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Ladha P, Truong EI, Kanuika P, Allan A, Kishawi S, Ho VP, Claridge JA, Brown LR. Diagnostic Adjunct Techniques in the Assessment of Hypovolemia: A Prospective Pilot Project. J Surg Res 2024; 293:1-7. [PMID: 37690381 PMCID: PMC11334708 DOI: 10.1016/j.jss.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/21/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Measuring the hypovolemic resuscitation end point remains a critical care challenge. Our project compared clinical hypovolemia (CH) with three diagnostic adjuncts: 1) noninvasive cardiac output monitoring (NICOM), 2) ultrasound (US) static IVC collapsibility (US-IVC), and 3) US dynamic carotid upstroke velocity (US-C). We hypothesized US measures would correlate more closely to CH than NICOM. METHODS Adult trauma/surgical intensive care unit patients were prospectively screened for suspected hypovolemia after acute resuscitation, excluding patients with burns, known heart failure, or severe liver/kidney disease. Adjunct measurements were assessed up to twice a day until clinical improvement. Hypovolemia was defined as: 1) NICOM: ≥10% stroke volume variation with passive leg raise, 2) US-IVC: <2.1 cm and >50% collapsibility (nonventilated) or >18% collapsibility (ventilated), 3) US-C: peak systolic velocity increase 15 cm/s with passive leg raise. Previously unknown cardiac dysfunction seen on US was noted. Observation-level data were analyzed with a Cohen's kappa (κ). RESULTS 44 patients (62% male, median age 60) yielded 65 measures. Positive agreement with CH was 47% for NICOM, 37% for US-IVC and 10% for US-C. None of the three adjuncts correlated with CH (κ -0.045 to 0.029). After adjusting for previously unknown cardiac dysfunction present in 10 patients, no adjuncts correlated with CH (κ -0.036 to 0.031). No technique correlated with any other (κ -0.118 to 0.083). CONCLUSIONS None of the adjunct measurements correlated with CH or each other, highlighting that fluid status assessment remains challenging in critical care. US should assess for right ventricular dysfunction prior to resuscitation.
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Affiliation(s)
- Prerna Ladha
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Evelyn I Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Peter Kanuika
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Annie Allan
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Sami Kishawi
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population Health and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | | | - Laura R Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio.
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Suriani I, van Houte J, de Boer EC, van Knippenberg L, Manzari S, Mischi M, Bouwman RA. Carotid Doppler ultrasound for non-invasive haemodynamic monitoring: a narrative review. Physiol Meas 2023; 43. [PMID: 36179705 DOI: 10.1088/1361-6579/ac96cb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022]
Abstract
Objective.Accurate haemodynamic monitoring is the cornerstone in the management of critically ill patients. It guides the optimization of tissue and organ perfusion in order to prevent multiple organ failure. In the past decades, carotid Doppler ultrasound (CDU) has been explored as a non-invasive alternative for long-established invasive haemodynamic monitoring techniques. Considering the large heterogeneity in reported studies, we conducted a review of the literature to clarify the current status of CDU as a haemodynamic monitoring tool.Approach.In this article, firstly an overview is given of the equipment and workflow required to perform a CDU exam in clinical practice, the limitations and technical challenges potentially faced by the CDU sonographer, and the cerebrovascular mechanisms that may influence CDU measurement outcomes. The following chapter describes alternative techniques for non-invasive haemodynamic monitoring, detailing advantages and limitations compared to CDU. Next, a comprehensive review of the literature regarding the use of CDU for haemodynamic monitoring is presented. Furthermore, feasibility aspects, training requirements and technical developments of CDU are addressed.Main results.Based on the outcomes of these studies, we assess the applicability of CDU-derived parameters within three clinical domains (cardiac output, volume status, and fluid responsiveness), and amongst different patient groups. Finally, recommendations are provided to improve the quality and standardization of future research and clinical practice in this field.Significance.Although CDU is not yet interchangeable with invasive 'gold standard' cardiac output monitoring, the present work shows that certain CDU-derived parameters prove promising in the context of functional haemodynamic monitoring.
