Search

The management of patients in shock or arrest is a critical aspect of emergency medicine and critical care. Rapid and accurate assessment is paramount in determining the underlying causes and initiating timely interventions. This article provides a summary of essential ultrasound protocols for the critically ill patient including the extended focused assessment with sonography for trauma (EFAST), rapid ultrasound for shock and hypotension (RUSH), and sonography in hypotension and cardiac arrest in the emergency department (SHoC-ED)., Competing Interests: Disclosure Dr J. Rosario has no financial disclosures. Dr J. Lin has no financial disclosures. Dr N. Saltarelli has no financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The primary purpose of this study was to investigate the predictive value of alterations in cervical artery hemodynamic parameters induced by a simulated end-inspiratory occlusion test (sEIOT) measured by ultrasound for predicting postinduction hypotension (PIH) during general anesthesia., Methods: Patients undergoing gastrointestinal tumor resection under general anesthesia were selected for this study. Ultrasound has been utilized to assess hemodynamic parameters in carotid artery blood flow before induction, specifically focusing on variations in corrected flow time (ΔFTc) and peak blood flow velocity (ΔCDPV), both before and after sEIOT. Anesthesia was induced by midazolam, sufentanil, propofol, and rocuronium, and blood pressure (BP) and heart rate (HR) were recorded within the first 10 min following endotracheal intubation. PIH was defined as fall in systolic blood pressure (SBP) or mean arterial pressure (MAP) by > 30% of baseline or MAP to < 60 mm Hg., Results: The area under the receiver operating characteristic curves (AUC) for carotid artery ΔFTc was 0.88 (95%CI, 0.81 to 0.96; P < 0.001), and the optimal cutoff value was -16.57%, with a sensitivity of 91.4% and specificity of 77.60%. The gray zone for carotid artery ΔFTc was -16.34% to -15.36% and included 14% of the patients. The AUC for ΔCDPV was 0.54, with an optimal cutoff value of -1.47%. The sensitivity and specificity were calculated as 55.20% and 57.10%, respectively., Conclusion: The corrected blood flow time changes in the carotid artery induced by sEIOT can predict hypotension following general anesthesia-induced hypotension, wherein ΔFTc less than 16.57% is the threshold., Trial Registration: Chinese Clinical Trial Registry ( www.chictr.org.cn ; 20/06/2023; ChiCTR2300072632)., (© 2023. The Author(s).)

Background: Shock and preshock are defined on the basis of the presence of hypotension, hypoperfusion, or both. We sought to determine the hemodynamic underpinnings of shock and preshock noninvasively using transthoracic echocardiography (TTE)., Methods and Results: We included Mayo Clinic cardiac intensive care unit patients from 2007 to 2015 with TTE within 1 day of admission. Hypotension and hypoperfusion at the time of cardiac intensive care unit admission were used to define 4 groups. TTE findings were evaluated across these groups, and in-hospital mortality was evaluated according to TTE findings in each group. We included 5375 patients with a median age of 69.2 years (36.8% women). The median left ventricular ejection fraction was 50%. Groups based on hypotension and hypoperfusion were assigned as follows: no hypotension or hypoperfusion, 59.7%; isolated hypotension, 15.3%; isolated hypoperfusion, 16.4%; and both hypotension and hypoperfusion, 8.7%. Most TTE variables of interest varied across these groups, with worse biventricular function, lower forward flow, and higher filling pressures as the degree of hemodynamic compromise increased. In-hospital mortality occurred in 8.2%, and inpatient deaths had more TTE parameter abnormalities. In-hospital mortality increased with the degree of hemodynamic compromise, and a marked gradient in in-hospital mortality was observed when the clinical classification of shock and preshock was combined with TTE findings reflecting worse biventricular function, lower forward flow, or higher filling pressures., Conclusions: Substantial differences in cardiac function are observed between cardiac intensive care unit patients with preshock and shock using TTE, and the combination of the clinical and TTE hemodynamic assessment provides robust mortality risk stratification.

Background: Accurately determining the fluid status of a patient during resuscitation in the emergency department (ED) helps guide appropriate fluid administration in the setting of undifferentiated hypotension. Our goal was to determine the diagnostic utility of point-of-care ultrasound (PoCUS) for inferior vena cava (IVC) size and collapsibility in predicting a volume overload fluid status in spontaneously breathing hypotensive ED patients., Methods: This was a post hoc secondary analysis of the SHOC-ED data, a prospective randomized controlled trial investigating PoCUS in patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility for 138 patients in the PoCUS group using a standard data collection form, and independently assigned a fluid status (volume overloaded, normal, volume deplete) from a composite clinical chart review blinded to PoCUS findings. The primary outcome was the diagnostic performance of IVC characteristics on PoCUS in the detection of a volume overloaded fluid status., Results: One hundred twenty-nine patients had completed determinant IVC assessment by PoCUS, with one hundred twenty-five receiving successful final fluid status determination, of which one hundred and seven were classified as volume deplete, thirteen normal, and seven volume overloaded. A receiver operating characteristic (ROC) curve was plotted using several IVC size and collapsibility categories. The best overall performance utilized the combined parameters of a dilated IVC (> 2.5 cm) with minimal collapsibility (less than 50%) which had a sensitivity of 85.7% and specificity of 86.4% with an area under the curve (AOC) of 0.92 for predicting an volume overloaded fluid status., Conclusion: IVC PoCUS is feasible in spontaneously breathing hypotensive adult ED patients, and demonstrates potential value as a predictor of a volume overloaded fluid status in patients with undifferentiated hypotension. IVC size may be the preferred measure., (© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: Prophylactic vasopressor infusion can effectively assist with fluid loading to prevent spinal anesthesia-induced hypotension. However, the ideal dose varies widely among individuals. We hypothesized that hypotension-susceptible patients requiring cesarean section (C-section) could be identified using combined ultrasound parameters to enable differentiated prophylactic medical interventions., Methods: This prospective observational trial was carried out within a regional center hospital for women and children in Sichuan Province, China. Singleton pregnant women undergoing combined spinal-epidural anesthesia for elective C-sections were eligible. Women with contraindications to spinal anesthesia or medical comorbidities were excluded. Velocity time integral (VTI) and left ventricular end-diastolic area (LVEDA) in the supine and left lateral positions were measured on ultrasound before anesthesia. Stroke volume, cardiac output, and the percentage change (%) in each parameter between two positions were calculated. Vital signs and demographic data were recorded. Spinal anesthesia-induced hypotension was defined as a mean arterial pressure decrease of > 20% from baseline. The area under the receiver operating characteristic curve (AUROC) was used to analyze the associations of ultrasound measurements, vital signs, and demographic characteristics with spinal anesthesia-induced hypotension. This exploratory study did not have a predefined outcome; however, various parameter combinations were compared using the AUROC to determine which combined parameters had better predictive values., Results: Patients were divided into the normotension (n = 31) and hypotension groups (n = 57). A combination of heart rate (HR), LVEDA s , and VTI% was significantly better at predicting hypotension than was HR (AUROC 0.827 vs. 0.707, P = 0.020) or LVEDA s (AUROC 0.827 vs. 0.711, P = 0.039) alone, but not significantly better than VTI% alone (AUROC 0.827 vs. 0.766, P = 0.098)., Conclusion: The combined parameters of HR and LVEDA s with VTI% may predict spinal anesthesia-induced hypotension more precisely than the single parameters. Future research is necessary to determine whether this knowledge improves maternal and neonatal outcomes., Trial Registration: ChiCTR1900025191., (© 2023. The Author(s).)

