Hepatic portal venous gas associated with poor outcome in out-of-hospital cardiac arrest patients

Impact of Hepatic Portal Venous Gas on the Prognosis of Traumatic Out-of-Hospital Cardiac Arrest: A Reason to Consider Terminating Cardiopulmonary Resuscitation

Background

We evaluated the prognosis of traumatic out-of-hospital cardiac arrest (OHCA) by assessing the presence of hepatic portal vein gas (HPVG) observed in ultrasound (US) or point-of-care ultrasonography (POCUS) performed during CPR. Furthermore, we aimed to understand the role of HPVG in decision-making regarding CPR discontinuation or withholding in traumatic OHCA.

Methods

The retrospective study was conducted at the level 1 trauma center of urban academic medical centers in South Korea. We included adult trauma OHCA patients who underwent CPR between January 1, 2020, and June 30, 2022. Data on traumatic OHCA patients who presented to the level I trauma center during this period were extracted from the hospital's electronic medical record system. The arrest data were separately managed through the hospital's electronic medical record system for quality control, specifically the arrest registry. US images or clips of the hepatic portal vasculature (HPV) during CPR were used to assess the presence of HPVG. These images were independently reviewed by two emergency medicine physicians with several years of US examination experience who were blinded to all clinical details and outcomes. We evaluated the prognosis of traumatic OHCA by assessing the presence of HPVG using the US. In addition, we analyzed the general characteristics and assessed the impact on the ROSC in traumatic OHCA.

Results

Among the 383 cardiac arrest patients, 318 traumatic OHCA patients were included. The mean age was 54.9 ± 19.4 years, and most patients were male. The initial rhythm was mainly asystole, and falls were the most frequent cause of injury. The overall ROSC rate was 18.8%, with a survival rate of 7.2% at hospital discharge. Among the 50 patients who underwent a US examination of HPV, 40 showed HPVG. The HPVG group had a significantly lower ROSC rate and survival rate at ED discharge and hospital discharge compared to the group without HPVG.

Conclusion

Traumatic OHCA with HPVG presents a significantly worse prognosis. This suggests that early consideration of termination or withholding of CPR may be appropriate in such cases.

Mortality in patients with hepatic gas on point-of-care ultrasound in cardiac arrest: Does location matter?

PURPOSE

Prior research has suggested an association of hepatic venous gas with mortality in cardiac arrest. As point of care ultrasound (POCUS) is frequently used in the context of resuscitation, we sought to evaluate if the presence of hepatic gas on POCUS had a similar mortality association.

METHODS

A retrospective review was conducted of patients who experienced nontraumatic cardiac arrest. Archived ultrasound images were independently reviewed to determine the presence of gas in the hepatic parenchyma and vasculature. Electronic medical records were then reviewed to collect remaining clinical data.

RESULTS

From 1 January 2017 through 16 June 2019, 87 patients met inclusion criteria. Among them, 68 (78.2%) patients died. Among those who died, 40 (58.8%) had hepatic gas, while 28 (41.2%) had none. Only a single survivor demonstrated hepatic venous gas (11%). While the difference in mortality with respect to presence of undifferentiated hepatic gas was not significant (P = .37), there was a significant difference with respect to the presence of venous gas (P = .004).

CONCLUSION

Our study demonstrated that the incidence of postarrest hepatic gas on POCUS was common, and that the presence of hepatic venous gas during cardiac resuscitation was associated with increased mortality, while hepatic parenchymal gas alone was not.

Arterial Gas Emboli Secondary to Portal Venous Gas Diagnosed With Point-of-Care Ultrasound: Case Report and Literature Review

BACKGROUND

Portal venous gas (PVG) is a rarely observed clinical finding generally associated with intestinal ischemia. The proper clinical response to the finding of PVG depends somewhat on the setting in which it is observed. Here we describe a case in which extensive arterial gas emboli (AGE) were encountered during point-of-care ultrasound (POCUS) and subsequent computed tomography (CT) identified PVG secondary to gastric wall ischemia as the likely source.

CASE REPORT

A 69-year-old woman with history of metastatic colon cancer presented to the emergency department (ED) with altered mental status. On arrival, she was hypotensive, hypothermic, cachectic, and with abdominal distension. POCUS was performed to evaluate the source of the patient's hypotension, revealing the presence of PVG, as well as gas bubbles in all four chambers of the heart and the aorta. CT scan revealed gastric wall ischemia and confirmed the presence of significant air emboli throughout the portal venous system. Given the overall poor prognosis, the decision was made to forego further chemotherapy or surgery and the patient died later that week while under hospice care. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: AGE can occur in the setting of PVG. This may cause multi-organ failure by disrupting blood flow to organs, especially in patients with circulatory dysfunction, such as shock. Depending on the setting in which it is diagnosed, early detection of PVG may expedite earlier assessments of a patient's negative prognosis or initiation of attempted life-saving treatment. In this case report, we show that POCUS can be used to obtain an expedited diagnosis in a critically ill patient.

Echography of the Portal Vein in a Patient With Shock

OBJECTIVES

To report the utility of abdominal ultrasonography to identify portal venous gas in patients with shock, as an indicator of acute mesenteric ischemia, and to illustrate the aspect of portal venous gas on ultrasonography.