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Affiliation(s)
- Irene Suriani
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Joris van Houte
- Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Esmée C de Boer
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Luuk van Knippenberg
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Sabina Manzari
- Philips Research High Tech Campus 34, 5656 AE Eindhoven, The Netherlands
| | - Massimo Mischi
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - R Arthur Bouwman
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands.,Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
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Cardozo Júnior LCM, Lemos GSD, Besen BAMP. Fluid responsiveness assessment using inferior vena cava collapsibility among spontaneously breathing patients: Systematic review and meta-analysis. Med Intensiva 2023; 47:90-98. [PMID: 36272909 DOI: 10.1016/j.medine.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/28/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To synthesize the evidence about diagnostic accuracy of inferior vena cava collapsibility (IVCc) in prediction of fluid responsiveness among spontaneously breathing patients. DESIGN Systematic review of diagnostic accuracy studies. SETTING Intensive care units or emergency departments. PATIENTS AND PARTICIPANTS spontaneously breathing patients with indication for fluid bolus administration. INTERVENTIONS A search was conducted in MEDLINE and EMBASE. We included studies assessing IVCc accuracy for fluid responsiveness assessment with a standard method for cardiac output measure as index test. MAIN VARIABLES OF INTEREST General information (year, setting, cutoffs, standard method), sensitivity, specificity, and area under the receiving operator characteristics curve (AUROC). Risk of bias was assessed with QUADAS 2 tool. We obtained the pooled sensitivity, specificity and summary ROC curve, with estimated confidence intervals from a bivariate model. We also calculated positive and negative likelihood ratios and developed a Fagon nomogram. RESULTS Eight studies were included with 497 patients. Overall, the studies presented a high risk of bias. IVCc sensitivity was 63% (95% CI - 46-78%) and specificity 83% (95% CI - 76-87%). Despite moderate accuracy of IVCc (SROC 0.83, 95% CI - 0.80-0.86), post-test probability of being fluid responsive based on a 50% pre-test probability led to considerable misclassification. CONCLUSIONS IVCc had moderate accuracy for fluid responsiveness assessment in spontaneously breathing patients and should not be used in isolation for this purpose.
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Affiliation(s)
- L C M Cardozo Júnior
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - G S D Lemos
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil; ICU, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - B A M P Besen
- Medical ICU, Disciplina de Emergências Clínicas, Departamento de Clínica Médica, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil; ICU, Hospital A.C. Camargo Cancer Center, São Paulo, SP, Brazil
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Spiliotaki E, Saranteas T, Moschovaki N, Panagouli K, Pistioli E, Kitsinelis V, Briasoulis P, Papadimos T. Inferior vena cava ultrasonography in the assessment of intravascular volume status and fluid responsiveness in the emergency department and intensive care unit: A critical analysis review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:733-744. [PMID: 35302241 DOI: 10.1002/jcu.23194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 06/14/2023]
Abstract
Rapid evaluation of intravascular volume status is vital; either excessive or limited fluid administration may result in adverse patient outcomes. In this narrative review, critical analysis of pertinent diagnostic accuracy studies is developed to delineate the role of inferior vena cava ultrasound measurements in the assessment of both intravascular volume status and fluid responsiveness in the emergency department and intensive care unit. In addition, limitations, and technical considerations of inferior vena cava ultrasound measurements as well as directions for future research are thoroughly discussed.
