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Introduction: The objective of this study was to describe the implementation and outcomes of a protocol outlining angiotensin-II utilization for vasoplegia following cardiac surgery. Methods: This was a retrospective chart review at a single-center university hospital. Included patients received angiotensin-II for vasoplegia refractory to standard interventions, including norepinephrine 20 mcg/min and vasopressin 0.04 units/min, following cardiac surgery between April 2021 and April 2022. Results: 30 patients received angiotensin-II for refractory vasoplegia. Adjunctive agents at angiotensin-II initiation included corticosteroids (26 patients; 87%), epinephrine (26 patients; 87%), dobutamine (17 patients; 57%), dopamine (9 patients; 30%), milrinone (2 patients; 7%), and hydroxocobalamin (4 patients; 13%). At 3 hours, the median mean arterial pressure increased from baseline (70 vs 61.5 mmHg, p =.0006). Median norepinephrine doses at angiotensin-II initiation, 1 hour, 3 hours, and angiotensin-II discontinuation were 0.22, 0.16 (p =.0023), 0.10 (p <.0001), and 0.07 (p <.0001) mcg/kg/min. Median dobutamine doses decreased throughout angiotensin-II infusion from eight to six mcg/kg/min (p =.0313). Other vasoactive medication doses were unchanged. Three patients (10%) subsequently received hydroxocobalamin. Thirteen (43.3%) and five (16.7%) patients experienced mortality by day 28 and venous or arterial thrombosis events, respectively. Conclusions: The administration of angiotensin-II to vasoplegic patients following cardiac surgery was associated with increased mean arterial pressure, reduced norepinephrine dosages, and reduced dobutamine dosages. [ABSTRACT FROM AUTHOR]

Acute circulatory shock is a life-threatening emergency requiring an efficient and timely management plan, which varies according to shock etiology and pathophysiology. Specific guidelines have been developed for each type of shock; however, there is a need for a clear timeline to promptly implement initial life-saving interventions during the early phase of shock recognition and management. A simple, easily memorable bundle of interventions could facilitate standardized management with clear targets and specified timeline. The authors propose the "MINUTES" acronym which summarizes essential interventions which should be performed within the first 30 min following shock recognition. All the interventions in the MINUTES bundle are suitable for any patient with undifferentiated shock. In addition to the acronym, we suggest a timeline for each step, balancing the feasibility and urgency of each intervention. The MINUTES acronym includes seven sequential steps which should be performed in the first 30 min following shock recognition: Maintain "ABCs", INfuse vasopressors and/or fluids (to support hemodynamic/perfusion) and INvestigate with simple blood tests, Ultrasound to detect the type of shock, Treat the underlying Etiology, and Stabilize organ perfusion. [ABSTRACT FROM AUTHOR]

The use of custom-made foot orthoses has been associated with numerous benefits, such as decreased impact accelerations. However, it is not known whether this effect could be due to better customisation. The present study analysed the effects of the first generation of a microwavable prefabricated self-customised foot orthosis vs. a prefabricated standard one on impact accelerations throughout a prolonged run. Thirty runners performed two tests of 30-min running on a treadmill, each one with an orthosis condition. Impact acceleration variables of tibia and head were recorded every 5 min. Microwavable self-customised foot orthosis increased the following variables in the first instants compared to the prefabricated standard one: tibial peak (min1: 6.5 (1.8) vs. 6.0 (1.7) g, P =.009, min5: 6.6 (1.7) vs. 6.2 (1.7) g, P =.035), tibial magnitude (min1: 8.3 (2.6) vs. 7.7 (2.4) g, P =.030, min5: 8.5 (2.6) vs. 7.9 (2.5) g, P =.026) and shock attenuation (min1: 61.4 (16.8) vs. 56.3 (16.3)%, P =.014, min5: 62.0 (15.5) vs. 57.2 (15.3)%, P =.040), and tibial rate throughout the entire run (504.3 (229.7) vs. 422.7 (212.9) g/s, P =.006). However, it was more stable throughout 30-min running (P <.05). These results show that the shape customisation entailed by the thermoformable material does not provide impact acceleration improvements. [ABSTRACT FROM AUTHOR]

The renin-angiotensin system (RAS) constitutes one of the principal mechanisms to maintain hemodynamic and fluid homeostasis. However, most research until now on RAS primarily focuses on its relationship with hypertension and its role in critically ill hypotensive populations is not well understood. With the approval of angiotensin II (Ang II) in the United States and Europe, following a phase 3 randomized controlled trial showing efficacy in catecholamine-resistant vasodilatory shock, there is growing interest in RAS in critically ill patients. Among the fundamental components of RAS, renin acts as the initial stimulus for the entire system. In the context of hypotension, its release increases in response to low blood pressure sensed by renal baroreceptors and attenuated negative Ang II feedback loop. Thus, elevated renin could reflect disease severity and predict poor outcomes. Studies investigating this hypothesis have validated the prognostic accuracy of renin in various critically ill populations, with several reports indicating its superiority to lactate for mortality prediction. Accordingly, renin reduction has been used to assess the effectiveness of Ang II administration. Furthermore, renin holds potential to identify patients who might benefit from Ang II treatment, potentially paving the way for personalized vasopressor management. Despite these promising data, most available evidence is derived from retrospective analysis and necessitates prospective confirmation. The absence of a rapid, point-of-care and reliable renin assay presents another hurdle to its integration into routine clinical practice. This narrative review aims to describe the current understanding and future directions of renin as a biomarker during resuscitation of critically ill patients. [ABSTRACT FROM AUTHOR]

Background: The hemodynamic profile in multisystem inflammatory syndrome in children (MIS-C) has not been well described. Therefore, we conducted the study utilizing electrocardiometry (EC) to assess the hemodynamic characteristics in MIS-C patients presenting with shock. Subjects and Methods: This pilot prospective observational study was conducted in the pediatric intensive care unit of a tertiary care hospital. Children between 2 months and 18 years meeting the WHO criteria for MIS-C presenting with shock during second COVID-19 pandemic were included in the study. All patients underwent measurement of hemodynamic profile with EC for the initial 48 h of enrollment. Based on EC assessment at enrolment, the systemic vascular resistance index (SVRi) of 1000–1600 dyn s/ cm5 /m² was regarded as normal. The hemodynamic categorization was defined as vasodilatory shock in EC (VDEC) (SVRi <1000 dyn s/[cm5 /m² ]) and vasoconstrictive shock in EC (VCEC) (SVRi > 1600 dyn s/[cm5 /m² ]). Results: Thirty-one children met the WHO case definition of MIS-C during the study period. Sixteen children with shock were enrolled and studied. Clinically, 7 (43.75%) children had cold shock, whereas 9 (56.25%) had warm shock. The measured baseline (mean [standard deviation]) hemodynamic variables were cardiac index (CI) of 6 ± 1.41 L/min/m², stroke volume variation of 23% ±9.6%, SVRi of 954.75 ± 263.35 dyn s/(cm5 /m² ), and thoracic fluid content of 51.18 ± 17.26 ml. VDEC was the predominant manifestation (87.5%) based on EC. Conclusions: Vasodilatory shock was the predominant phenotype observed in critically ill children with MIS-C with shock by EC assessment. [ABSTRACT FROM AUTHOR]