DATA SOURCES

Clinical observation of a patient, images of abdominal ultrasonography and abdominal computed tomography, and video of portal venous gas.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Relevant information contained in the medical observation of the patient and selection of image and video of ultrasonography performed in the patient.

DATA SYNTHESIS

We report a case of nonocclusive mesenteric ischemia in a 76-year-old patient following cardiac surgery. The diagnosis of acute mesenteric ischemia was proposed based on evidence of portal venous gas on abdominal ultrasonography and then confirmed by abdominal computed tomography showing transverse colonic ischemia, the presence of gas in the mesenteric veins but not in the portal vein. Urgent laparotomy confirmed extensive nonocclusive mesenteric ischemia, and the patient rapidly died of multiple organ failure.

CONCLUSIONS

Intensive care physicians should be aware of the ultrasound characteristics of portal venous gas. In patients with shock, in addition to cardiac and thoracic echography, investigation of portal venous gas using bedside ultrasonography may help the clinician to identify patients in whom acute mesenteric ischemia develops.

Prognostic values of blood ammonia and partial pressure of ammonia on hospital arrival in out-of-hospital cardiac arrests

PURPOSES

Outcome prediction for out-of-hospital cardiac arrest (OHCA) is of medical, ethical, and socioeconomic importance. We hypothesized that blood ammonia may reflect tissue hypoxia in OHCA patients and conducted this study to evaluate the prognostic value of ammonia for the return of spontaneous circulation (ROSC).

METHODS

This prospective, observational study was conducted in a tertiary university hospital between January 2008 and December 2008. The subjects consisted of OHCA patients who were sent to the emergency department (ED). The primary outcome was ROSC. The prognostic values were calculated for ammonia levels and the partial pressure of ammonia (pNH(3)), and the results were depicted as a receiver operating characteristics curve with an area under the curve.

RESULTS

Among 119 patients enrolled in this study, 28 patients (23.5%) achieved ROSC. Ammonia levels and pNH(3) in the non-ROSC group were significantly higher than those in the ROSC group (167.0 μmol/L vs 80.0 μmol/L, P < .05; 2.61 × 10(-5) vs 1.67 × 10(-5) mm Hg, P < .05, respectively). The predictive capacity of area under the curve for ammonia and pNH(3) for non-ROSC was 0.85 (95% confidence interval, 0.75-0.95) and 0.73 (95% confidence interval, 0.61-0.84), respectively. The multivariate analysis confirmed that ammonia and pNH(3) are independent predictors of non-ROSC. The prognostic value of ammonia was better than that of pNH(3). The cutoff level for ammonia of 84 μmol/L was 94.5% sensitive and 75.0% specific for predicting non-ROSC with a diagnostic accuracy of 89.9%.

CONCLUSIONS

Hyperammonemia on ED arrival is independently predictive of non-ROSC for OHCA patients. The findings may offer useful information for clinical management.

Portal vein gas in emergency surgery

Background

Portal vein gas is an ominous radiological sign, which indicates a serious gastrointestinal problem in the majority of patients. Many causes have been identified and the most important was bowel ischemia and mesenteric vascular accident. The presentation of patients is varied and the diagnosis of the underlying problem depends mainly on the radiological findings and clinical signs. The aim of this article is to show the clinical importance of portal vein gas and its management in emergency surgery.

Methods

A computerised search was made of the Medline for publications discussing portal vein gas through March 2008. Sixty articles were identified and selected for this review because of their relevance. These articles cover a period from 1975–2008.

Results

Two hundreds and seventy-five patients with gas in the portal venous system were reported. The commonest cause for portal vein gas was bowel ischemia and mesenteric vascular pathology (61.44%). This was followed by inflammation of the gastrointestinal tract (16.26%), obstruction and dilatation (9.03%), sepsis (6.6%), iatrogenic injury and trauma (3.01%) and cancer (1.8%). Idiopathic portal vein gas was also reported (1.8%).

Conclusion

Portal vein gas is a diagnostic sign, which indicates a serious intra-abdominal pathology requiring emergency surgery in the majority of patients. Portal vein gas due to simple and benign cause can be treated conservatively. Correlation between clinical and diagnostic findings is important to set the management plan.

Hepatic portal venous gas in ultrasonogram--benign or noxious

The purpose of this study was to investigate and differentiate the characteristics of benign hepatic portal venous gas (HPVG) and noxious HPVG on sonographic images. This study included seven patients (age 65 to 89 y; mean 75 y) with sonograms and computed tomography (CT) images performed within 4-h interval. The sonographic findings of HPVG could be categorized into three patterns: (1) dot-like pattern in two patients; (2) streak-like pattern in three patients; and (3) fruit-pulp-like pattern in two. In the cases of dot-like pattern, it is of a benign transient situation; this phenomenon may be only demonstrated on sonograms but not necessarily on CT. The prognosis is more favorable and any subsequent CT may not be required. In the cases of streak-like or fruit-pulp-like patterns without localized liver lesions (e.g., abscess), it usually indicates a noxious scenario with worse clinical sequelae. We concluded that the identification of sonographic patterns of HPVG might be important to predict patient's outcome.