Introduction: Post-contrast acute kidney injury (PC-AKI) is a major complication of contrast media usage; risks for PC-AKI are generally evaluated before computed tomography (CT) with contrast at the emergency department (ED). Although persistent hypotension (systolic blood pressure [sBP] <80 mm Hg for 1 h) is associated with increased PC-AKI incidence, it remains unclear whether transient hypotension that is haemodynamically stabilized before CT is a risk of PC-AKI. We hypothesized that hypotension on ED arrival would be associated with higher PC-AKI incidence even if CT with contrast was performed after patients are appropriately resuscitated., Methods: This multicentre retrospective observational study was conducted at three tertiary care centres during 2013-2014. We identified 280 patients who underwent CT with contrast at the ED. Patients were classified into two groups based on sBP on arrival (<80 vs. ≥80 mm Hg); hypotension was considered as transient because CT with contrast has always been performed after patients were stabilized at participating hospitals. PC-AKI incidence was compared between the groups; inverse probability weighting (IPW) was conducted to adjust background characteristics., Results: Eighteen patients were excluded due to chronic haemodialysis, cardiac arrest on arrival, or death within 72 h; 262 were eligible for this study. PC-AKI incidence was higher in the transient hypotension group than the normotension group {7/27 (28.6%) vs. 24/235 (10.2%), odds ratio (OR) 3.08 (95% confidence interval [CI] 1.18-8.03), p = 0.026}, which was confirmed by IPW (OR 3.25 [95% CI 1.99-5.29], p < 0.001)., Conclusion: Transient hypotension at the ED was associated with PC-AKI development., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Preoperative ultrasound assessment of inferior vena cava (IVC) diameter and the collapsi-bility index might identify patients with intravascular volume depletion. The purpose of this review was to gather the existing evidence to find out whether preoperative IVC ultrasound (IVCUS) derived parameters can reliably predict hypotension after spinal or general anaesthesia. PubMed was searched to identify research articles that addressed the role of IVC ultrasound in predicting hypotension after spinal and general anaesthesia in adult patients. We included 4 randomized control trials and 17 observational studies in our final review. Among these, 15 studies involved spinal anaesthesia and 6 studies involved general anaesthesia. Heterogeneity with respect to the patient populations under evaluation, definitions used for hypotension after anaesthesia, IVCUS assessment methods, and cut-off values for IVCUS-derived parameters to predict hypotension precluded pooled meta-analysis. The maximum and minimum reported sensitivity of the IVC collapsibility index (IVCCI) for predicting post-spinal hypotension was 84.6% and 58.8% respectively, while the maximum and minimum specificities were 93.1% and 23.5% respectively. For the prediction of hypotension after general anaesthesia induction, the reported ranges of sensitivity and specificity of IVCCI were 86.67% to 45.5% and 94.29% to 77.27%, respectively. Current literature on the predictive role of IVCUS for hypotension after anaesthesia is heterogeneous both in methodology and in results. Standardization of the definition of hypotension under anaesthesia, method of IVCUS assessment, and the cut-offs for IVC diameter and the collapsibility index for prediction of hypotension after anaesthesia are necessary for drawing clinically relevant conclusions.

Purpose: Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension., Methods: This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis., Results: Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9-98.5) vs.93.8% (87.7-97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88-97.2) vs 93.6% (87.8-97.2)]. Diagnostic performance measures were similar across sub-categories of shock., Conclusion: This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment., (© 2022. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: Point-of-care ultrasound (POCUS) has been adopted as a powerful tool in acute medicine. This systematic review aims to critically appraise the existing literature on point-of-care ultrasound in respiratory or circulatory deterioration., Methods: Original studies on POCUS and dyspnea, nontraumatic hypotension, and shock from March 2002 until March 2022 were assessed in the PubMed and Embase Databases. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist., Results: We included 89 articles in this review. Point-of-care ultrasound in the initial workup increases the diagnostic accuracy in patients with dyspnea, nontraumatic hypotension and shock in the ED, ICU and medical ward setting. No improvement is found in patients with severe sepsis in the ICU setting. POCUS is capable of narrowing the differential diagnoses and is faster, and more feasible in the acute setting than other diagnostics available. Results on outcome measures are heterogenous. The quality of the included studies is considered low most of the times, mainly because of performance and selection bias and absence of a gold standard as the reference test., Conclusion: We conclude that POCUS contributes to a higher diagnostic accuracy in dyspnea, nontraumatic hypotension, and shock. It aides in narrowing the differential diagnoses and shortening the time to correct diagnosis and effective treatment., Trial Registry: INPLASY; Registration number: INPLASY202220020; URL: https://inplasy.com/., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Purpose: Hypotension is a risk factor for adverse perioperative outcomes. Preoperative transthoracic echocardiography has been extended for preoperative risk assessment before noncardiac surgery. This study aimed to develop a machine learning model to predict postinduction hypotension risk using preoperative echocardiographic data and compared it with conventional statistic models. We also aimed to identify preoperative echocardiographic factors that cause postinduction hypotension., Methods: In this retrospective observational study, we extracted data from electronic health records of patients aged >18 years who underwent general anesthesia at a single tertiary care center between April 2014 and September 2019. Multiple supervised machine learning classification techniques were used, with postinduction hypotension (mean arterial pressure <55 mmHg from intubation to the start of the procedure) as the primary outcome and 95 transthoracic echocardiography measurements as factors influencing the primary outcome. Based on the mean cross-validation performance, we used 10-fold cross-validation with the training set (70%) to select the optimal hyperparameters and architecture, assessed ten times using a separate test set (30%)., Results: Of 1,956 patients, 670 (34%) had postinduction hypotension. The area under the receiver operating characteristic curve using the deep neural network was 0.72 (95% confidence interval (CI) = 0.67-0.76), gradient boosting machine was 0.54 (95% CI = 0.51-0.59), linear discriminant analysis was 0.56 (95% CI = 0.51-0.61), and logistic regression was 0.56 (95% CI = 0.51-0.61). Variables of high importance included the ascending aorta diameter, transmitral flow A wave, heart rate, pulmonary venous flow S wave, tricuspid regurgitation pressure gradient, inferior vena cava expiratory diameter, fractional shortening, left ventricular mass index, and end-systolic volume., Conclusion: We have created developing models that can predict postinduction hypotension using preoperative echocardiographic data, thereby demonstrating the feasibility of using machine learning models of preoperative echocardiographic data for produce higher accuracy than the conventional model., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Yoshimura et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Hypotension is one of the most common complications following induction of general anesthesia. Preemptive diagnosis and correcting the hypovolemic status can reduce the incidence of post-induction hypotension. However, an association between preoperative volume status and severity of post-induction hypotension has not been established in neurosurgical patients. We hypothesized that preoperative ultrasonographic assessment of intravascular volume status can be used to predict post-induction hypotension in neurosurgical patients. Our study objective was to establish the relationship between pre-induction maximum inferior vena cava (IVC) diameter, collapsibility index (CI), and post-induction reduction in mean arterial blood pressure in neurosurgical patients., Materials and Methods: A prospective observational study was conducted including 100 patients undergoing elective intracranial surgeries. IVC assessment was done before induction of general anesthesia. Receiver operating characteristic (ROC) curve analysis was used to determine the cutoff values of maximum and minimum IVC diameter (IVCD max and IVCD min , respectively) and CI for prediction of hypotension., Results: Post-induction hypotension was observed in 41% patients. Patients with small IVCD max and higher CI% developed hypotension. The areas under the ROC curve (AUCs) were 0.64 (0.53-0.75) for IVCD max and 0.69 (0.59-0.80) for IVCD min . The optimal cutoff values were1.38 cm for IVCD max and 0.94 cm for IVCD min . The AUC for CI was 0.65 (0.54-0.77) and the optimal cutoff value was 37.5%., Conclusion: Pre-induction IVC assessment with ultrasound is a reliable method to predict post-induction hypotension resulting from hypovolemia in neurosurgical patients., Competing Interests: None