In Wilkie Collins's 1872 novel Poor Miss Finch, epilepsy is represented as an event which brings modifying effects through the kind of writing developed in Collins's earlier, more 'canonical' sensation fictions. Drawing on ideas explored in the medical literature of his day, especially the works of Edward Sieveking, Charles Radcliffe, and Russell Reynolds, Collins portrays epileptic disorder as a shock which establishes a new plot trajectory and allows for an examination of the apparent intersections between biology, identity, and different models of (biological) determinism. The argyria experienced by Oscar Dubourg in response to chemical treatment for epileptic seizures and the theft of his identity by his identical twin brother Nugent both literalise a perceived loss of character believed to be an effect of epilepsy. But in Oscar the neurological condition also allows for modifications in the development of new, heroic, and sympathetic depths of character. The theories of neurological compensation developed by John Hughlings Jackson inspired Poor Miss Finch to demonstrate how the calamitous and the sensational (embodied here in epileptic seizures) play a fundamental role in real life and that our constitutions have evolved to respond creatively and dynamically to such events. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to offer further evidence of the utility of metabolic monitoring in early recognition of sepsis. Metabolic derangement in sepsis is of increasing interest. Sepsis was redefined as a dysregulated host response to infection, and studies have since emerged advising that disrupted metabolic pathways in sepsis may interfere with the host's ability to convert oxygen to useable energy. Indirect calorimetry (IC) is a metabolic monitoring technology that measures oxygen consumption (V02) and resting energy expenditure (REE). IC offers clinically important, specific information in terms of patient's metabolic state and has been shown to differentiate patients with sepsis from those without. Additionally, IC is more specific than predictive equations used as the established standard for clinical nutrition. Research Methods and Procedures: Data for this retrospective descriptive study were obtained from chart review of records of critically ill patients who received metabolic monitoring while under the care of the nutrition support team. Data were retrieved from January through March of 2020. The cases included were from January 2018 through January 2020. Variables included key demographics, sepsis diagnosis and specific metabolic variables of cellular respiration and energy expenditure. Results: For this all‐male sample (N = 56), mean age was 56 years (±17.5). Significant differences were noted in V02 between the two groups of cases (sepsis and non‐sepsis); (p =.026, Cohen's d = 0.618); and REE (p =.032, Cohen's d = 0.607). A strong association was found between V02 and sepsis (Eta 0.981). REE as measured by IC was statistically more specific than predictive equation (p <.001, Cohen's d = 0.527). Conclusions: VO2 and REE were significantly altered in subjects with sepsis in this study, demonstrating that IC may be a useful tool in identifying sepsis. This study was based on an earlier pilot which yielded similar results. Indirect calorimetry can be easily performed clinically, offering specific metabolic information that can be helpful in the determination of a diagnosis of sepsis. Patient or Public Contribution: No patient or public contribution to this manuscript. The study design, analysis of retrospective data, and manuscript preparation were completed entirely by the authors. Implications for Clinicians: Sepsis remains one of the number one killers of hospitalized patients globallyCurrent means of identifying sepsis remain overly sensitive and under‐specific, making recognition of sepsis challenging for Emergency CliniciansMetabolic monitoring can be done easily in the clinical setting by nurses and respiratory therapists.Metabolic monitoring has the capability of offering further information specific to the identification of sepsis, and to further understanding of the altered metabolic phenotype of patients with sepsis [ABSTRACT FROM AUTHOR]

Shock is the clinical manifestation of acute circulatory failure, which results in inadequate utilization of cellular oxygen. It is a common condition with high mortality rates in intensive care units. The intravenous administration of Shenfu Injection (SFI) may attenuate inflammation, regulate hemodynamics and oxygen metabolism; inhibit ischemia-reperfusion responses; and have adaptogenic and antiapoptotic effects. In this review, we have discussed the clinical applications and antishock pharmacological effects of SFI. Further in-depth and large-scale multicenter clinical studies are warranted to determine the therapeutic effects of SFI on shock. [ABSTRACT FROM AUTHOR]

Idiopathic capillary leak syndrome, also known as Clarkson's Disease, is a rare cause of hypovolemic shock that physicians should be aware of. It is characterized by a state of hypovolemia with features of widespread fluid third spacing and poses diagnostic and therapeutic challenges. Here, we present a challenging case of a 36-year-old woman who experienced recurrent episodes of widespread edema and hypovolemic shock symptoms suggestive of capillary leak syndrome. The resuscitative and therapeutic measures employed in managing this disease are described in this case report. [ABSTRACT FROM AUTHOR]

Objectives To explore the hypothesis that beta 1 adrenergic receptor blockage might be protective through attenuation of destructive sympathetic activity and catecholaminergic inflammatory effects in severe sepsis patients. Design Prospective, randomized, controlled study. Settings Critical care department in Alexandria main university hospital. Patients and methods The study was conducted on 50 adult patients who were admitted to the Department of Critical Care Medicine in the Alexandria Main University Hospital who fulfilled the criteria for severe sepsis according to The American College Of Chest Physicians, patients were randomly assigned into two groups, group I: Included 25 patients receiving Bisoprolol 2.5 to 10 mg enterally for a target heart rate 80–90 beat/minute within the first 24 h according to the effect on hemodynamic stabilization and group II: Included 25 patients, as a control group, who received routine management of severe sepsis. Both groups were followed up and compared regarding the primary end points (discharge from the intensive care unit after recovery, septic shock or death) and the secondary end points (length of ICU stay, days of mechanical ventilation and need for inotropes). Results The heart rate at the end of the study was significantly lower in survived patients in group I with mean value of 80.06+9.05 beats/minute compared to mean value of 102.22+7.58 beats/minute in the died patients in the same group (P=0.003). The mean arterial blood pressure (mmHg) in studied patients, was not significantly different between the two groups on admission (P=0.099) and on the 1st day (P=0.172) the significant differences started to appear on the 2nd day (P=0.003), and over the whole period of observation till the end point of the study as the mean value of 83.31+16.90 in group I compared to mean value of 72.0+16.07 in group II (P=<0.021), regarding the comparison between the survived and died patients in group I, on admission there was no statistically significant difference between them (p 0.213) while by the end point of the study, there was a statistically significant difference being higher in survived patients with mean value of 95.38+3.38 compared to mean value of 61.44+2.70 in died patients (P<0.001). Regarding the occurrence of septic shock, it was less in group I as 40% compared to 72% in group II (P=0.023), group I had longer ICU stay (5.0 to 24.0 days) compared to group II (7.0 to 20.0 days), with a statistically significant difference (P=0.029). The duration of mechanical ventilation days (P=0.001), as longer in group II compared group I (group I= 8.37±3.43 days, group II=12.0±3.21 days). The mortality was lower in group I about 36% compared to 68% in group II with a statistically significant difference between the two groups (P= 0.024). Conclusion The administration of bisoprolol to patients with severe sepsis decrease the mortality, length of stay in ICU, days of mechanical ventilation and improves tissue perfusion without significant effect on hemodynamics. [ABSTRACT FROM AUTHOR]

This review article provides a comprehensive overview of common medical emergencies that can occur in pregnant patients. We summarize the key diagnostic and management steps for each emergency to assist health care professionals in identifying and treating these potentially life-threatening conditions. The medical emergencies discussed in this article include postpartum hemorrhage: hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome; acute fatty liver of pregnancy: amniotic fluid embolism: pulmonary embolism; acute respiratory distress syndrome, and shock. Each condition is described in detail, with a focus on the clinical presentation, diagnostic workup, and treatment options. The information presented in this review article is based on current best practices and guidelines from leading medical organizations. We hope this article will serve as a valuable resource for health care professionals who care for pregnant patients and help improve outcomes for these patients in emergency situations. [ABSTRACT FROM AUTHOR]

Point-of-care sonography is a precondition in acute and emergency medicine for the diagnosis and initiation of therapy for critically ill and injured patients. While emergency sonography is a mandatory part of the training for clinical acute and emergency medicine, it is not everywhere required for prehospital emergency medicine. Although some medical societies in Germany have already established their own learning concepts for emergency ultrasound, a uniform national training concept for the use of emergency sonography in the out-of-hospital setting is still lacking. Experts of several professional medical societies have therefore joined forces and developed a structured training concept for emergency sonography in the prehospital setting. The consensus paper serves as quality assurance in prehospital emergency sonography. [ABSTRACT FROM AUTHOR]

