirnya melakukan resusitasi cairan dengan panduan pemeriksaan klinis secara berulang semata disertai pemeriksaan ultrasonografi inferior vena cava (IVC). Pasien berhasil diresusitasi dengan bolus cairan intravena dalam jumlah besar tanpa komplikasi sekunder. Penilaian klinis tetap diperlukan terutama pada kondisi patologis tertentu yang membatasi utilisasi POCUS jantung.

We are Clinicians, not Ultrasound Geeks: when Cardiac Point-of-Care Ultrasonography Meets its Limitation in Guiding Fluid Resuscitation

Cardiac point-of-care ultrasonography (POCUS) has shown its superiority in guiding resuscitation of compromised critically ill patients. Despite its emerging usage, cardiac POCUS has limitations that should involve physical examination during its interpretation. An 84-year-old woman was admitted to the intensive care unit with hemodynamic instability following acute lower gastrointestinal bleeding. The patient appeared somnolent with physical examination revealed tachypnea, hypotension, and jugular venous distention. Laboratory data underlined no other than acute anemia. Chest radiography revealed cardiomegaly and implanted pacemaker. The patient was found hypotensive in her ward and treated with fluid bolus. In clinical reevaluation, the patient showed transient hemodynamic stability, for she underwent persistent lower gastrointestinal bleeding. Due to suspected compromised cardiac function, a cautious fluid resuscitation guided by echocardiography was commenced revealing no visible variation of the left ventricular outflow tract (LVOT) velocity-time integral (VTi), moderate aortic regurgitation (AR), and other parameters that might limit cardiac POCUS utility to assist fluid responsiveness test. We decided to administer fluid based on a regular reassessment of clinical hemodynamic parameters combined with inferior vena cava (IVC) ultrasound, Finally, the patient survived and did not suffer any complication following a large intravenous volume bolus. Intensivists' clinical assessment is paramount, especially in particular pathological conditions that limit cardiac POCUS utilization.