Introduction: Intraoperative hypotension (IH) is an independent predictor of mortality. Some experts have suggested that ultrasound measurement of the inferior vena cava (IVC) in spontaneous ventilation can predict IH., Objective: To evaluate the capacity of ultrasound measures of IVC in spontaneous ventilation to predict episodes of IH after anaesthesia induction., Patients and Methods: We studied 55 high-risk cardiac patients undergoing vascular surgery. The maximum (dIVCmax) and minimum (dIVCmin) diameter of the IVC were measured and the collapsibility index CI = (dIVCmax-dIVCmin)/dIVCmax was calculated prior to anaesthesia induction. Three definitions of IH were used: systolic blood pressure (SBP) less than 100 mmHg, mean arterial pressure (MAP) less than 60 mmHg, and a decrease in MAP greater than or equal to 30% compared to baseline., Results: There were no significant differences in dIVCmax or in CI between patients presenting IH after anaesthesia induction and those who did not. ROC curves for dIVCmax showed an area under the curve of 0.55 (0.39-0.70), 0.69 (0.48-0.90), and 0.57 (0.42-0.73) and ROC curves for the CI were 0.62 (0.47-0.78), 0.60 (0.41-0.78) and 0.62 (0.47-0.78) for the 3 definitions of IH (<100 mmHg, MAP < 60 mmHg, and MAP ≥30% baseline), respectively., Conclusions: Ultrasound measurements of IVC in spontaneous ventilation are not good predictors of IH after anaesthesia induction in these patients. The optimal cut-off points show low specificity and moderate sensitivity for predicting IH., (Copyright © 2021 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Focused cardiac ultrasound (FoCUS) has become a valuable tool to assess unexplained hypotension in critically ill patients. Due to increasing availability of transthoracic echocardiography (TTE) equipment in the operating room, there is a widespread interest in its usefulness for intraoperative diagnosis of hypotension as an alternative to transesophageal echocardiography (TEE). The objective of this systematic review is to evaluate the utility of intraoperative FoCUS to assess patients experiencing unexplained hypotension while undergoing noncardiac surgery. We performed a systematic literature search of multiple publication databases for studies that evaluated the utility of intraoperative FoCUS for assessment and management of unexplained hypotension in patients undergoing noncardiac surgery, including retro- and prospective clinical studies. A summary of the study findings, study quality, and assessment of level of evidence is presented. We identified 2227 unique articles from the literature search, of which 27 were potentially relevant, and 9 were included in this review. The number of patients pooled from these studies was 255, of whom 228 had intraoperative diagnoses with the aid of intraoperative FoCUS. The level of evidence of all studies included was very low according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. This systematic review has demonstrated that FoCUS may be a useful, noninvasive method to differentiate causes of intraoperative hypotension and guide correcting interventions, although the quality of evidence is very low. Further prospective high-quality studies are needed to investigate whether intraoperative FoCUS has a diagnostic utility that is associated with improved outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Purpose: We sought to assess whether ultrasound (US) measurements of carotid flow time (CFTc) and carotid blood flow (CBF) predict fluid responsiveness in patients with suspected sepsis., Methods: This was a prospective observational study of hypotensive (systolic blood pressure < 90) patients "at risk" for sepsis receiving intravenous fluids (IVF) in the emergency department. US measurements of CFTc and CBF were performed at time zero and upon completion of IVF. All US measurements were repeated after a passive leg raise (PLR) maneuver. Fluid responsiveness was defined as normalization of blood pressure without persistent hypotension or need for vasopressors., Results: A convenience sample of 69 patients was enrolled. The mean age was 65; 49% were female. Fluid responders comprised 52% of the cohort. CFTc values increased significantly with both PLR (P = 0.047) and IVF administration (P = 0.003), but CBF values did not (P = 0.924 and P = 0.064 respectively). Neither absolute CFTc or CBF measures, nor changes in these values with PLR or IVF bolus, predicted fluid responsiveness, mortality, or the need for intensive care unit admission., Conclusion: In patients with suspected sepsis, a fluid challenge resulted in a significant change in CFTc, but not CBF. Neither absolute measurement nor delta measurements with fluid challenge predicted clinical outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by the Shock Society.)

Background: Late recovery in patients following prolonged coma from carbon monoxide poisoning have been reported, but the probability is unclear. The purpose of this research was to assess the prognosis of patients in prolonged coma after severe carbon monoxide poisoning and related clinical and imaging features., Methods: There were 13 patients who had been in a state of coma for >7 days after acute carbon monoxide poisoning in the retrospective observational study, and demographic data, clinical data, laboratory data, complications, and image data were collected. Outcome was assessed by means of the Glasgow outcome scale after 1 year. The relationship between complications and imaging manifestations and prognosis was also analyzed., Results: One year after severe carbon monoxide poisoning, two patients (15.4%) had died (GOS 1), nine (69.2%) were in a persistent vegetative state (GOS 2), one (7.7%) was moderately disabled (GOS 4), and one (7.7%) achieved a good recovery (GOS 5) with minimal disability., Conclusions: Most patients with prolonged coma after severe carbon monoxide poisoning had a poor prognosis, although the younger patients had a better prognosis. Respiratory failure, hypotension and renal failure during the course of the disease were associated with a poor prognosis. The prognosis of patients with injuries in two sites in early CT was poor. Multiple lesions (≥3) and extensive white matter damage (Fazekas grade (PVH or DWMH) = 3) on MRI of chronic phase were also associated with a poor prognosis.