Introduction: Predicting which patients with acute circulatory failure will respond to the fluid by an increase in cardiac output is a daily challenge. End-expiratory occlusion test (EEOT) and mini-fluid challenge (MFC) can be used for assessing fluid responsiveness in patients with spontaneous breathing activity, cardiac arrhythmias, low-tidal volume and/or low lung compliance. Methods: The objective of the study is to evaluate the value of EEOT and MFC-induced rise in left ventricular outflow tract (LVOT) velocity time integral (VTI) in predicting fluid responsiveness in acute circulatory failure in comparison to the passive leg-raising (PLR) test. Hundred critically ill ventilated and sedated patients with acute circulatory failure were studied. LVOT VTI was measured by transthoracic echocardiography before and after EEOT (interrupting the ventilator at end-expiration over 15 s), and before and after MFC (100 ml of Ringer lactate was infused over 1 min). The variation of LVOT VTI after EEOT and the MFC was calculated from the baseline. Sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) curve of LVOT VTI after EEOT and MFC to predict fluid responsiveness were determined. Results: After PLR, stroke volume (SV) increased by ≥12% in 49 patients, who were defined as responders and 34 patients in whom the increase in SV <12% were defined as nonresponders. A cutoff of 9.1% Change in VTI after MFC (ΔVTIMFC) predicted fluid responsiveness with an AUROC of 0.96 (P < 0.001) with sensitivity and specificity of 91.5% and 88.9%, respectively. Change in VTI after EEOT (ΔVTIEEOT) >4.3% predicted fluid responsiveness with sensitivity and specificity 89.4% and 88.9%, respectively, with an AUROC of 0.97 (P < 0.001), but in 17 patients, EEOT was not possible because triggering of the ventilator by the patient's inspiratory effort. Conclusion: In conclusion, in mechanically ventilated patients with acute circulatory failure Δ VTIMFC and Δ VTI EEOT accurately predicts fluid responsiveness. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic haemorrhagic shock can be difficult to diagnose. Models for predicting critical bleeding and massive transfusion have been developed to aid clinicians. The aim of this review is to outline the various available models and report on their performance and validation. Methods: A review of the English and non-English literature in Medline, PubMed and Google Scholar was conducted from 1990 to September 2015. We combined several terms for i) haemorrhage AND ii) prediction, in the setting of iii) trauma. We included models that had at least two data points. We extracted information about the models, their developments, performance and validation. Results: There were 36 different models identified that diagnose critical bleeding, which included a total of 36 unique variables. All models were developed retrospectively. The models performed with variable predictive abilities-the most superior with an area under the receiver operating characteristics curve of 0.985, but included detailed findings on imaging and was based on a small cohort. The most commonly included variable was systolic blood pressure, featuring in all but five models. Pattern or mechanism of injury were used by 16 models. Pathology results were used by 15 models, of which nine included base deficit and eight models included haemoglobin. Imaging was utilised in eight models. Thirteen models were known to be validated, with only one being prospectively validated. Conclusions: Several models for predicting critical bleeding exist, however none were deemed accurate enough to dictate treatment. Potential areas of improvement identified include measures of variability in vital signs and point of care imaging and pathology testing. [ABSTRACT FROM AUTHOR]

Background: Tissue oxygen saturation (StO2) decrease could appear earlier than lactate alteration. However, the correlation between StO2 and lactate clearance was unknown. Methods: This was a prospective observational study. All consecutive patients with circulatory shock and lactate over 3 mmol/L were included. Based on the rule of nines, a BSA (body surface area) weighted StO2 was calculated from four sites of StO2 (masseter, deltoid, thenar and knee). The formulation was as follows: masseter StO2 × 9% + (deltoid StO2 + thenar StO2) × (18% + 27%)/ 2 + knee StO2 × 46%. Vital signs, blood lactate, arterial and central venous blood gas were measured simultaneously within 48 h of ICU admission. The predictive value of BSA-weighted StO2 on 6-hour lactate clearance > 10% since StO2 initially monitored was assessed. Results: A total of 34 patients were included, of whom 19 (55.9%) had a lactate clearance higher than 10%. The mean SOFA score was lower in cLac ≥ 10% group compared with cLac < 10% group (11 ± 3 vs. 15 ± 4, p = 0.007). Other baseline characteristics were comparable between groups. Compared to non-clearance group, StO2 in deltoid, thenar and knee were significantly higher in clearance group. The area under the receiver operating curves (AUROC) of BSA-weighted StO2 for prediction of lactate clearance (0.92, 95% CI [Confidence Interval] 0.82-1.00) was significantly higher than StO2 of masseter (0.65, 95% CI 0.45–0.84; p < 0.01), deltoid (0.77, 95% CI 0.60–0.94; p = 0.04), thenar (0.72, 95% CI 0.55–0.90; p = 0.01), and similar to knee (0.87, 0.73-1.00; p = 0.40), mean StO2 (0.85, 0.73–0.98; p = 0.09). Additionally, BSA-weighted StO2 model had continuous net reclassification improvement (NRI) over the knee StO2 and mean StO2 model (continuous NRI 48.1% and 90.2%, respectively). The AUROC of BSA-weighted StO2 was 0.91(95% CI 0.75-1.0) adjusted by mean arterial pressure and norepinephrine dose. Conclusions: Our results suggested that BSA-weighted StO2 was a strong predictor of 6-hour lactate clearance in patients with shock. [ABSTRACT FROM AUTHOR]

SLICE is an algorithm for the integration of point‐of‐care ultrasound in the assessment and resuscitation of the shocked or breathless patient. It aims to determine the patient's fluid status, and identify reversible causes for the patient's clinical picture. SLICE stands for 'In a patient who is Shocked/Short of breath, scan the Lungs, IVC, Cardiac and Extra regions as indicated'. Its key advantages are that it explicitly guides resuscitative fluid management, can be performed rapidly and by clinicians with a broad range of sonographic experience, and can be used in a broad range of clinical scenarios. Its use has been successfully taught and implemented in routine clinical practice at our local institution. [ABSTRACT FROM AUTHOR]

Background. Vasopressin is frequently utilized for a variety of shock states in critically ill patients. Short stability (≤24 hours) after intravenous admixture with current manufacturer labeling requires just in time preparation and may lead to delays in therapy and increased medication waste. We aimed to evaluate vasopressin stability in 0.9% sodium chloride stored in polyvinyl chloride bags and polypropylene syringes for up to 90 days. Additionally, we evaluated the impact of extended stability on the time to administration and cost savings from reduced medical waste at an academic medical center. Methods. Dilutions of vasopressin to concentrations of 0.4 and 1.0 unit/mL were performed under aseptic conditions. The bags and syringes were stored at room temperature (23°C-25°C) or under refrigeration (3°C-5°C). Three samples of each preparation and storage environment were analyzed on days 0, 2, 14, 30, 45, 60, and 90. Physical stability was performed by visual examination. The pH was assessed at each point and upon final degradation evaluation. Sterility of the samples was not assessed. Chemical stability of vasopressin was evaluated using liquid chromatography with tandem mass spectrometry. Samples were considered stable if there was <10% degradation of the initial concentration. Results. Vasopressin diluted to 0.4 and 1.0 unit/mL with 0.9% sodium chloride injection was physically stable throughout the study. No precipitation was observed. At days 2, 14, 30, 45, 60, and 90 all bags and syringes diluted to 0.4 units/mL had <10% degradation. Vasopressin diluted to 1 unit/mL and stored under refrigeration had <10% degradation at all measured days, but when stored under room temperature was found to have >10% degradation at day 30. Implementation of a batching process resulted in reduced waste ($185 300) and improved time to administration (26 vs 4 minutes). Conclusion. Vasopressin diluted to a concentration of 0.4 units/mL with 0.9% sodium chloride injection is stable for 90 days at room temperature and under refrigeration. When diluted to 1.0 unit/mL with 0.9% sodium chloride injection it is stable for 90 days under refrigeration. Use of extended stability and sterility testing to batch prepare infusions may lead to improved time to administration and cost savings from reduced medication waste. [ABSTRACT FROM AUTHOR]

