When a patient arrives in our emergency department with persistent hypotension, our team needs to quickly answer one question: will IV fluids help this patient, or will they cause harm?
That question doesn’t wait for an ICU admission or a specialist consult. It gets answered in the first hour with whatever information is available to us at that moment.
For most of my career, we have answered that question using vital signs, lactate, physical exam, and clinical judgment. It’s not wrong. It’s the data available to us, and our decisions are often correct. But in certain situations, my management has amounted to little more than a guess as to how the patient will respond to IV fluids, a medical version of Schrödinger’s cat. If only I could look inside the box and know.
As the prevalence of heart failure has increased, due in part to our ability to treat heart disease and prolong these patients’ lives, judging how they will respond to IV fluids amidst the ravaging inflammatory effects of sepsis has become more difficult. I can specifically recall an edematous, elderly nursing home patient with fever, hypotension, and unknown heart function. I gave her IV fluids, caused respiratory failure, and had to intubate her. What if I had access to a technology that would have told me, minutes after her arrival, that she immediately needed vasopressors because IV fluids would cause harm? It might have prevented the resulting complications of mechanical ventilation and her prolonged recovery.
Sepsis gets the most attention in conversations about fluid management, but the problem I’m describing is broader. Patients with cardiac dysfunction and renal impairment complicated by undifferentiated shock come through my department every day, and these are patients where IV fluids, either too much or too little, can cause serious harm. Studies suggest only about half of septic patients remain fluid responsive after initial resuscitation. Having that knowledge sooner can be the difference between helping and harming, a balance that Hippocrates thought I should mind carefully.
Doppler-based hemodynamic assessments help us identify the correct treatments for these patients, but this technology has historically been anchored to ICU settings due to its complexity. It required trained providers and bulky equipment, and the results depended on the skill of the operator. Such a process is least practical when repeat measurements are required to guide ongoing treatment. For these reasons, the technology was never broadly adopted in the emergency department, and our first-hour fluid decisions were guided by incomplete information.
Fortunately, wireless, wearable Doppler ultrasound has changed that. Critical to its adoption in the ED is the fact that its use is entirely nurse-driven, with no operator variability between measurements. Our ED team simply decides that real-time hemodynamic data is necessary for a patient, the device is attached, and the data is generated. A single number helps me decide how to proceed with fluid management. No ultrasound cart required. No consult needed.
This data, “carotid flow time,” an ultrasound measurement of the time spent pumping blood during systole, is now recognized by CMS as valid documentation for SEP-1 fluid reassessment, which is part of every hospital’s required SEP-1 compliance metrics and documentation. For EDs already performing these assessments, the compliance and regulatory infrastructure is catching up to clinical practice. It’s worth every ED considering how these systems fit into their patient care.
At my hospital, we started using a wireless, wearable Doppler device in the emergency department. We did not limit it to a sepsis protocol. We use it for any patient where IV fluid responsiveness is genuinely uncertain and suboptimal treatment carries meaningful risk. The device adheres to the neck and produces an assessment in under three minutes. It stays attached for easy subsequent measurements.
The cases that have stayed with me are not the dramatic ones; they are the quiet course corrections. Consider the persistently hypotensive, altered patients who arrive by EMS from distant skilled nursing facilities and boarding homes without any clinical history or paperwork . (The same black hole that ate my homework as a kid now also consumes SNF paperwork.) Without real-time data, a clinician might reasonably reach for vasopressors. A bedside assessment can quickly show that the patient is fluid responsive. Their hemodynamics improve and an ICU admission or transfer is avoided.
Conversely, I evaluated a patient with end-stage renal disease, severe sepsis, and hypotension whose last dialysis date was unknown. This is a patient where one liter too many precipitates respiratory failure. An initial assessment showed the patient was not fluid responsive, and vasopressors were immediately started. The patient was admitted to the ICU without the need for ongoing fluid boluses and reassessments to determine medical floor versus ICU suitability. The patient arrived in the proper inpatient setting while freeing an ED bed for a waiting room patient. The speed of this assessment benefited the entire department, including patients whose ED care hadn’t yet begun.
Given the availability of these technologies, hospital and health system leaders should be asking whether their clinicians would benefit from this real-time data and how it would affect patient outcomes and ED throughput.
Earlier assessment does not replace what happens in the ICU. But for patients where fluid management is genuinely uncertain, making the correct clinical decision in the emergency department can redirect the entire arc of their admission and, most importantly, their medical outcome.
John Skovran, DO, is the Emergency Department Medical Director at Alta Bates Summit Medical Center, part of Sutter Health in the San Francisco Bay Area. His department uses FloPatch, a wireless, wearable Doppler ultrasound cleared by the FDA, as part of its approach to early hemodynamic assessment.
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