Introduction: Ultrasound hypotension protocols (UHP) involve imaging multiple body areas, each with different transducers and imaging presets. The time for task switching between presets and transducers to perform an UHP has not been previously studied. A novel hand-carried ultrasound (HCU) has been developed that uses a multifrequency single transducer to image areas of the body (lung, heart, abdomen, superficial) that would typically require three transducers using a traditional cart-based ultrasound (CBU) system. Our primary aim was to compare the time to complete UHPs with a single transducer HCU to a multiple transducer CBU., Methods: We performed a randomized, crossover feasibility trial in the emergency department of an urban, safety-net hospital. This was a convenience sample of non-hypotensive emergency department patients presenting during a two-month period of time. Ultrasound hypotension protocols were performed by emergency physicians (EP) on patients using the HCU and the CBU. The EPs collected UHP views in sequential order using the most appropriate transducer and preset for the area/organ to be imaged. Time to complete each view, time for task switching, total time to complete the examination, and image diagnostic quality were recorded., Results: A total of 29 patients were scanned by one of eight EPs. When comparing the HCU to the CBU, the median time to complete the UHP was 4.3 vs 8.5 minutes (P <0.0001), respectively. When the transport and plugin times were excluded, the median times were 4.1 vs 5.8 minutes (P <0.0001), respectively. There was no difference in the diagnostic quality of images obtained by the two devices., Conclusion: Ultrasound hypotension protocols were performed significantly faster using the single transducer HCU compared to a multiple transducer CBU with no difference in the number of images deemed to be diagnostic quality.

In chronic hemodialysis (HD) patients, intradialytic hypotension (IDH) is a complication that increases mortality risk. We run a pilot study to analyzing possible relationships between optical coherence tomography angiography (OCT-A) metrics and IDH with the aim of evaluating if OCT-A could represent a useful tool to stratify the hypotensive risk in dialysis patients. A total of 35 eyes (35 patients) were analyzed. OCT-A was performed before and after a single dialysis session. We performed OCT-A 3 × 3 mm and 6 × 6 mm scanning area focused on the fovea centralis. Patients were then followed up to 30 days (10 HD sessions) and a total of 73 IDHs were recorded, with 12 patients (60%) experiencing at least one IDH. Different OCT-A parameters were reduced after dialysis: central choroid thickness (CCT), 6 × 6 mm foveal whole vessel density (VD) of superficial capillary plexus (SPC) and 6 × 6 mm foveal VD of deep capillary plexus (DCP). At logistic regression analysis, IDH was positively associated with baseline foveal VD of SCP and DCP, while an inverse association was found with the choroid. In Kaplan-Meier analyses of patients categorized according to the ROC-derived optimal thresholds, CCT, the 3 × 3 foveal VD of SCP, the 3 × 3 mm and 6 × 6 mm foveal VD of DCP and the 6 × 6 mm foveal VD of SCP were strongly associated with a higher risk of IDH over the 30-days follow-up. In HD patients, a single OCT-A measurement may represent a non-invasive, rapid tool to evaluate the compliance of vascular bed to HD stress and to stratify the risk of IDH in the short term.

Vascular Endothelial Growth Factor (VEGF), a key mediator of angiogenesis and vascular repair, is reduced in chronic ischemic renal diseases, leading to microvascular rarefaction and deterioration of renal function. We developed a chimeric fusion of human VEGF-A 121 with the carrier protein Elastin-like Polypeptide (ELP-VEGF) to induce therapeutic angiogenesis via targeted renal VEGF therapy. We previously showed that ELP-VEGF improves renal vascular density, renal fibrosis, and renal function in swine models of chronic renal diseases. However, VEGF is a potent cytokine that induces angiogenesis and increases vascular permeability, which could cause undesired off-target effects or be deleterious in a patient with a solid tumor. Therefore, the current study aims to define the toxicological profile of ELP-VEGF and assess its risk for exacerbating tumor progression and vascularity using rodent models. A dose escalating toxicology assessment of ELP-VEGF was performed by administering a bolus intravenous injection at doses ranging from 0.1 to 200 mg/kg in Sprague Dawley (SD) rats. Blood pressure, body weight, and glomerular filtration rate (GFR) were quantified longitudinally, and terminal blood sampling and renal vascular density measurements were made 14 days after treatment. Additionally, the effects of a single administration of ELP-VEGF (0.1-10 mg/kg) on tumor growth rate, mass, and vascular density were examined in a mouse model of breast cancer. At doses up to 200 mg/kg, ELP-VEGF had no effect on body weight, caused no changes in plasma or urinary markers of renal injury, and did not induce renal fibrosis or other histopathological findings in SD rats. At the highest doses (100-200 mg/kg), ELP-VEGF caused an acute, transient hypotension (30 min), increased GFR, and reduced renal microvascular density 14 days after injection. In a mouse tumor model, ELP-VEGF did not affect tumor growth rate or tumor mass, but analysis of tumor vascular density by micro-computed tomography (μCT) revealed significant, dose dependent increases in tumor vascularity after ELP-VEGF administration. ELP-VEGF did not induce toxicity in the therapeutic dosing range, and doses one hundred times higher than the expected maximum therapeutic dose were needed to observe any adverse signs in rats. In breast tumor-bearing mice, ELP-VEGF therapy induced a dose-dependent increase in tumor vascularity, demanding caution for potential use in a patient suffering from kidney disease but with known or suspected malignancy.

Objective: To determine the role of internal jugular vein (IJV) ultrasonography to predict postspinal hypotension in patients undergoing elective surgery., Study Design: A prospective observational study., Place and Duration of Study: Department of Anesthesiology and Reanimation, Osmangazi University, Eskişehir, Turkey, from January to September 2020., Methodology: Patients aged between 18 and 65 years, who underwent elective surgery under spinal anesthesia, were included in the study. Sonographic examination of IJV was performed before spinal anesthesia. Significant postspinal hypotension was defined as a mean arterial pressure less than 65 mmHg or more than 20% decrease compared to the baseline value. The patients were classified as hypotensive and non-hypotensive groups. The association between sonographic IJV measurements and postspinal hypotension was analysed., Results: The evaluation was performed on 47 patients. Twenty-two (46.8%) patients developed postspinal hypotension. The two groups were similar in all baseline characteristics (p>0.05). Among all sonographic measurements, IJV collapsibility index was significantly different between the two groups (p=0.014). Receiver operating characteristic curve analysis showed that IJV collapsibility index had a sensitivity of 64% and a specificity of 63.6% to predict the postspinal hypotension at a cut-off point of 22.6%. Area under curve (AUC) was 0.709., Conclusion: Despite the moderate sensitivity and specifity rates, IJV collapsibility index can be considered as an alternative predictor of postspinal hypotension. Key Words: Internal jugular vein, Postspinal hypotension, Spinal anesthesia, Ultrasonography.