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Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become an important support modality for patients with acute respiratory failure refractory to optimal medical therapy, such as low tidal volume mechanical ventilator support, early paralytic infusion, and early prone positioning. The objective of this cohort study was to investigate the causes and timing of in-hospital mortality in patients on VV ECMO. All patients, excluding trauma and bridge to lung transplant, admitted 8/2014–6/2019 to a specialty ICU for VV ECMO were reviewed. Two hundred twenty-five patients were included. In-hospital mortality was 24.4% (n = 55). Most non-survivors (46/55, 84%) died prior to lung recovery and decannulation from VV ECMO. Most common cause of death (COD) for patients who died on VV ECMO was removal of life sustaining therapy (LST) in setting of multisystem organ failure (MSOF) (n = 24). Nine patients died a median of 9 days [6, 11] after decannulation. Most common COD in these patients was palliative withdrawal of LST due to poor prognosis (n = 3). Non-survivors were older and had worse predictive mortality scores than survivors. We found that death in patients supported with VV ECMO in our study most often occurs prior to decannulation and lung recovery. This study demonstrated that the most common cause of death in patients supported with VV ECMO was removal of LST due MSOF. Acute hemorrhage (systemic or intracranial) was not found to be a common cause of death in our patient population. [ABSTRACT FROM AUTHOR]

The clinical features of severe hypothyroidism vary in presentation, ranging from subclinical symptoms to multiorgan failure referred to as myxedema coma. The cornerstone treatments of myxedema coma include aggressive thyroid hormone replacement combined with excellent supportive care in the intensive care unit. We report a rare case of a 56-year-old female with history of hypothyroidism treated with levothyroxine, who developed myxedema coma post-pericardial window surgery for a large pericardial effusion. She was supported with substantial doses of vasopressors and inotropes for shock. In addition, she was initiated on lung-protection ventilation for acute respiratory distress syndrome. After the diagnosis of myxedema coma was made, she was started on intravenous levothyroxine and hydrocortisone with great sustained clinical response. This case illustrated myxedema coma as an unusual cause of shock in post-operative patients with past medical history of hypothyroidism. [ABSTRACT FROM AUTHOR]

Objective: Current guidelines suggest the immediate initiation of crystalloid for sepsis-induced hypoperfusion but note that supporting evidence is low quality. The aim of this study is to examine the effect of timing of fluid initiation on mortality for adults with sepsis. Data Sources: Two authors independently reviewed relevant articles and extracted study details from PubMed, Scopus, Cochrane, Google Scholar, and previous relevant systematic reviews from 1-1-2000 to 1-6-2022. Registered with PROSPERO (CRD42021245431) and bias assessed using CLARITY. Study Selection: A minimum of severe sepsis (Sepsis-2) or sepsis (Sepsis-3) for patients =18 years old. Fluid initiation timing ranging from prehospital to 120 min within sepsis onset defined as "early" initiation. Data Extraction: Included studies providing mortality-based odds ratios (or comparable) adjusting for confounders or prospective trials. Data Synthesis: From 1643 citations, five retrospective cohort studies were included (n =20,209) with in-hospital mortality of 21.8%. A pooled analysis (odds ratio =OR [95% CI]) did not observe an impact on mortality for the early initiation of fluids among all patients, OR=0.79 [0.62-1.02]; heterogeneity: I2=86% [70-94%], but when studies analyzed cases of hypotension where available, a survival benefit was observed, OR=0.74 [0.61-0.90]. Initiation of fluids in two prehospital studies did not impact mortality, OR=0.82 [0.27-2.43]. However, both prehospital cohorts observed benefit among hypotensive patients individually, although heterogenous results precluded significance when pooled, OR=0.50 [0.21-1.18]. Three hospital-based studies with initiation stratified at 30, 100, and 120 min, observed survival benefit both individually and when pooled, OR=0.78 [0.63-0.97]. No differences were observed between prehospital versus hospital subgroups. Conclusion: This meta-analysis supports the guideline recommendations for early fluid initiation once sepsis is recognized, especially in cases of hypotension. Findings are limited by the small number, heterogeneity, and retrospective nature of available studies. Further retrospective investigations may be worthwhile as randomized studies on fluid initiation are unlikely. [ABSTRACT FROM AUTHOR]

Objectives: Describe the variation in practice and identify predictors of invasive mechanical ventilation (IMV) use in shock. Explore the association between the timing of IMV initiation ("Early" vs. "Delayed") on shock duration. Design: Multicenter, prospective, observational cohort study between September 2017 and February 2018 Setting: 34 hospitals in the United States and Jordan. Patients: Consecutive, adult, critically ill patients with shock, defined as a systolic blood pressure less than or equal to 90mm Hg, mean arterial pressure less than or equal to 65mm Hg, or need for a vasopressor medication. Interventions: None. Measurements and Main Results: "Early" IMV was defined as starting IMV 0-6 hours of shock onset and "Delayed" IMV was defined as starting IMV between 6 and 48 hours of shock onset. The primary outcome was shock-free days, defined as the number of days without shock after the first 48 hours of shock onset. Variation and predictors of IMV use were examined within the whole cohort as well as the subgroup of those intubated within 0-48 hours of shock onset. Mixed effects modeling with hospital site as a random effect showed that there was 7% variation by site in the use and timing of IMV in this shock cohort. In a propensity-matched model for the timing of IMV, "Early" IMV after shock onset was associated with more shock-free days when compared to "Delayed" IMV in those intubated within 0-48 hours of shock onset (Beta coefficient 0.65 days, 95% CI 0.14-1.16 days). Conclusions: Timing of IMV initiation for patients in shock has potentially important implications for patient outcomes and merits further study. [ABSTRACT FROM AUTHOR]

Background: Monitoring oxygen saturation in shocked patients is a challenging nursing procedure. Shock syndrome alters peripheral tissue perfusion and hinders peripheral capillary oxygen saturation (SpO2) measurements. Our study aimed to find a solution to this problem. The pharynx is expected to be an accurate SpO2 measurement site in shocked patients. We clinically evaluated the pharyngeal SpO2 measurements against the arterial oxygen saturation (SaO2) measurements. Methods: A prospective cohort research design was used. This study included 168 adult shocked patients. They were admitted to five intensive care units from March to December 2020 in an Egyptian hospital. A wrap oximeter sensor was attached to the posterior surface of an oropharyngeal airway (OPA) by adhesive tape. The optical component of the sensor adhered to the pharyngeal surface after the OPA insertion. Simultaneous pharyngeal peripheral capillary oxygen saturation (SpO2) and arterial oxygen saturation (SaO2) measurements were recorded. The pharyngeal SpO2 was clinically evaluated. Also, variables associated with the SpO2 bias were evaluated for their association with the pharyngeal SpO2 bias. Results: The pharyngeal SpO2 bias was − 0.44% with − 1.65 to 0.78% limits of agreement. The precision was 0.62, and the accuracy was 0.05. The sensitivity to detect mild and severe hypoxemia was 100%, while specificity to minimize false alarm of hypoxemia was 100% for mild hypoxemia and 99.4% for severe hypoxemia. None of the studied variables were significantly associated with the pharyngeal SpO2 bias. Conclusion: The pharyngeal SpO2 has a clinically acceptable bias, which is less than 0.5% with high precision, which is less than 2%. [ABSTRACT FROM AUTHOR]

