Monitoring modalities and assessment of fluid status: A practice management guideline from the Eastern Association for the Surgery of Trauma

A possible role of e-FAST in the hemodynamically stable polytrauma patient: results of a single trauma center preliminary restrospective study

PURPOSE

The purpose of this work is to evaluate whether EFAST can also play a role in the hemodynamically stable polytrauma patient, without delaying his arrival in the CT-scan room.

METHODS

In a period of seven month, 748 polytrauma patients were retrospective valued; we analyzed the findings of the CT exams of 485 haemodynamically stable patients for whom the EFAST investigation was not requested, highlighting the possible presence of findings that, if reported during the EFAST, could have changed the patient management.

RESULTS

52 hemodynamically stable patients with CT examination findings potentially detectable by ultrasound examination directly in the shock room, which represent a percentage of about 11% of all the hemodynamically stable patients analyzed; about 54% of CT findings are represented by the presence of pneumothorax.

CONCLUSION

Looking to the results and the sensitivity of thoracic ultrasound in identifying even small flaps of pneumothorax, the evaluation by EFAST ultrasound examination could be extended at least to all those patients with chest trauma or who require endotracheal intubation. The risk of generating a hypertensive pneumothorax following positive pressure intubation is widely known, and certainly the presence of a pre-existing layer of pneumothorax, even if of modest entity, further increases this possibility.

Association Between Arterial Pulse Waveform Analysis and Mortality in Patients With Septic Shock: A Retrospective Cohort Study Using Japanese Diagnosis Procedure Combination Data

Purpose: Specialized pressure transducers for arterial pulse waveform analysis (S-APWA) devices are dedicated kits connected to an arterial pressure catheter that monitors hemodynamic parameters, such as cardiac output, pulse pressure variation, and stroke volume variation, less invasively. While the association between the use of S-APWA devices and clinical outcomes in perioperative patients has been previously evaluated, its assessment in patients with septic shock remains inadequate. Materials and Methods: This retrospective cohort study utilized a nationwide Diagnosis Procedure Combination database in Japan. Adult patients with septic shock admitted to the intensive care unit (ICU) with arterial pressure catheter placement on the admission day from August 2012 to February 2021 were included. Hospitalizations meeting the eligibility criteria were categorized into groups based on S-APWA device usage. The primary outcome, evaluated using Cox regression analysis, was 30-day all-cause mortality in the propensity score overlap-weighted population. Secondary outcomes included in-hospital mortality, ICU duration, and overall hospital stay. Results: Among 5130 eligible hospitalizations, 643 were in the S-APWA group and 4487 were in the conventional pressure transducer group. Cox regression analysis within the propensity score overlap-weighted population showed no significant difference in 30-day mortality (adjusted hazard ratio: 0.94; 95% confidence interval: 0.9-1.38; P = .58). Logistic regression analysis indicated no significant differences in the in-hospital mortality. While the S-APWA group had prolonged ICU stays, no significant difference in the overall hospital stay was observed according to linear regression analyses. Conclusions: Our study found no significant association between S-APWA use and 30-day mortality in patients with septic shock. These findings offer insights into optimizing monitoring systems in ICUs.

Management of Patients After Cardiac Arrest

Cardiac arrest remains a significant cause of morbidity and mortality, although contemporary care now enables potential survival with good neurologic outcome. The core acute management goals for survivors of cardiac arrest are to provide organ support, sustain adequate hemodynamics, and evaluate the underlying cause of the cardiac arrest. In this article, the authors review the current state of knowledge and clinical intensive care unit practice recommendations for patients after cardiac arrest, particularly focusing on important areas of uncertainty, such as targeted temperature management, neuroprognostication, coronary evaluation, and hemodynamic targets.

Ultrasound assessment is useful for evaluating balloon volume of resuscitative endovascular balloon occlusion of the aorta

BACKGROUND

Endovascular balloon occlusion of the aorta (EBOA) increases proximal arterial pressure but may also induce life-threatening ischemic complications. Although partial REBOA (P-REBOA) mitigates distal ischemia, it requires invasive monitoring of femoral artery pressure for titration. In this study, we aimed to titrate P-REBOA to prevent high-degree P-REBOA using ultrasound assessment of femoral arterial flow.

METHODS

Proximal (carotid) and distal (femoral) arterial pressures were recorded, and perfusion velocity of distal arterial pressures was measured by pulse wave Doppler. Systolic and diastolic peak velocities were measured among all ten pigs. Total REBOA was defined as a cessation of distal pulse pressure, and maximum balloon volume was documented. The balloon volume (BV) was titrated at 20% increments of maximum capacity to adjust the degree of P-REBOA. The distal/proximal arterial pressure gradient and the perfusion velocity of distal arterial pressures were recorded.