Cardiac output may increase after volume administration with relative intravascular volume depletion, or after ultrafiltration (UF) with relative intravascular volume overload. Assessing relative intravascular volume using respiratory/ventilatory changes in inferior vena cava (IVC) diameters may guide volume management to optimize cardiac output in critically ill patients requiring hemodialysis (HD) and/or UF.We retrospectively studied 22 critically ill patients having relative intravascular volume assessed by IVC Collapsibility Index (IVC CI) = (IVCmax-IVCmin)/IVCmax*100%, within 24 h of cardiac output measurement, during 37 intermittent and 21 continuous HD encounters. Cardiac output increase >10% was considered significant. Net volume changes between cardiac outputs were estimated from "isonatremic volume equivalent" (0.9% saline) gains and losses.Cardiac output increased >10% in 15 of 42 encounters with IVC CI <20% after net volume removal, and in 1 of 16 encounters with IVC CI ≥20% after net volume administration ( p  = 0.0136). All intermittent and continuous HD encounters resulted in intradialytic hypotension. Net volume changes between cardiac output measurements were significantly less (median +1.0 mL/kg) with intractable hypotension or vasopressor initiation, and net volume removal was larger (median -22.9 mL/kg) with less severe intradialytic hypotension ( p  < 0.001). Cardiac output increased >10% more frequently with least severe intradialytic hypotension and decreased with most severe intradialytic hypotension ( p  = 0.047).In summary, cardiac output may increase with net volume removal by ultrafiltration in some critically ill patients with relative intravascular volume overload assessed by IVC collapsibility. Severe intradialytic hypotension may limit volume removal with ultrafiltration, rather than larger volume removal causing severe intradialytic hypotension.

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.

Competing Interests: Competing interests: None declared.

Background: Bedside sonography of the inferior vena cava has been demonstrated to be a reliable tool for assessing intravascular volume status. Subclavian vein (SCV) assessment was proposed as a reasonable adjunct for measuring the inferior vena cava., Objective: We examined whether the preoperative diameter and collapsibility index of the SCV or the infraclavicular axillary vein could predict the incidence of hypotension after induction of general anaesthesia in patients undergoing laparoscopic cholecystectomy., Design: Prospective, observational study., Setting: Tertiary university hospital., Patients: Adults scheduled for laparoscopic cholecystectomy., Intervention: Sonographic evaluation of the SCV or the axillary vein (SCV-AV) before induction of anaesthesia., Main Outcome Measures: The main outcome was the association between the SCV-AV measurements (diameter an collapsibility index) and intra-operative hypotension (IOH) after induction of anaesthesia., Results: Patients who developed IOH had a higher collapsibility index of the SCV-AV during spontaneous breathing (P = 0.009) and deep inspiration (P = 0.002). After adjusting for confounding variables, the collapsibility index of the SCV-AV during spontaneous breathing was not a significant predictor of a decrease in mean arterial blood pressure (MAP) after inducing anaesthesia (P = 0.127), whereas the collapsibility index of the SCV-AV during deep inspiration was a significant predictor (P < 0.001)., Conclusion: The collapsibility index of the SCV-AV during deep inspiration was a significant predictor of IOH occurrence and the percentage decrease in MAP after inducing anaesthesia. Further studies in patients with higher collapsibility index are needed to confirm our findings, before the collapsibility index of the SCV-AV can be recommended unequivocally for clinical use., Trial Registration: This trial was registered on 8 September 2017 at the Clinical Trial Registry of Korea (https://cris.nih.go.kr/cris/index.jsp; Identifier: KCT0001078KCT0002457), and the first patient was enrolled on 14 October 2017.

Background: Mechanical thrombectomy (MT) for acute ischemic stroke can be performed under local anesthesia, with or without conscious sedation (CS), or under general anesthesia (GA). The hemodynamic consequence of anesthetic drugs may explain why GA may be associated with worse outcomes. We evaluated the association between hypotension duration during MT and the 90 day functional outcome under both anesthetic regimens., Methods: Patients were included in this retrospective study if they had an ischemic stroke treated by MT under GA or CS. The main exposure variable was the time below 90% of the reference value of arterial pressure measured before MT. The primary outcome was poor functional outcome defined as a 90 day modified Rankin Score ≥3., Results: 371 patients were included in the study. GA was performed in 42%. A linear association between the duration of arterial hypotension and outcome was observed. The odds ratio for poor functional outcome of 10 min under 90% of the baseline mean arterial pressure was 1.13 (95% CI 1.06 to 1.21) without adjustment and 1.11 (95% CI 1.02 to 1.21) after adjustment for confounding factors. The functional outcome was poorer for patients treated under GA compared with CS, but the association with the depth of hypotension remained similar under both conditions., Conclusion: In this study, we observed a linear association between the duration of hypotension during MT and the functional outcome at 90 days. An aggressive and personalized strategy for the treatment of hypotension should be considered. Further trials should be conducted to address this question., Competing Interests: Competing interests: EG received consultancy fees from Magnisense and Adrenomed and research grant from Retia Medical., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The aim of the present study was to evaluate the relationship of fluid-attenuated inversion recovery (FLAIR) vascular hyperintensities (FVH) with haemodynamic abnormality and severity of arterial stenosis in patients with transient ischemic attack (TIA) of the carotid artery system. Patients and Methods . Consecutive inpatients ( N  = 38) diagnosed with TIAs of the carotid system in a 4-year period (2014-2017) were retrospectively analysed in our study and divided into FVH-negative and FVH-positive groups based on the presence of FVH sign. Each inpatient had undergone magnetic resonance imaging (MRI) followed by computed tomography (CT) perfusion imaging studies. We investigated the degree of arterial stenosis, number of stenosis, watershed regions, and related CT perfusion indexes, including hypoperfusion regions, mean transit time (MTT), cerebral blood flow (CBF), and cerebral blood volume (CBV). Spearman rank correlation was performed between FVHs score, the degree of arterial stenosis, and CT perfusion indexes with significant difference., Results: Thirty-one patients (81.6%) observed with FVH sign were assigned to the FVH-positive group. The hypoperfusion regions, MTT, and CBF values were significantly different between the FVH-negative group and FVH-positive groups. Spearman correlation analysis showed significant positive correlations between hypoperfusion regions, MTT, and FVHs scores ( r  = 0.755 and 0.674, respectively, p < 0.01); a moderate negative correlation was found between CBF and FVHs scores ( r  = 0.755 and 0.674, respectively, p < 0.01); a moderate negative correlation was found between CBF and FVHs scores ( r  = 0.755 and 0.674, respectively, p < 0.01); a moderate negative correlation was found between CBF and FVHs scores (., Conclusion: Hyperintense vessels on FLAIR were closely associated with hypoperfused regions, MTT, and CBF values, which indicated that the presence of FVHs could be an important and convenient imaging marker of haemodynamic impairment in patients with TIA., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Bei Ding et al.)