Acute circulatory collapse is one of the most familiar challenges in ICUs. It is considered that artefacts generated by lung ultrasound (LUS) can help in diagnosis and management. FALLS-protocol using LUS is a tool proposed for the management of unexplained shock. Objectives To investigate the role of LUS FALLS-protocol in differentiating types of shock in critically ill patients. Patients and methods A total of 50 patients presented with undiagnosed shock. Fast bedside echocardiography and LUS FALLS-protocol were applied along with inferior vena cava diameter and collapsibility measurement. Results A total of 19 patients with septic shock on presentation had A profile in all of themand AB profile in three of them, and after resuscitation, they were transformed to B profile with 100% sensitivity, 90.5% specificity, 90.5% positive predictive value (PPV), and 100% negative predictive value (NPV). Overall, 16 patients with hypovolemic shock had A profile in all of them on presentation and after resuscitation, with 100% sensitivity, 94.1% specificity, 88.9% PPV, and 100% NPV. Moreover, eight patients with cardiogenic shock had B profile in all of them on presentation with 100% sensitivity, 95.2% specificity, 80% PPV, and 100% NPV; three patients with obstructive shock had A profile in all of them on presentation, with 100% sensitivity, 25.5% specificity, 7.9% PPV, and 100% NPV; and two patients with anaphylactic shock had A profile in all of them on presentation and transformed to B profile after resuscitation with 100% sensitivity, 50% specificity, 9.5% PPV, and 100% NPV. Our findings showed preference of FALLS-protocol than inferior vena cava diameter and collapsibility in directing fluid therapy. Conclusion Bedside chest ultrasound FALLS-protocol should be considered in the resuscitation pathways with a possible significant effect on patient management. [ABSTRACT FROM AUTHOR]

Shock is a life-threatening pathophysiologic state referring to inadequate organ perfusion, which can progress to end-organ dysfunction and eventually, multiple organ failure and death. The diagnosis of shock is clinical, necessitating good understanding of the underlying etiology, pathophysiology, as well as the clinical, biochemical, and hemodynamic manifestations of the various presentations of shock. This article describes an approach to shock, highlighting the important initial actions, pertinent clinical findings, and the four main types of shock, and offers an overview of the inotropes and vasopressors used in the intensive care setting. A case study and additional figures are included to supplement the presented concepts. [ABSTRACT FROM AUTHOR]

Background: Intensive care management of diabetic ketoacidosis (DKA) is targeted to reverse ketoacidosis, replace the fluid deficit, and correct electrolyte imbalances. Adequate restoration of circulation and treatment of shock is key. Pediatric treatment guidelines of DKA have become standard but complexities arise in children with co-morbidities. Congenital nephrogenic diabetes insipidus (NDI) is a rare hereditary disorder characterized by impaired kidney concentrating ability and treatment is challenging. NDI and DKA together have only been previously reported in one patient. Case diagnosis/treatment: We present the case of a 12-year-old male with NDI and new onset DKA with hyperosmolality. He presented in hypovolemic shock with altered mental status. Rehydration was challenging and isotonic fluid resuscitation resulted in increased urine output and worsening hyperosmolar state. Use of hypotonic fluid and insulin infusion led to lowering of serum osmolality faster than desired and increased the risk for cerebral edema. Despite the rapid decline in serum osmolality his mental status improved so we allowed him to drink free water mixed with potassium phosphorous every hour to match his urinary output (1:1 replacement) and continued 0.45% sodium chloride based on his fluid deficit and replacement rate with improvement in his clinical status. Conclusions: This case illustrates the challenges in managing hypovolemic shock, hyperosmolality, and extreme electrolyte derangements driven by NDI and DKA, as both disease processes drive excessive urine output, electrolyte and acid–base imbalances, and rapid fluctuation in osmolality. [ABSTRACT FROM AUTHOR]

Objectives: Shock is a life-threatening condition in children in low- and middle-income countries (LMIC), with several controversies. This systematic review summarizes the etiology, pathophysiology and mortality of shock in children in LMIC.Methods: We searched for studies reporting on children with shock in LMIC in PubMed, Embase and through snowballing (up to 1 October 2019). Studies conducted in LMIC that reported on shock in children (1 month-18 years) were included. We excluded studies only containing data on neonates, cardiac surgery patients or iatrogenic causes. We presented prevalence data, pooled mortality estimates and conducted subgroup analyses per definition, region and disease. Etiology and pathophysiology data were systematically collected.Results: We identified 959 studies and included 59 studies of which six primarily studied shock. Definitions used for shock were classified into five groups. Prevalence of shock ranged from 1.5% in a pediatric hospital population to 44.3% in critically ill children. Pooled mortality estimates ranged between 3.9-33.3% for the five definition groups. Important etiologies included gastroenteritis, sepsis, malaria and severe anemia, which often coincided. The pathophysiology was poorly studied but suggests that in addition to hypovolemia, dissociative and cardiogenic shock are common in LMIC.Conclusions: Shock is associated with high mortality in hospitalized children in LMIC. Despite the importance few studies investigated shock and as a consequence limited data on etiology and pathophysiology of shock is available. A uniform bedside definition may help boost future studies unravelling shock etiology and pathophysiology in LMIC. [ABSTRACT FROM AUTHOR]

Purpose Prolonged duration of intravenous (IV) vasopressor dependence in critically ill adult patients with vasodilatory shock results in increased length of stay in both the intensive care unit (ICU) and hospital, translating to higher risk of infection, delirium, immobility, and cost. Acceleration of vasopressor liberation can aid in reducing these risks. Midodrine is an oral α 1-adrenergic receptor agonist that offers a potential means of liberating patients from IV vasopressor therapy. This clinical review summarizes primary literature and proposes a clinical application for midodrine in the recovery phase of vasodilatory shock. Summary Five studies with a total of over 1,000 patients conducted between 2011 and 2021 were identified. In observational studies, midodrine administration was demonstrated to lead to faster time to liberation from IV vasopressor therapy and shorter ICU length of stay in patients recovering from vasodilatory shock. These findings were not replicated in a prospective, multicenter, randomized controlled trial. In this review, literature evaluating midodrine use for IV vasopressor liberation is summarized and study limitations are discussed. Conclusion On the basis of this review of current literature, recommendations are provided on selecting appropriate candidates for adjunctive midodrine in the recovery phase of vasodilatory shock and considerations are discussed for safely and effectively initiating, titrating, and discontinuing therapy. [ABSTRACT FROM AUTHOR]

Shock is a life-threatening condition of circulatory failure that causes an imbalance between cellular oxygen supply and demand resulting in organ dysfunction. It is important to recognize promptly as it is reversible in earlier stages but will transition to an irreversible phase if left untreated. This will result in multiorgan failure and subsequent death. The clinician should therefore consider shock in the differential for all patients with new organ failure. This article will review the pathophysiology, classification, evaluation, and management of shock. [ABSTRACT FROM AUTHOR]

The term ‘shock’ is used to describe a complex, life-threatening clinical condition that arises from acute circulatory failure. Shock is a pathological state that results when the circulation is unable to deliver sufficient oxygen and nutrients to the cells and tissues. The resulting hypoxia, tissue hypoperfusion and cellular dysfunction can lead to multi-organ failure; if this is not treated in a timely and appropriate manner, it can lead to death. This article gives an introduction to shock with an overview of the condition and its physiological impact on patients. Focusing on the aetiology and underlying causes, discussion will highlight the different types, stages and general pathophysiology of shock, as well as providing a guide to treatment options and nursing interventions. [ABSTRACT FROM AUTHOR]

Aim: To assess the efficacy and safety of metaraminol infusions in comparison to other vasopressors in critically ill patients with shock with regard to hospital mortality, effect on haemodynamics (mean arterial pressure or systolic blood pressure), duration of vasopressor use, and adverse events. Data sources: A systematic review was conducted in eight electronic databases and nine trial registers from inception to 17 March 2021. Study selection: Studies included randomised or non‐randomised controlled trials, and retrospective or prospective observational studies of critically ill adult patients admitted to the intensive care unit or emergency department with shock of any aetiology and who received metaraminol via continuous infusion compared to patients who received other vasopressors. Results: Out of 1387 eligible articles, three observational studies and one controlled trial were included involving a total of 54 patients. Study patients had different types of shock including septic (n = 28), cardiogenic (n = 21), hypovolemic (n = 3) and neurogenic shock (n = 2). All studies compared metaraminol to noradrenaline and were of poor quality and high risk of bias. There was no difference in hospital mortality or effect on mean arterial pressure or systolic blood pressure between metaraminol and noradrenaline in any of the studies. None of the studies reported the duration of vasopressor use or adverse drug events such as extravasation or tissue injury. Conclusion: There is limited and low‐quality efficacy and safety data to support the use of metaraminol over other vasopressors in critically ill patients with shock. Future clinical trials are needed before this agent is routinely used in this patient population. [ABSTRACT FROM AUTHOR]