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Affiliation(s)
- Eleni Spiliotaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodosios Saranteas
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nefeli Moschovaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Panagouli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathia Pistioli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Kitsinelis
- Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Briasoulis
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas Papadimos
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Fluid responsiveness assessment using inferior vena cava collapsibility among spontaneously breathing patients: Systematic review and meta-analysis. Med Intensiva 2022. [DOI: 10.1016/j.medin.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kim DW, Chung S, Kang WS, Kim J. Diagnostic Accuracy of Ultrasonographic Respiratory Variation in the Inferior Vena Cava, Subclavian Vein, Internal Jugular Vein, and Femoral Vein Diameter to Predict Fluid Responsiveness: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2021; 12:diagnostics12010049. [PMID: 35054215 PMCID: PMC8774961 DOI: 10.3390/diagnostics12010049] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 01/08/2023] Open
Abstract
This systematic review and meta-analysis aimed to investigate the ultrasonographic variation of the diameter of the inferior vena cava (IVC), internal jugular vein (IJV), subclavian vein (SCV), and femoral vein (FV) to predict fluid responsiveness in critically ill patients. Relevant articles were obtained by searching PubMed, EMBASE, and Cochrane databases (articles up to 21 October 2021). The number of true positives, false positives, false negatives, and true negatives for the index test to predict fluid responsiveness was collected. We used a hierarchical summary receiver operating characteristics model and bivariate model for meta-analysis. Finally, 30 studies comprising 1719 patients were included in this review. The ultrasonographic variation of the IVC showed a pooled sensitivity and specificity of 0.75 and 0.83, respectively. The area under the receiver operating characteristics curve was 0.86. In the subgroup analysis, there was no difference between patients on mechanical ventilation and those breathing spontaneously. In terms of the IJV, SCV, and FV, meta-analysis was not conducted due to the limited number of studies. The ultrasonographic measurement of the variation in diameter of the IVC has a favorable diagnostic accuracy for predicting fluid responsiveness in critically ill patients. However, there was insufficient evidence in terms of the IJV, SCV, and FV.
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Affiliation(s)
- Do-Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju 61469, Korea;
| | - Seungwoo Chung
- Department of Critical Care Medicine, Gyeongsang National University Changwon Hospital, Changwon 51472, Korea;
| | - Wu-Seong Kang
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Korea;
- Correspondence:
| | - Joongsuck Kim
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Korea;
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Unal Akoglu E, Akoglu H. Does respiratory variation in inferior vena cava diameter predict fluid responsiveness in adult patients? A systematic review and meta-analysis of diagnostic accuracy studies. HONG KONG J EMERG ME 2021. [DOI: 10.1177/10249079211029781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: To systematically review the diagnostic utility of the respiratory variation of the inferior vena cava diameter measured using ultrasonography for predicting fluid responsiveness in adult patients and compare the three commonly used equations, inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability. Methods: We searched PubMed, Scopus, Web of Science and Cochrane library, and included studies investigating the diagnostic accuracy of the respiratory variation of the inferior vena cava measured using ultrasonography compared to a reference standard for measuring cardiac output after a fluid challenge for fluid responsiveness, and stratified participants as fluid responsive or not. We included studies conducted in the emergency department or intensive care unit. We excluded studies on paediatric, prehospital, cancer, pregnant, dialysis patients or healthy volunteers. Results: We retrieved 270 records and excluded 171 because of irrelevance, patient population or publication type. We screened the abstracts of 99 studies and then the full texts of 42 studies. Overall, 21 studies with 1321 patients were included, of whom 689 (52%) were fluid responsive. The mean threshold value for positive inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability was 17%, 35% and 12%, respectively. The heterogeneity between studies was high. Bivariate diagnostic random-effects meta-analysis was used to calculate the summary receiver operating characteristics curves. The overall accuracy, sensitivity and specificity of respiratory variation of the inferior vena cava diameter were 0.85, 0.72 and 0.81, respectively. The accuracy of inferior vena cava distensibility and inferior vena cava collapsibility was similar. The diagnostic utility of respiratory variation of the inferior vena cava diameter was lower but not statistically significant in mechanically ventilated patients compared with spontaneous breathing for predicting fluid responsiveness. Conclusion: The respiratory variation of the inferior vena cava diameter has moderate diagnostic utility for predicting fluid responsiveness independent of the equation used.