Increased concentrations of the vasodilator histamine have been observed in patients undergoing abdominal surgery. The role of histamine during orthotopic liver transplantation (OLT) has only been studied in animals. The aim of this study was to measure plasma concentrations of histamine and its degrading enzyme diamine oxidase (DAO) in patients undergoing orthotopic liver transplantation, and assess whether histamine or DAO correlate with intraoperative noradrenaline requirements. Histamine and DAO concentrations were measured in 22 adults undergoing liver transplantation and 22 healthy adults. Furthermore, norepinephrine requirements during liver transplantation were recorded. Baseline concentrations of histamine and DAO were greater in patients, who underwent liver transplantation, than in healthy individuals (Histamine: 6.4 nM, IQR[2.9-11.7] versus 4.3 nM, IQR[3.7-7.1], p = 0.029; DAO: 2.0 ng/mL, IQR[1.5-4.1] versus <0,5 ng/mL, IQR[<0.5-1.1], p < 0.001). During liver transplantation, histamine concentrations decreased to 1.8 nM, IQR[0.5-4.9] in the anhepatic phase (p < 0.0001 versus baseline), and to 1.5 nM, IQR[0.5-2.9] after reperfusion (p < 0.0001 versus baseline). In contrast, DAO concentrations increased to 35.5 ng/ml, IQR[20-50] in the anhepatic phase (p = 0.001 versus baseline) and to 39.5 ng/ml, IQR[23-64] after reperfusion (p = 0.001 versus baseline), correlating inversely with histamine. Norepinephrine requirements during human liver transplantation correlated significantly with DAO concentrations in the anhepatic phase (r = 0.58, p = 0.011) and after reperfusion (r = 0.56; p = 0.022). In patients undergoing orthotopic liver transplantation, histamine concentrations decrease whereas DAO concentrations increase manifold. Diamine oxidase correlates with intraoperative norepinephrine requirements in patients undergoing OLT.

Background: Intradialytic hypotension, a complication of intermittent hemodialysis, decreases the efficacy of dialysis and increases long-term mortality. This study was aimed to determine whether different predialysis ultrasound cardiopulmonary profiles could predict intradialytic hypotension., Methods: This prospective observational single-center study was performed in 248 critically ill patients with acute kidney injury undergoing intermittent hemodialysis. Immediately before hemodialysis, vena cava collapsibility was measured by vena cava ultrasound and pulmonary congestion by lung ultrasound. Factors predicting intradialytic hypotension were identified by multiple logistic regression analysis., Results: Intradialytic hypotension was observed in 31.9% (n = 79) of the patients, interruption of dialysis because of intradialytic hypotension occurred in 6.8% (n = 31) of the sessions, and overall 28-day mortality was 20.1% (n = 50). Patients were classified in four ultrasound profiles: (A) 108 with B lines > 14 and vena cava collapsibility > 11.5 mm m -2 , (B) 38 with B lines < 14 and vena cava collapsibility ≤ 11.5 mm m -2 , (C) 36 with B lines > 14 and vena cava collapsibility Di ≤ 11.5 mm m -2 , and (D) 66 with B lines < 14 and vena cava collapsibility > 11.5 mm m -2 . There was an increased risk of intradialytic hypotension in patients receiving norepinephrine (odds ratios = 15, p = 0.001) and with profiles B (odds ratios = 12, p = 0.001) and C (odds ratios = 17, p = 0.001)., Conclusion: In critically ill patients on intermittent hemodialysis, the absence of hypervolemia as assessed by lung and vena cava ultrasound predisposes to intradialytic hypotension and suggests alternative techniques of hemodialysis to provide better hemodynamic stability.

Acute promyelocytic leukaemia differentiation syndrome (APL DS) is seen when patients with APL are treated with all-trans retinoic acid (ATRA) and/or arsenic trioxide (ATO). Presenting symptoms are varied but frequently include dyspnoea, unexplained fever, weight gain >5 kg, unexplained hypotension, acute renal failure and a chest radiograph demonstrating pulmonary infiltrates or pleural or pericardial effusion. Immediate treatment with steroids at the first clinical suspicion is recommended and ATRA/ATO should be stopped in severe cases or if there is no response to treatment. The utility of steroid prophylaxis in order to prevent APL DS is less certain. Here we provide a detailed review of the pathogenesis, clinical signs and symptoms as well as management and prophylaxis strategies of APL DS., (© 2019 British Society for Haematology and John Wiley & Sons Ltd.)

Background: For patients with end stage renal disease undergoing hemodialysis, erythrocytosis occurs rarely. Erythrocytosis increases the risk of thrombosis, which is a common complication in hemodialysis patients. The risk of thrombosis may also be increased by hypotension. The purpose of our report is to examine the relationship between intradialytic hypotension and erythrocytosis., Case Presentation: We present a series of five patients with end stage renal disease and erythrocytosis (peak hemoglobin range 15.2-18.5 g/dL). All were erythropoiesis-stimulating agent naïve and non-smokers. Prior to developing erythrocytosis, each patient developed recurring episodes of intradialytic hypotension over several months. A statistically significant inverse correlation was observed between nadir intradialytic systolic blood pressure and hemoglobin concentration. In the index case, midodrine treatment resulted in resolution of the hypotension and erythrocytosis. Most of the patients had multiple acquired renal cysts, which is a potential source of erythropoietin. Four of the five cases developed arteriovenous dialysis access or deep venous thrombosis., Conclusions: An association between intradialytic hypotension and erythrocytosis was observed in five cases. We postulate that chronic intermittent hypotension and renal ischemia may lead to erythropoietin secretion, and this cascade could represent a newly recognized cause of secondary erythrocytosis.

Pediatric myocarditis symptoms can be mild or as extreme as sudden cardiac arrest. Early identification of the severity of illness and timely provision of critical care is helpful; however, the risk factors associated with mortality remain unclear and controversial. We undertook a retrospective review of the medical records of pediatric patients with myocarditis in a tertiary care referral hospital for over 12 years to identify the predictive factors of mortality. Demographics, presentation, laboratory test results, echocardiography findings, and treatment outcomes were obtained. Regression analyses revealed the clinical parameters for predicting mortality. During the 12-year period, 94 patients with myocarditis were included. Of these, 16 (17%) patients died, with 12 succumbing in the first 72 hours after admission. Fatal cases more commonly presented with arrhythmia, hypotension, acidosis, gastrointestinal symptoms, decreased left ventricular ejection fraction, and elevated isoenzyme of creatine kinase and troponin I levels than nonfatal cases. In multivariate analysis, troponin I > 45 ng/mL and left ventricular ejection fraction < 42% were significantly associated with mortality. Pediatric myocarditis had a high mortality rate, much of which was concentrated in the first 72 hours after hospitalization. Children with very high troponin levels or reduced ejection fraction in the first 24 hours were at higher risk of mortality, and targeting these individuals for more intensive therapies may be warranted., Competing Interests: The authors have declared that no competing interests exist.