Trauma to the adrenal glands is very rare. The variation in clinical manifestations is marked and markers for its diagnosis being limited, makes it tough to be diagnosed. Computed tomography remains the gold standard for detecting this injury. Prompt recognition and the potential for mortality with adrenal insufficiency can provide the best guidance for the treatment and care of the severely injured. We present a case of a 33-year-old trauma patient who was not responding to the management of his shock. He was finally found to have a right adrenal haemorrhage leading to adrenal crisis. The patient was resuscitated in the Emergency Department but succumbed 10 days post admission. [ABSTRACT FROM AUTHOR]

A retrospective study that compared children younger than 6 months versus older children of a Spanish cohort of patients diagnosed with Kawasaki disease between 2011 and 2016 (Kawa-Race study). From the 598 patients recruited, 42 patients were younger than 6 months (7%) and presented more frequently with an incomplete diagnosis of Kawasaki disease (52.4 vs 27.9%, p = 0.001). Cardiac abnormalities detected by echocardiography were more common in younger patients (52.4 vs 30%, p = 0.002). These younger patients presented with a higher proportion of coronary aneurysms as well (19 vs 8.6%, p < 0.001). Shock at diagnosis (9.5 vs 1.9%, p = 0.016) and admission to intensive care units (17.7 vs 4.1%, p = 0.003) were more frequent in patients younger than 6 months. There were no statistically significant differences in relation to infections, non-response to IVIG, or mid- or long-term outcomes. Conclusion: Data of the Spanish cohort are consistent with other American and Asian studies, although Spanish children younger than 6 months had a lower rate of non-response to IVIG and better clinical outcomes. A high index of suspicion should be considered for this population due to a higher risk of coronary abnormalities, presentation of shock, and admission to the intensive care unit. What is Known: •Children below 6 months of age with Kawasaki disease (KD) have different features compared to older. •Younger patients usually have an incomplete form of KD and coronary artery abnormalities. What is New: •Younger than 6 months with KD presented with shock and required admission to PICU more frequently compared to older. •Infections play a similar role in KD despite the age of the patients. [ABSTRACT FROM AUTHOR]

Purpose: The modified Trauma-Induced Coagulopathy Clinical Score (mTICCS) presents a new scoring system for the early detection of the need for a massive transfusion (MT). This easily applicable score was validated in a large trauma cohort and proven comparable to more established complex scoring systems. However, the inter-rater reliability of the mTICCS has not yet been investigated. Methods: Therefore, a dataset of 15 randomly selected and severely injured patients (ISS ≥ 16) derived from the database of a level I trauma centre (2010–2015) was used. Moreover, 15 severely injured subjects that received MT were chosen from the same databank. A web-based survey was sent to medical professionals working in the field of trauma care asking them to evaluate each patient using the mTICCS. Results: In total, 16 raters (9 residents and 7 specialists) completed the survey. Ratings from 15 medical professionals could be evaluated and led to an ICC of 0.7587 (95% Bootstrap confidence interval (BCI) 0.7149–0.8283). A comparison of working experience specific ICC (n = 7 specialists, ICC: 0.7558, BCI: 0.7076–0.8270; n = 8 residents, ICC: 0.7634, BCI: 0.7183–0.8335) showed no significant difference between the two groups (p = 0.67). Conclusion: In summary, reliability values need to be considered when making clinical decisions based on scoring systems. Due to its easy applicability and its almost perfect inter-rater reliability, even with non-specialists, the mTICCS might therefore be a useful tool to predict the early need for MT in multiple trauma. [ABSTRACT FROM AUTHOR]

Introduction: Electromagnetic interference (EMI) from left ventricular assist devices (LVADs) can cause implantable cardioverter‐defibrillator (ICD) oversensing. We sought to assess the frequency of inappropriate shocks/oversensing due to LVAD‐related EMI and prospectively compare integrated (IB) versus dedicated bipolar (DB) sensing in patients with LVADs. Methods: Single‐center study in LVAD patients with Medtronic or Abbott ICDs between September 2017 and March 2020. We excluded patients that were pacemaker dependent. Measurements were obtained of IB and DB sensing and noise to calculate a signal‐to‐noise ratio (SNR). Device checks were reviewed to assess appropriate and inappropriate sensing events. Results: Forty patients (age 52 ± 14 years, 75% men, 38% ischemic cardiomyopathy) were included with the median time between LVAD implantation and enrollment of 6.7 months (2.3, 11.4 months). LVAD subtypes included: HeartWare (n = 22, 55%), Heartmate II (n = 10, 25%), and Heartmate III (n = 8, 20%). Over a follow‐up duration of 21.6 ± 12.9 months after LVAD implantation, 5% of patients (n = 2) had oversensing of EMI from the LVAD (both with HeartWare LVADs and Abbott ICDs) at 4 days and 10.8 months after LVAD implantation. Both patients underwent adjustment of ventricular sensing with resolution of oversensing and no further events over 5 and 15 months of further follow‐up. The SNR was similar between IB and DB sensing (50 [29–67] and 57 [41–69], p = 0.89). Conclusion: ICD oversensing of EMI from LVADs is infrequent and can be managed with reprogramming the sensitivity. There was no significant difference in the R‐wave SNR with IB versus DB ICD leads. [ABSTRACT FROM AUTHOR]

The article presents a case study of a woman aged in her 70s who was diagnosed with COVID-19 and transferred to the hospital (Oita University Hospital, Oita, Japan) because of persistent dyspnea for 3 days. She had several pre-existing cardiovascular diseases, including patent foramen ovale and ventricular septal defect. It notes that she was successfully treated for acetaminophen induced non-anaphylactic shock.

Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a temporary therapy option for refractory cardiac or respiratory failure. Preliminary study suggests that ECMO aids in the recovery of end-organ function by maintaining systemic perfusion. Methods: A retrospective IRB approved database research and chart review was performed on patients initiated on veno-arterial (VA-) ECMO between September 2010 and April 2019. End-organ injury markers were compared between the pre-ECMO period, defined as markers recorded before ECMO initiation, and the pre-decannulation period, defined as markers prior to ECMO decannulation. Data was expressed with mean ± standard deviation, or median [quartile 1, quartile 3] and compared between Pre-ECMO and per-decannulation period. Results: Among the 159 VA-ECMO patients, 100 patients (63%) survived ECMO with mean ECMO duration 10 ± 7 days. Within the survival group, 78 patients (49%) weaned to recovery, and 22 patients (14%) weaned off to durable implantable devices. Compared to the pre-ECMO period, the pre-decannulation period significantly improved in pH (7.23 ± 0.19 vs. 7.40 ± 0.09; p < 0.001) and lactate (5.5 [2.3, 9.0] vs. 1.6 [0.9, 2.3]; p < 0.001), and serum creatinine (1.4 [1.1, 2.1] vs. 1.1 [0.8, 1.7]; p < 0.001). Significant changes were noted in ventilation parameters as well, such as FiO2 (100 [100, 100] vs. 50 [50, 50]; p < 0.001), PaO2 (88 [62, 135], 126 [87, 162]; p < 0.001) and PEEP (8.0 [5.0, 12.0] vs. 5.0 [5.0, 8.0]; p < 0.001). Conclusion: Maintaining perfusion with VA-ECMO utilization on indicated patients demonstrated improvements in end-organ functions. Survival rates of VA-ECMO patients were also optimistic. [ABSTRACT FROM AUTHOR]

