Search

Objectives Gastrointestinal (GI) bleeding is a common illness seen in the emergency department. The prognosis varies from self-limited to potentially life threatening. Currently available GI bleeding risk scores have only a modest predictive value, limiting their wide implementation. The aim of this study was to assess the association and capability of point-of-care ultrasound (POCUS) used by emergency physicians to improve common GI bleeding scores for predicting complications and long-term outcomes of patients with GI bleeding, which to our knowledge have never been studied. Methods Between August 2015 and April 2017, 203 hemodynamically stable patients with acute GI bleeding admitted to the emergency department were prospectively investigated. Using ultrasound, we measured the inferior vena cava diameter, cardiac output with surrogate markers such as the velocity time integral before and after the passive leg-raising test, and the presence of systolic obliteration of the left ventricle. The Rockall and Glasgow-Blatchford scores were calculated for patients with upper GI bleeding and the Velayos score for lower GI bleeding. The patients had follow-up during hospitalization and 30 days later to assess for early and late adverse events (AEs). Then we integrated the ultrasound findings of hypovolemia into the GI bleeding scores, assessing the capability to detect AEs. Results In our cohort, patients with upper GI bleeding who showed left ventricle kissing walls had a worse evolution, with a greater presence of late AEs (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.32-10.96; P = .01). Patients with lower GI bleeding who showed a collapse of the inferior vena cava (>50%) after passive leg raising had a greater presence of early AEs (OR, 3.6; 95% CI, 1.46-9.00; P = .004). The predictive performance of the Rockall score (receiver operating characteristic analysis: area under the curve [AUC], 77.6%; 95% CI, 66.3%-88.8%) increased with POCUS (AUC, 80.3%; 95% CI, 69.5%-91.1%); that of the Glasgow-Blatchford score (AUC, 72.5%; 95% CI, 59.9%-85.2%) increased with POCUS (AUC, 73.2%; 95% CI, 61.1%-85.4%); and that of Velayos score (AUC, 55.7%; 95% CI, 42.5%-69.0%) also increased with POCUS (AUC, 72.2%; 95% CI, 61.1%-83.3%). Conclusions The use of POCUS in GI bleeding is feasible and enhances common GI bleeding risk scores, showing better predictive performance in detecting AEs.

The link between coagulation system disorders and COVID-19 has not yet been fully elucidated. With the aim of evaluating the association of several coagulation proteins with COVID-19 severity and mortality, we performed a cross-sectional study in 134 patients classified according to the highest disease severity reached during the disease. We found higher levels of antithrombin, prothrombin, factor XI, factor XII and factor XIII in asymptomatic/mild and moderate COVID-19 patients than healthy individuals. Interestingly, decreased levels of antithrombin, factor XI, XII and XIII were observed in those patients who eventually developed severe illness. Additionally, survival models showed us that patients with lower levels of these coagulation proteins had an increased risk of death. In conclusion, COVID-19 provokes early increments of some specific coagulation proteins in most patients. However, lower levels of these proteins at diagnosis might “paradoxically” imply a higher risk of progression to severe disease and COVID-19-related mortality.

Gastrointestinal bleeding, one of the main reasons for emergency department visits, is associated with significant mortality, complications, and high health care spending. Studies have shown the usefulness of hemodynamic monitoring by ultrasound of the inferior vena cava (IVC), imaging of systolic obstruction of the left ventricle (the kissing sign), changes in cardiac output, or surrogates for cardiac output such as the left ventricular velocity time integral before and after a passive leg raise. There is currently no evidence for applying this approach to evaluating hypovolemia due to gastrointestinal bleeding.We prospectively recruited 203 emergency department patients with gastrointestinal bleeding between August 2015 and April 2017; this sample size provided a 95% CI for a proportion of 5%, with a precision of 3% and expected losses of 15%. Recorded data were as follows: medical histories, observations during physical examinations, laboratory results, diagnostic variables, treatment details, clinical course, and ultrasound findings related to hemodynamics.Clinical course was worse in patients with evidence of hypovolemia such as a small (1 cm) end-expiratory IVC diameter (IVCEE) or the kissing sign. Complications were more prevalent at 24 hours and 30 days, a finding that was not associated with the other clinical or laboratory variables commonly monitored. We also saw that both a small IVCEE and persistent inspiratory collapse of the IVC of more than 50% after a passive leg raise test might prove useful for identifying patients at risk for anemia at 24 hours, allowing time to start preventive measures.The analysis of IVCEE, inspiratory collapse of the IVC, or the kissing sign in combination with clinical and laboratory findings can facilitate the use of clinical practice algorithms that can encourage the efficient risk-based assignment of resources and improve prognosis.La hemorragia digestiva (HD) constituye un problema médico con significativa morbimortalidad y elevado consumo de recursos sanitarios, y es uno de los motivos principales de consulta en los servicios de urgencias. Varios estudios han destacado la utilidad de la ecografía clínica en la monitorización hemodinámica, a partir del análisis de la vena cava inferior (VCI), visualizando la obliteración sistólica del ventrículo izquierdo (“kissing del VI”) así como cambios en el gasto cardíaco (GC) o marcadores subrogados al GC como la integral velocidad tiempo (IVT) en el tracto de salida del VI, antes y después de la prueba de elevación pasiva de miembros inferiores (EPMI). En la actualidad, no hay evidencia directa relacionada con la aplicabilidad de este enfoque en la hipovolemia por HD.Entre agosto de 2015 y abril de 2017, se reclutaron prospectivamente 203 pacientes (nivel de confianza del 95%, precisión 3%, proporción 5%, pérdidas estimadas 15%), que consultaron en el servicio de urgencias por HD. Se recogieron los antecedentes médicos, la exploración física, los hallazgos analíticos, variables relacionadas con el diagnóstico, con el tratamiento, con la evolución clínica y variables ecográficas relacionadas con la situación hemodinámica.Los pacientes con datos de hipovolemia como un diámetro de VCI espiratorio (CAVAesp)1 cm o un “kissing del VI” presentaron peor evolución, con mayor presencia de complicaciones a las 24 horas y 30 días, hallazgo que no se observó con otros parámetros clínicos o analíticos comúnmente empleados. Además se observó que tanto la CAVAesp1 cm, como la persistencia del colapso inspiratorio de la VCI (CICAVA)50% tras la PLR podrían ser de utilidad para identificar a los pacientes en los que es esperable una anemización a las 24 horas.El análisis de marcadores ecográficos como la CAVAesp, CIVACA o el “kissing del VI”, combinados con variables clínicas y de laboratorio, permitiría implementar algoritmos de actuación más eficientes y asignar mejor los recursos en función del perfil de riesgo, lo cual podría conducir a una mejora en el pronóstico.