In addition to symptoms including fatigue, dizziness, reduced drive, or mood disturbance, individuals with chronic low blood pressure (hypotension) frequently report cognitive complaints. While attentional deficits have been empirically confirmed, it is still unknown whether the impairments also encompass executive functions. This study investigated cerebral blood flow modulations in hypotension during a precued antisaccade/prosaccade task requiring the executive function of proactive inhibition in addition to preparatory attention. Using functional transcranial Doppler sonography, bilateral blood flow velocities in the middle cerebral arteries (MCA) were recorded in 39 hypotensive and 40 normotensive participants. In the task, a stimulus appeared left or right of a fixation point 5 s after a cuing stimulus; subjects had to move their gaze to the mirror image position of the stimulus (antisaccade) or toward it (prosaccade control condition). Video-based eye tracking was used for ocular recording. A right dominant MCA blood flow increase arose during task preparation, which was smaller in hypotensive than normotensive participants. In addition, hypotensive participants exhibited lower peak velocity of the saccadic response. The extent of the reductions in blood flow and task performance in hypotension did not differ between antisaccade and prosaccade conditions. The smaller MCA flow increase may reflect reduced activity in the dorsolateral prefrontal and inferior parietal cortices during proactive inhibition and preparatory attention in hypotension. Given that group differences in blood flow and performance arose independent of task complexity and executive function load, hypotension may be characterized by basic attentional impairments rather than particular executive function deficits., (© 2018 Society for Psychophysiological Research.)

Objective: Proficiency in the use of ultrasound is presently not an ACGME required core competency for accredited surgical training. There should be a basic unified ultrasound curriculum for surgical trainees. We developed a multimodal ultrasound-training program to ensure baseline proficiency and readiness for clinical performance without impacting trainee duty hours., Design: We developed and implemented a multimodal curriculum for ultrasound education and its use as a supplement to clinical evaluation of unstable patients., Setting: A single-center study was completed in a hospital setting., Participants: Post-graduate year-1 surgical residents at our institution were invited to participate in a multimodal perioperative course., Results: 51 residents attended the course over the three sessions. The vignette exam as a whole demonstrated a Cronbach's alpha of 0.819 indicating good internal reliability of the entire test. There was significant improvement in their knowledge in clinical vignettes (55% ± 12.4 on pre-test vs. 83% ± 13.2% on post-test, p<0.001)., Conclusion: It is feasible to incorporate a focused ultrasound curriculum to assess clinically unstable patients. The multimodal nature of the course aid in the development of preclinical proficiency and decreased the orientation phase of ultrasound use., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Early hemolysis occurs in the hematoma within 24 h in rat model of intracerebral hemorrhage (ICH). The present study investigated the prevalence of early hemolysis in ICH patients using MRI and the relationship between early hemolysis and perihematomal edema. Thirty ICH patients were prospectively enrolled within 24 h of onset. All patients had cranial CT on admission. Cranial MRI with T2 FLAIR-weighted imaging and T2*-weighted imaging were undertaken at days 1 and 14. The evolution of a non-hypointense lesion on T2*-weighted images and the relationship between the volume of that non-hypointense lesion and perihematomal edema volume were investigated. MRI images of 15 patients were analyzed. The median hematoma volume was 16.3 ml on admission. All patients underwent a baseline MRI within 24 h of ICH onset and showed a non-hypointense lesion within the hematoma on T2*-weighted images. The volume of non-hypointense lesion on T2*-weighted image was 6.0 (8.9) ml at day 1 and 8.6 (17.3) ml at day 14. The absolute perihematomal edema volume was 16.0 (17.9) ml and 24.8 (27.5) ml at days 1 and 14, respectively. There was a linear correlation between non-hypointense T2* lesion and perihematomal edema volume at day 1 and day 14 (p < 0.01). Early hemolysis in the hematoma occurs in humans and contributes to the development of perihematomal edema.

Background: We present a case of intracardiac rhabdomyosarcoma associated with cardiopulmonary instability which was diagnosed by emergency providers using point-of-care echocardiography., Case Report: A previously healthy 49-year-old man presented to the Emergency Department with progressive dyspnea and hypotension. Emergency providers identified a left atrial mass using point-of-care ultrasound. Expedited advanced imaging and surgical management showed a malignant cardiac rhabdomyosarcoma. Why should an emergency physician be aware of this? This case report highlights the utility of point-of-care ultrasound in the work-up of patients with undifferentiated dyspnea and hypotension, even in cases of rare diagnoses. Early diagnosis and management of both benign and malignant intracardiac tumors is essential to preoperative planning and patient prognosis. Ultrasound findings consistent with intracardiac masses should be recognized and used to guide further consultation, advanced imaging, and treatment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Objective: Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes., Methods: This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure <100 mm Hg or shock index >1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay., Results: Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] -10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI -8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI -15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay., Conclusion: To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group., (Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background and objective : Hypotension and bradycardia are the most common hemodynamic disorders and side effects of spinal anesthesia (SA) on the cardiovascular system. SA-induced sympathetic denervation causes peripheral vasodilatation and redistribution of central blood volume that may lead to decreased venous return to the heart. The aim of the study was to evaluate the changes of inferior vena cava collapsibility index (IVC-CI) during SA in spontaneously breathing patients during elective knee joint replacement surgery to prognose manifestation of intraoperative hypotension and bradycardia. Materials and methods : 60 patients (American Society of Anesthesiologists (ASA) physical status I or II, no clinically significant cardiovascular pathology) of both sexes undergoing elective knee joint replacement surgery under SA were included in the prospective study. Inspiratory and expiratory inferior vena cava (IVCin, IVCex) diameters were measured using an ultrasound device in supine position before and immediately after SA, then 15 min, 30 min, and 45 min after SA was performed. The heart rate, along with systolic, diastolic, and mean arterial blood pressures were collected. The parameters were measured at the baseline and at the next four time points. Results : There were no significant changes in IVCin, IVCex, and IVC-CI compared to baseline and other time point measurements in hypotensive versus nonhypotensive and bradycardic versus nonbradycardic patients ( p > 0.05). Changes in IVC diameter do not prognose hypotension and/or bradycardia during SA: the area under the curve (AUC) of the receiver operating characteristic (ROC) curve for IVC-CI at all measuring points was <0.7, p > 0.05. Conclusions : Reduction in IVC diameters and increase in IVC-CI do not predict hypotension and bradycardia during SA in spontaneously breathing patients undergoing elective knee joint replacement surgery.

Cardiac ultrasound techniques are increasingly used in the neonatal intensive care unit to guide cardiorespiratory care of the sick newborn. This is the first in a series of eight review articles discussing the current status of "neonatologist-performed echocardiography" (NPE). The aim of this introductory review is to discuss four key elements of NPE. Indications for scanning are summarized to give the neonatologist with echocardiography skills a clear scope of practice. The fundamental physics of ultrasound are explained to allow for image optimization and avoid erroneous conclusions from artifacts. To ensure patient safety during echocardiography recommendations are given to prevent cardiorespiratory instability, hypothermia, infection, and skin lesions. A structured approach to echocardiography, with the same standard views acquired in the same sequence at each scan, is suggested in order to ensure that the neonatologist confirms normal structural anatomy or acquires the necessary images for a pediatric cardiologist to do so when reviewing the scan.