Background: Vancomycin (VCM) is effective in fighting Gram-positive bacteria related severe infections, and topical application of VCM powder is widely used in orthopedic surgery to prevent wound infection. However, VCM could lead to infusion rate-dependent antibody-and complement-independent anaphylaxis reaction by inducing direct release of histamine. Case presentation: We retrospectively analyzed seven cases of severe hypotension and shock during wound closure or immediately after orthopedic surgery with unidentifiable reasons. We found that these cases were all associated with local application of VCM powder during wound closure process. Two patients experienced sudden cardiac arrest. Most of the cases (6/7) with circulatory collapse were discharged without severe sequelae. While one case with application of 3 g VCM developed cardiac arrest and remained in a coma due to hypoxic-hypoxic encephalopathy. The clinical presentations and the time of the shock onset were considered to be related with a VCM induced anaphylaxis reaction. However, as this was a retrospective study, and there was no laboratory examination performed, the conclusion was made upon differential diagnosis based on clinical manifestations and the timing of the shock. Conclusions: Local application of VCM may not be as safe as was once believed and may lead to a related anaphylaxis. As VCM induced infusion-rate dependent, non-IgE mediated anaphylaxis is characterized by delayed occurrence, severe hypotension and even circulatory collapse, surgeons and anesthesiologists should be extra vigilant during and after VCM application. [ABSTRACT FROM AUTHOR]

Traumatic injury is a common cause of morbidity and mortality. Fluid resuscitation is an important component of treatment of haemorrhagic shock after trauma. In patients with major trauma, after the control of bleeding, the blood volume needs to be replenished. Blood and blood products, crystalloids and colloids are available options for increasing plasma volume. With the availability of several options, choice of fluid therapy in trauma patients creates a dilemma. The choice of intravenous fluid is based on its ability to increase intravascular volume, tissue perfusion and oxygenation and lesser risk of adverse effects. Blood and blood components are a precious commodity and need to be tested, typed and matched and often not readily available. Polygeline is an important option among other colloids which exerts clinically evident benefits, making it an appropriate choice for the management of hypovolemia due to trauma. For a better understanding of the current practices in trauma management, an expert group discussion was facilitated. [ABSTRACT FROM AUTHOR]

Objectives: In this systematic review and meta-analysis, we assessed whether a high CO2 gap predicts mortality in adult critically ill patients with circulatory shock.Data Sources: A systematic search of MEDLINE and EMBASE electronic databases from inception to October 2019.Study Selection: Studies from adult (age ≥ 18 yr) ICU patients with shock reporting CO2 gap and outcomes of interest. Case reports and conference abstracts were excluded.Data Extraction: Data extraction and study quality assessment were performed independently in duplicate.Data Synthesis: We used the Newcastle-Ottawa Scale to assess methodological study quality. Effect sizes were pooled using a random-effects model. The primary outcome was mortality (28 d and hospital). Secondary outcomes were ICU length of stay, hospital length of stay, duration of mechanical ventilation, use of renal replacement therapy, use of vasopressors and inotropes, and association with cardiac index, lactate, and central venous oxygen saturation.Conclusions: We included 21 studies (n = 2,155 patients) from medical (n = 925), cardiovascular (n = 685), surgical (n = 483), and mixed (n = 62) ICUs. A high CO2 gap was associated with increased mortality (odds ratio, 2.22; 95% CI, 1.30-3.82; p = 0.004) in patients with shock, but only those from medical and surgical ICUs. A high CO2 gap was associated with higher lactate levels (mean difference 0.44 mmol/L; 95% CI, 0.20-0.68 mmol/L; p = 0.0004), lower cardiac index (mean difference, -0.76 L/min/m; 95% CI, -1.04 to -0.49 L/min/m; p = 0.00001), and central venous oxygen saturation (mean difference, -5.07; 95% CI, -7.78 to -2.37; p = 0.0002). A high CO2 gap was not associated with longer ICU or hospital length of stays, requirement for renal replacement therapy, longer duration of mechanical ventilation, or higher vasopressors and inotropes use. Future studies should evaluate whether resuscitation aimed at closing the CO2 gap improves mortality in shock. [ABSTRACT FROM AUTHOR]

Shock in newborns and preterm infants carries significant morbidity and mortality risks unless there is early recognition and adequate treatment. Signs may only be identified in the late decompensated phase with lactic acidosis, cellular disruption, and irreversible multiorgan damage. In neonates, the etiopathological origin is unique, particularly in extremely preterm infants with a complicated postnatal transition phase, an immature myocardium, and high peripheral systemic resistance. Hypovolemic shock shortly after birth is uncommon and may complicate fetomaternal or fetoplacental transfusion, abruptio placenta, intracranial hemorrhage, or capillary leak syndrome. Without a blood loss history, secondary clinical assessment may reveal the underlying etiology and facilitate targeted interventions. [ABSTRACT FROM AUTHOR]

Rationale: There are no prospective observational studies exploring the relationship between relative hypotension and adverse kidney-related outcomes among critically ill patients with shock.Objectives: To investigate the magnitude of relative hypotension during vasopressor support among critically ill patients with shock and to determine whether such relative hypotension is associated with new significant acute kidney injury (AKI) or major adverse kidney events (MAKE) within 14 days of vasopressor initiation.Methods: At seven multidisciplinary ICUs, 302 patients, aged ≥40 years and requiring ≥4 hours of vasopressor support for nonhemorrhagic shock, were prospectively enrolled. We assessed the time-weighted average of the mean perfusion pressure (MPP) deficit (i.e., the percentage difference between patients' preillness basal MPP and achieved MPP) during vasopressor support and the percentage of time points with an MPP deficit > 20% as key exposure variables. New significant AKI was defined as an AKI-stage increase of two or more (Kidney Disease: Improving Global Outcome creatinine-based criteria).Measurements and Main Results: The median MPP deficit was 19% (interquartile range, 13-25), and 54% (interquartile range, 19-82) of time points were spent with an MPP deficit > 20%. Seventy-three (24%) patients developed new significant AKI; 86 (29%) patients developed MAKE. For every percentage increase in the time-weighted average MPP deficit, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 5.6% (95% confidence interval, 2.2-9.1; P = 0.001) and 5.9% (95% confidence interval, 2.2-9.8; P = 0.002), respectively. Likewise, for every one-unit increase in the percentage of time points with an MPP deficit > 20%, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 1.2% (0.3-2.2; P = 0.008) and 1.4% (0.4-2.4; P = 0.004), respectively.Conclusions: Vasopressor-treated patients with shock are often exposed to a significant degree and duration of relative hypotension, which is associated with new-onset, adverse kidney-related outcomes.Study registered with Australian New Zealand Clinical Trial Registry (ACTRN 12613001368729). [ABSTRACT FROM AUTHOR]