RESULTS

Proximal blood pressure increased with increasing BV. Distal pressure decreased with increasing BV, and distal pressure sharply decreased by > 80% of BV. Both systolic and diastolic velocities of the distal arterial pressure decreased with increasing BV. Diastolic velocity could not be recorded when the BV of REBOA was > 80%.

CONCLUSION

The diastolic peak velocity in the femoral artery disappeared when %BV was > 80%. Evaluation of the femoral artery pressure by pulse wave Doppler may predict the degree of P-REBOA without invasive arterial monitoring.

SHoC-IVC: Does assessment of the inferior vena cava by point-of-care ultrasound independently predict fluid status in spontaneously breathing patients with undifferentiated hypotension?

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.

Clinical features and management of children with dengue-associated obstructive shock syndrome: A case report

RATIONALE

Dengue obstructive shock syndrome is a fatal complication commonly observed in the late critical phase of dengue infection and is associated with a high mortality rate. The main pathogenesis involves a dramatic increase in chest pressure, owing to severe plasma leakage and mechanical respiratory support, hampering the heart's ability to pump effectively and impeding adequate blood venous return to the heart chambers. To date, there is a paucity of clinical data about Dengue obstructive shock syndrome reported.

PATIENT CONCERNS

The 2 reported patients presented with prolonged and decompensated dengue shock with critical multi-organ failures and mechanical ventilation. The patients' hemodynamics were profoundly affected by high pressure in the thoracic and abdominal cavities resulting from Dengue-induced severe plasma leakage and mechanical ventilation.

DIAGNOSES

Clinical presentations, laboratory data, mini-fluid challenge test, and point-of-care (POCUS) were used to make diagnoses and guide management.

INTERVENTIONS

Clinical monitoring, judicious fluid (colloids and blood products) administration guided by repeated POCUS to properly assess the adequacy of the intravascular volume, homeostasis adjustments by plasma exchange, and continuous renal replacement therapies.

OUTCOMES

The patients had favorable outcomes.

LESSONS

Our study highlights the clinical manifestations and management of children with dengue obstructive shock syndrome and underscores the importance of monitoring hemodynamics by consecutive POCUS at the bedside in order to make a timely diagnosis and assess intravascular fluid volume inadequacy accurately as well as closely monitor the fluid management responses.

Do I really need this transthoracic ECHO? An over-utilized test in trauma and surgical intensive care units

INTRODUCTION

Clinical use of transthoracic echocardiogram (TTE) in intensive care units (ICU) has dramatically increased without clear guidance on validated assessment indications, appropriateness, and patient value.

METHODS

A retrospective analysis of consecutive TTEs performed among patients admitted to a tertiary trauma/surgical ICU over 2.5 years was performed. A bivariate analysis and Poisson regression was used to compare patients who received a TTE. Sensitivity analysis was performed to assess patient factors that predict change in management based on TTE. An abnormal exam was defined as having at least one of the following: ejection fraction < 55%, wall motion, pericardial effusion, pericardial effusion, or other significant abnormality including filling defect. The effect on management was derived from clinical course. We hypothesize that these studies are usually normal and rarely lead to changes in clinical management.

RESULTS

912 TTEs were performed in 806 patients. The median age was 68 years (IQR 57, 77) and 63.5% were male. Syncope (21.7%) or hypotension/hypovolemia (20.5%) were the most common indications for a TTE. In total, 39.4% TTEs were abnormal and only 7.6% resulted in a change in management. Predictive factors associated with an abnormal exam included: age >50, serum troponin ≥0.1 ng/ml, abnormal ECG, and clinical suspicion of heart failure or acute myocardial infarction. A troponin cutoff level <0.25 ng/mL was the most reliable factor to predict no change in management after TTE with a negative predictive value of 94.3% (95% CI 93.1, 95.3).

CONCLUSION

TTE is commonly used for patient assessment in critically ill surgical patients but the majority of exams are normal without change in clinical management. Certain patient factors, such as troponin level, may help distinguish which patients would benefit from this diagnostic test. Given the considerable cost associated with TTE and the minimal effect on management, guidelines on appropriate use would provide improved patient value.

ICU Management of Trauma Patients

OBJECTIVES

To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU.

DATA SOURCES AND STUDY SELECTION

A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord.

DATA EXTRACTION AND DATA SYNTHESIS

The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries.

CONCLUSIONS

The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.