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Affiliation(s)
- Ebru Unal Akoglu
- Department of Emergency Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Haldun Akoglu
- Department of Emergency Medicine, Marmara University School of Medicine, Istanbul, Turkey
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Akoglu EU, Demir H, Ozturk TC, Ar AY, Turan G. Respiratory variability of inferior vena cava at different mechanical ventilator settings. Am J Emerg Med 2021; 48:96-102. [PMID: 33866270 DOI: 10.1016/j.ajem.2021.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 03/17/2021] [Accepted: 04/02/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Assessment of the respiratory changes of the inferior vena cava (IVC) diameter have been investigated as a reliable tool to estimate the volume status in mechanically ventilated and spontaneously breathing patients. Our purpose was to compare the echocardiographic measurements the IVC diameter, stroke volume and cardiac output in different positive pressure ventilation parameters. METHODS This prospective clinical study with crossover design was conducted in the Intensive Care Unit (ICU). Twenty-five sedated, paralyzed, intubated, and mechanically ventilated patients with volume control mode (CMV) in the ICU due to respiratory failure were included in the study. Positive End-Expiratory Pressure (PEEP) and Tidal Volume (TV) were changed in each patient consecutively (Group A: TV 6 ml/kg, PEEP 5 cmH20, B: TV 6, PEEP 8, C: TV 8, PEEP 5, D: TV 8, PEEP 8) and the changes in vital parameters, central venous pressure (CVP) and ultrasonographic changes in IVC and cardiac parameters were measured. All measures were compared between groups by robust repeated measures ANOVA with trimmed mean. RESULTS The respiratory changes of the IVC diameter and echocardiographic parameters showed no significant difference in separate mechanical ventilator settings. Significant difference was found in peak and plateau pressure values among groups (p < 0.05). CONCLUSION The results of our study suggest that IVC related parameters are not affected with different ventilatory settings. Further studies are needed to confirm the reliability of these parameters as a predictor of fluid assessment.
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Affiliation(s)
- Ebru Unal Akoglu
- Fatih Sultan Mehmet Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey.
| | - Hasan Demir
- Marmara University Pendik Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Tuba Cimilli Ozturk
- Fatih Sultan Mehmet Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Arzu Yildirim Ar
- Fatih Sultan Mehmet Training and Research Hospital, Department of Critical Care Medicine, Istanbul, Turkey
| | - Guldem Turan
- Fatih Sultan Mehmet Training and Research Hospital, Department of Critical Care Medicine, Istanbul, Turkey
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Chukwulebe SB, Gaieski DF, Bhardwaj A, Mulugeta-Gordon L, Shofer FS, Dean AJ. Early hemodynamic assessment using NICOM in patients at risk of developing Sepsis immediately after emergency department triage. Scand J Trauma Resusc Emerg Med 2021; 29:23. [PMID: 33509242 PMCID: PMC7842048 DOI: 10.1186/s13049-021-00833-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 01/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background One factor leading to the high mortality rate seen in sepsis is the subtle, dynamic nature of the disease, which can lead to delayed detection and under-resuscitation. This study investigated whether serial hemodynamic parameters obtained from a non-invasive cardiac output monitor (NICOM) predicts disease severity in patients at risk for sepsis. Methods Prospective clinical trial of the NICOM device in a convenience sample of adult ED patients at risk for sepsis who did not have obvious organ dysfunction at the time of triage. Hemodynamic data were collected immediately following triage and 2 hours after initial measurement and compared in two outcome groupings: (1) admitted vs. dehydrated, febrile, hypovolemicdischarged patients; (2) infectious vs. non-infectious sources. Receiver operator characteristic (ROC) curves were calculated to determine whether the NICOM values predict hospital admission better than a serum lactate. Results 50 patients were enrolled, 32 (64 %) were admitted to the hospital. Mean age was 49.5 (± 16.5) years and 62 % were female. There were no significant associations between changes in hemodynamic variables and patient disposition from the ED or diagnosis of infection. Lactate was significantly higher in admitted patients and those with infection (p = 0.01, p = 0.01 respectively). The area under the ROC [95 % Confidence Intervals] for lactate was 0.83 [0.64–0.92] compared to 0.59 [0.41–0.73] for cardiac output (CO), 0.68 [0.49–0.80] for cardiac index (CI), and 0.63 [0.36–0.80] for heart rate (HR) for predicting hospital admission. Conclusions CO and CI, obtained at two separate time points, do not help with early disease severity differentiation of patients at risk for severe sepsis. Although mean HR was higher in those patients who were admitted, a serum lactate still served as a better predictor of patient admission from the ED.
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Affiliation(s)
- Steve B Chukwulebe
- Department of Emergency Medicine, Advocate Sherman Hospital, Elgin, IL, USA
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 1025 Walnut Street; 300 College Building, 19107, Philadelphia, PA, USA.
| | - Abhishek Bhardwaj
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Lakeisha Mulugeta-Gordon
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Frances S Shofer
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony J Dean
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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