Purpose: "Polytrauma" patients are of a higher risk of complications and death than the summation of expected mortality and morbidity of their individual injuries. The ideal goal in trauma resuscitation care is to identify and treat all injuries. With clinical and technological advanced imaging available for diagnosis and treatment of traumatic patients, point of care-rapid ultrasound in shock and hypotension (RUSH) significantly affects modern trauma services and patient outcomes. This study aims to evaluate the accuracy of RUSH and patient outcomes by early detection of the causes of unstable polytrauma., Methods: This cross-sectional, prospective study included 100 unstable polytrauma patients admitted in Suez Canal University Hospital. Clinical exam, RUSH and pan-computed tomography (pan-CT) were conducted. The result of CT was taken as the standard. Patients were managed according to the advanced trauma life support (ATLS) guidelines and treated of life threatening conditions if present. Patients were followed up for 28 days for a short outcome., Results: The most diagnostic causes of unstability in polytrauma patients by RUSH are hypovolemic shock (64%), followed by obstructive shock (14%), distributive shock (12%) and cardiogenic shock (10%) respectively. RUSH had 94.2% sensitivity in the diagnosis of unstable polytrauma patients; the accuracy of RUSH in shock patients was 95.2%., Conclusion: RUSH is accurate in the diagnosis of unstable polytrauma patients; and 4% of patients were diagnosed during follow-up after admission by RUSH and pan-CT., (Copyright © 2018 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.)

Background: In light of the increasing number of radiologic interventions performed under general anesthesia, the effects of contrast media (CM) on circulation and organ perfusion are of paramount importance. The objectives of this study were to systematically quantify effects on blood pressure, heart rate, and kidney function following intravenous administration of nonionic CM with normal and low osmolality., Methods: In this controlled, double-blinded phase IV clinical trial, 40 consecutive patients were randomly assigned to receive repeated measures of either low-osmolar iopromide or iso-osmolar iodixanol. Normal saline solution (NSS) served as control. Blood pressure and heart rate were measured continuously from 1 minute before until 3 minutes after administration of CM and NSS. Urine output was recorded hourly., Results: Administration of iopromide resulted in systemic hypotension lasting up to 300 seconds (105 ± 61 seconds) with the lowest mean arterial pressure of 39 mm Hg (56.7 ± 12.2 mm Hg). Iopromide caused a systolic/diastolic decrease of 31/26 mm Hg (P < .001), significant increase in heart rate (P = .042), and significant diuresis with a 2-fold higher per-hour urine output (P = .010). Administration of iodixanol and NSS had no significant influence on blood pressure (P > .640)., Conclusions: Administration of low-osmolar iopromide was followed by a significant transient decrease in blood pressure and a rise in heart rate. Anesthetists and radiologists should be aware of these effects in patients in whom short episodes of disturbed tissue microcirculation may pose a clinical risk.

Objective: To assess the impact of an ultrasound hypotension protocol in identifying life-threatening diagnoses that were missed in the initial evaluation of patients with hypotension and shock., Methods: A subset of cases from a previously published prospective study of hypotensive patients who presented at the Emergency Department in a single, academic tertiary care hospital is described. An ultrasound-trained emergency physician performed an ultrasound on each patient using a standardized hypotension protocol. In each case, the differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. This is a case series of patients with missed diagnoses in whom ultrasound led to a dramatic shift in diagnosis and management by detecting life threatening pathologies., Results: Following a published prospective study of the effect on an ultrasound protocol in 118 hypotensive patients, we identified a series of cases that ultrasound protocol unexpectedly determined serious life threatening diagnoses such as Takotsubo cardiomyopathy, pulmonary embolism, pericardial effusion with tamponade physiology, abdominal aortic aneurysm and perforated viscus resulting in proper diagnoses and management. These hypotensive patients had completely unsuspected but critical diagnoses explaining their hypotension, who in every case had their management altered to target the newly identified life-threatening condition., Conclusions: A hypotension protocol is an optimal use of ultrasound that exemplifies "right time, right place", and impacts decision-making at the bedside. In cases with undifferentiated hypotension, ultrasound is often the most readily available option to ensure that the most immediate life-threatening conditions are quickly identified and addressed in the order of their risk potential., (Copyright © 2017 Elsevier Inc. All rights reserved.)

In a healthy 12-year-old female with scoliosis, prone positioning resulted in pressor-refractory cardiovascular collapse. Resumption of supine position immediately improved hemodynamics. Intraoperative transesophageal echocardiography (TEE) revealed a collapsed left atrium and biventricular failure. Repeat prone positioning resulted in a recurrence of hypotension. However, hemodynamic stabilization was restored and maintained by repositioning chest pads caudally. The patient successfully underwent a 6-hour scoliosis repair without perioperative morbidity. With this case, we aim to: (1) reintroduce awareness of this mechanical obstructive cause of reversible hypotension; (2) highlight the use of intraoperative TEE during prone hemodynamic collapse; and (3) suggest an alternative prone positioning technique if chest compression results in hemodynamic instability.

Background: Sympathetic nerves-fire rate is generally enhanced in some types of hypertension models. Renal sympathetic denervation(RSD) by the radiofrequency ablation was used to treat the hypertension has achieved curative effect.HTN-1 and HTN-2 trial reported catheter-based renal denervation may cause substantial and sustained blood-pressure reduction in patients with resistant hypertension. However, recent controlled HTN-3 trial questioned the BP lowering effect of Renal denervation treatment. The controversial results maybe arised from the incompleted RSD which implemented inside the renal artery. Now renal denervation therapy for resistant hypertension is in attractive and controversial status. Our aim is to define the hyotensive value of complete renal denervation in adult spontaneous hypertensive rats., Methods: Male spontaneous hypertensive rats(SHR) aged 12 weeks were randomly selected for either unilateral renal artery sympathetic nerves ablation (URSNA), or conventional technique of renal denervation (CRD), or bilateral renal artery sympathetic nerves ablation (BRSNA) and sham operation. Blood pressure, sodium and water balance,serum reninangiotensin II and Norepinephrine concentration were measured during 20 weeks after renal denervation operation. Internal diameters of renal arteries and renal blood flow rate was tested by ultrasonic contrast imaging., Results: The continued increased blood pressure in SHR was delayed and significantly reduced by conventional renal denervation over a period of 8 weeks. Both the bilateral and unilateral renal sympathetic nerve ablation procedure did not prevent the development of hypertension in SHR. The attenuation of hypertension was accompanied with the increase of urinary sodium excretion and depression of rennin angiotensin system (RAS)., Conclusions: We concluded that renal denervation may not be an effective therapeutic method in the long-term control of hypertension in adult SHR., (Copyright © 2017 Elsevier Ltd. All rights reserved.)