Background: Fluid boluses aiming to improve the cardiac output and oxygen delivery are commonly administered in children with shock. An increased mean arterial pressure in addition to resolution of tachycardia and improved peripheral perfusion are often monitored as clinical surrogates for improvement in cardiac output. The objective of our study is to describe changes in cardiac index, mean arterial pressure, and their relationship to other indices of cardiovascular performance.Objective: The objective of our study is to describe changes in cardiac index, mean arterial pressure, and their relationship to other indices of cardiovascular performance.Design, Setting, Patients, and Interventions: We prospectively analyzed hemodynamic data from children in the cardiac ICU who received fluid bolus (10mL/kg of Ringers-Lactate over 30 min) for management of shock and/or hypoperfusion within 12h of cardiac surgery. Cardiac index responders and mean arterial pressure-responders were defined as CI ≥10% and mean arterial pressure ≥10%, respectively. We evaluated the gradient for venous-return (mean systemic filling pressure-central venous pressure), arterial load properties (systemic vascular resistance index and elastance index) and changes in vasopressor support after fluid bolus.Measurements and Main Results: Fifty-seven children between 1 month and 16 years (median Risk adjustment after congenital heart surgery Model for Outcome Surveillance in Australia and New Zealand score of 3.8 (interquartile range 3.7-4.6) received fluid bolus. Cardiac index-responsiveness and mean arterial pressure-responsiveness rates were 33% and 56%, respectively. No significant correlation was observed between changes in mean arterial pressure and cardiac index (r = 0.035, p = 0.79). Although the mean systemic filling pressure - central venous pressure and the number of cardiac index-responders after fluid bolus were similar, the arterial load parameters did not change in mean arterial pressure-nonresponders. Forty-three patients (75%) had a change in Vasoactive-Inotrope Score after the fluid bolus, of whom 60% received higher level of vasoactive support.Conclusions: The mean arterial pressure response to fluid bolus in cardiac ICU patients was unpredictable with a poor relationship between cardiac index-responsiveness and mean arterial pressure-responsiveness. Because arterial hypotension is frequently a trigger for administering fluids and changes in blood pressure are commonly used for tracking changes in cardiac output, we suggest a cautious and individualized approach to repeat fluid bolus based solely on lack of mean arterial pressure response to the initial fluid, since the implications include decreased arterial tone even if the cardiac index increases. [ABSTRACT FROM AUTHOR]

Shock is an acute condition of circulatory failure resulting in life-threatening organ dysfunction, high morbidity and high mortality. Current management includes fluid and catecholamine therapy to maintain adequate mean arterial pressure and organ perfusion. Norepinephrine is recommended as first-line vasopressor, but other agents are available. Angiotensin II is an alternative potent vasoconstrictor without chronotropic or inotropic properties. Several studies, including a large randomized controlled trial have demonstrated its ability to increase blood pressure with catecholamine-sparing effects. Angiotensin II was consequently approved by the US FDA in 2017 and the EU in 2019 as an add-on vasopressor in vasodilatory shock. This review aims to discuss its basic pharmacology, clinical efficacy, safety and future perspectives. [ABSTRACT FROM AUTHOR]

The Rapid Ultrasound for Shock and Hypotension (RUSH) examination is used for patients with hypotension without clear cause or undifferentiated hypotension. In the emergency department setting, clinicians may perform the RUSH examination to supplement the physical assessment and differentiate the diagnosis of hypovolemic, obstructive, cardiogenic, and distributive forms of shock. The key elements of the RUSH examination are the pump, tank, and pipes, meaning potentially causes of the hypotension are examined within the heart, vascular volume and integrity, and the vessels themselves. Clinicians follow a systemic protocol to seeking evidence of specific conditions including heart failure exacerbation, cardiac tamponade, pleural effusion, pneumothorax, abdominal aortic aneurysm, and deep vein thrombosis. Because ultrasonography is a user-dependent skill, the advanced practice nurse in the emergency department should be educated regarding the RUSH protocol and prepared to implement the examination. [ABSTRACT FROM AUTHOR]

The Rapid Ultrasound for Shock and Hypotension (RUSH) examination is used for patients with hypotension without clear cause or undifferentiated hypotension. In the emergency department setting, clinicians may perform the RUSH examination to supplement the physical assessment and differentiate the diagnosis of hypovolemic, obstructive, cardiogenic, and distributive forms of shock. The key elements of the RUSH examination are the pump, tank, and pipes, meaning potentially causes of the hypotension are examined within the heart, vascular volume and integrity, and the vessels themselves. Clinicians follow a systemic protocol to seeking evidence of specific conditions including heart failure exacerbation, cardiac tamponade, pleural effusion, pneumothorax, abdominal aortic aneurysm, and deep vein thrombosis. Because ultrasonography is a user-dependent skill, the advanced practice nurse in the emergency department should be educated regarding the RUSH protocol and prepared to implement the examination. [ABSTRACT FROM AUTHOR]

Objectives: Capillary refill time is a noninvasive method to assess tissue perfusion to determine shock status. Capillary refill time is defined as the time required to regain skin color after blanching pressure is applied. Although common methods to measure capillary refill time depend on clinicians' visual assessment, a new approach using a pulse oximeter waveform analysis exists, referred to as full finger reperfusion time. We aim to evaluate reproducibility and validity of the novel full finger reperfusion time measurement using clinicians' visual capillary refill time assessment as a reference standard.Design: Prospective observational study.Setting: PICUs and operating suites at a large academic children's hospital.Patients: Ninety-nine children 1-12 years old with various skin color tones.Interventions: Each child had 10 measurements, including five full finger reperfusion time and five clinician capillary refill time, alternating second and third digits.Measurements and Main Results: Eighteen children had prolonged capillary refill time (> 2 s) and four children with capillary refill time greater than 3 seconds. Four-hundred eighty-five data pairs were analyzed. Intraclass correlation coefficient of full finger reperfusion time within each patient was 0.76 (95% CI, 0.68-0.83), demonstrating good reproducibility. Correlation coefficient between full finger reperfusion time and clinician capillary refill time was moderate: r = 0.37 (p < 0.0001; 95% CI, 0.29-0.44) for the pairs and r = 0.52 (p < 0.0001; 95% CI, 0.36-0.65) for patient average. Bland-Altman plot showed a consistent difference between full finger reperfusion time and clinician capillary refill time (full finger reperfusion time 1.14 s longer). Weak association was found between force and full finger reperfusion time (β = -0.033 ± 0.016; 95% CI, -0.065 to -0.0016; p = 0.04), finger thickness (β = -0.20 ± 0.089; 95% CI, -0.37 to -0.19; p = 0.03), except for color tone (p = 0.31). Finger temperature was associated with full finger reperfusion time (β = -0.18 ± 0.041; 95% CI, -0.26 to -0.0999; p < 0.0001).Conclusions: Full finger reperfusion time demonstrated good reproducibility. Full finger reperfusion time showed moderate correlation with clinician capillary refill time. Full finger reperfusion time was 1.14 seconds longer than capillary refill time. Future studies should focus on the clinical value of full finger reperfusion time as a monitoring device for hemodynamics in critically ill children. [ABSTRACT FROM AUTHOR]

Objectives: To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality.Design: Multicenter prospective cohort study between September 2017 and February 2018.Settings: Thirty-four hospitals in the United States and Jordan.Patients: Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor.Interventions: None.Measurement and Main Results: Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18).Conclusions: The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration. [ABSTRACT FROM AUTHOR]

Road traffic injuries in Thailand are the major cause of death and disabilities in young adults. The presence of shock plays an important role in clinical outcomes. This cross-sectional study aimed to determine the incidence of shock and to identify factors predicting the presence of shock on discharge from the emergency department in patients sustaining moderate to serious road traffic injuries in Thailand. Five hundred and three patients (N=503), who scored at least 16 on the Injury Severity Score on admission to an emergency department were recruited. Population and contextual variables were collected from patients' medical records and patients and triage nurses' interviews. Two standardized tools were used to measure the severity of injury and the presence of shock. Data analyses included descriptive statistics, univariate analysis and multivariate logistical regression. Results indicated that the majority of patients were males, wearing no safety devices and had consumed alcohol prior to driving their motorcycle. The incidence of shock on discharge from the emergency department to the operating room, intensive care unit or general ward was 35%. Transport time, injury severity, shock on arrival and time spent in the emergency department all made significant contributions to whether patients were in shock on discharge from the emergency department. Our findings suggest that emergency nurses should perform routine ongoing calculation of Modified Shock Index scores for monitoring the moderately to severely injured. Further studies examining the superiority of the Modified Shock Index over cardiorespiratory parameters alone could provide evidence to consider the inclusion of this Index into best practice guidelines. [ABSTRACT FROM AUTHOR]