Resumen Fundamento y objetivo La frecuencia de la insuficiencia ventricular izquierda ( IVI ) en las fases precoces del sindrome coronario agudo sin elevacion del segmento ST (SCASEST) no esta descrita en la actualidad. El objetivo de este estudio es describir por vez primera la frecuencia de esta complicacion en la evolucion inicial del SCASEST y evaluar su asociacion a otras intervenciones. Pacientes y metodo Estudio observacional de cohortes prospectivo y multicentrico realizado en unidades de cuidados intensivos y coronarios (UCIC). Se incluyeron pacientes con SCASEST ingresados en las primeras 24 h de evolucion. El desenlace principal fue la aparicion de IVI . Se evaluo la asociacion entre esta y variables clinicas y terapeuticas. Resultados Se produjo IVI en el 15,6% de los pacientes. La realizacion de angiografia coronaria (AC) durante el ingreso en la UCIC fue una variable protectora frente al desenlace principal, realizada tanto antes de las 72 horas ( odds ratio [OR] 0,47; intervalo de confianza del 95% [IC 95%] 0,25-0,89; p = 0,022), como mas tarde (OR 0,39; IC 95% 0,15-0,98; p = 0,044). La administracion de betabloqueantes se mostro como variable protectora frente a la aparicion de IVI (OR 0,54; IC 95% 0,32-0,87; p = 0,013). La toma de acido acetilsalicilico antes del ingreso en la UCIC supuso un mayor riesgo de IVI (OR 1,74; IC 95% 1,06-2,86; p = 0,028). La edad fue factor de riesgo de presentar IVI (OR 1,02; IC 95% 1,00-1,05; p = 0,032). Conclusiones La realizacion de AC precoz y la administracion de betabloqueantes aparecen como capaces de disminuir la aparicion de IVI . La toma previa de acido acetilsalicilico y la edad se asociaron a la aparicion de IVI , pudiendo reflejar enfermedad cardiovascular de larga evolucion.

The frequency of left ventricular failure (LVF) in the early stages of non-ST-segment elevation acute coronary syndrome (NSTE ACS) has not been described so far. The objective of this study is to describe for the first time the frequency of LVF in the early course of NSTE ACS and to assess its association with other interventions.Observational prospective cohort multicenter study in intensive and coronary care units (ICCU). Patients with NSTE ACS admitted within 24h after onset were included. Main outcome was the occurrence of LVF. We evaluated the association between LVF and clinical and therapeutic variables.LVF occurred in 15.6% of patients. Coronary angiography (CA) during admission to the ICCU was a protective variable against the main outcome, performed before 72h (odds ratio [OR] 0.47; 95% confidence interval [95% CI] 0.25-0.89; P=.022) and later (OR 0,39; 95% CI 0,15-0,98; P=.044). The administration of beta-blockers was a protective variable against the occurrence of LVF (OR 0,54; 95% CI 0,32-0,87; P=.013). Patients receiving acetylsalicylic acid before admission to the ICCU had a higher risk of developing LVF (OR 1.74; 95% CI 1.06-2.86; P=.028). Age was also a factor of risk for LVF (OR 1.02; 95% CI 1.00-1.05; P=.032).CA and beta-blockers can decrease the occurrence of LVF. The association between previous administration of acetylsalicylic acid and age with the occurrence of LVF may reflect long-standing cardiovascular disease.