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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [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: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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Abstract
Rationale: Current guidelines recognize the utility of provocative maneuvers during right heart catheterization to aid the diagnosis of pulmonary hypertension. Few studies have compared the performance of different provocation maneuvers. Objectives: To assess the hemodynamic correlation among three provocative maneuvers, including their effect on pulmonary hypertension classification. Methods: This prospective trial was conducted between October 2016 and May 2018. Adult patients underwent three provocative maneuvers during right heart catheterization: passive leg raise (PLR), load-targeted supine bicycle exercise, and rapid crystalloid fluid infusion. Patients were classified as follows: no pulmonary hypertension, precapillary pulmonary hypertension, isolated postcapillary pulmonary hypertension, combined pre- and postcapillary pulmonary hypertension, and uncategorized pulmonary hypertension. We assessed the hemodynamic changes associated with each maneuver. We also assessed whether provocative maneuvers led to hemodynamic reclassification of the patient to either postcapillary pulmonary hypertension with provocation or exercise pulmonary hypertension. Results: Eighty-five patients (mean age 62 ± 12 years, 53% women) were included. Correlation between exercise and fluid challenge was moderate to strong (0.49-0.82; P < 0.001) for changes in right atrial pressure, mean pulmonary arterial pressure, pulmonary arterial wedge pressure, and cardiac index from baseline. Correlation between PLR and exercise (0.4-0.65; P < 0.001) and between PLR and fluid challenge (0.45-0.6; P < 0.001) was moderate for changes in right atrial pressure, mean pulmonary arterial pressure, pulmonary arterial wedge pressure, pulmonary vascular resistance, and cardiac index. Hemodynamic correlation between other provocative maneuvers was poor. Depending on provocative maneuver and classification criteria, there was significant variation in the number of patients reclassified as having exercise pulmonary hypertension (3-50%) or postcapillary pulmonary hypertension with provocation (11-48%). Conclusions: Hemodynamic determinations during exercise and fluid challenge showed moderate to strong hemodynamic correlation. Moderate hemodynamic correlation was seen between PLR and exercise or fluid challenge. Although some provocative maneuvers demonstrate good hemodynamic correlation, there is inconsistency when using these maneuvers to identify patients with postcapillary or exercise pulmonary hypertension.
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García-de-Acilu M, Pacheco A, Santafé M, Ramos FJ, Ruiz-Rodríguez JC, Ferrer R, Roca O. Pleth variability index may predict preload responsiveness in patients treated with nasal high flow: a physiological study. J Appl Physiol (1985) 2021; 130:1660-1667. [PMID: 33856256 DOI: 10.1152/japplphysiol.00614.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The purpose of this study was to determine whether the plethysmographic variability index ("PVi") can predict preload responsiveness in patients with nasal high flow (NHF) (≥30 L/min) with any sign of hypoperfusion. "Preload responsiveness" was defined as a ≥10% increase in stroke volume (SV), measured by transthoracic echocardiography, after passive leg raising. SV and PVi were reassessed in preload responders after receiving a 250-mL fluid challenge. Twenty patients were included and 12 patients (60%) were preload responders. Responders showed higher baseline mean PVi (24% vs. 13%; P = 0.001) and higher mean PVi variation (ΔPVi) after passive leg raising (6.8% vs. -1.7%; P < 0.001). No differences between mean ΔPVi after passive leg raising and mean ΔPVi after fluid challenge were observed (6.8% vs. 7.4%; P = 0.24); and both values were strongly correlated (r = 0.84; P < 0.001). Baseline PVi and ΔPVi after passive leg raising showed excellent diagnostic accuracy identifying preload responders (AUROC 0.92 and 1.00, respectively). Baseline PVi ≥ 16% had a sensitivity of 91.7% and a specificity of 87.5% for detecting preload responders. Similarly, ΔPVi after passive leg raising ≥2% had a 100% of both sensitivity and specificity. Thus, PVi might predict "preload responsiveness" in patients treated with NHF, suggesting that it may guide fluid administration in these patients.NEW & NOTEWORTHY This is the first study that analyzes the use of noninvasive plethysmographic variability index (PVi) for preload assessment in patients treated with nasal high flow (NHF). Its results showed that PVi might identify preload responders. Therefore, PVi may be used in the day-to-day clinical decision-making process in critically ill patients treated with NHF, helping to provide adequate resuscitation volume.
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Affiliation(s)
- Marina García-de-Acilu
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Andrés Pacheco
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Manel Santafé
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Francisco-Javier Ramos
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Juan C Ruiz-Rodríguez
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Ricard Ferrer
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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EL-Nawawy AA, Omar OM, Hassouna HM. Role of Inferior Vena Cava Parameters as Predictors of Fluid Responsiveness in Pediatric Septic Shock: A Prospective Study. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0041-1724034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractFluid resuscitation is the initial therapy for septic shock worldwide. Prediction of fluid responsiveness is essential for optimizing fluid administration. Only few pediatric studies have evaluated the role of inferior vena cava (IVC) as a reliable predictor of fluid responsiveness. The aim of this study was to evaluate the role of IVC parameters as predictors of fluid responsiveness in children (under the age of 5 years) having septic shock at different times from admission. A prospective observational study included 51 children having septic shock. It was conducted in the nine-bedded pediatric intensive care unit of a university hospital from January 1, 2018, to the August 31, 2018. Echocardiography was used to assess minimal and maximal IVC diameters and its distensibility index with simultaneous assessment of stroke volume (SV), at 1, 6, and 24 hours from admission. The decision to give fluid in these children was thereby based on the presence of at least one sign of inadequate tissue perfusion. SV was reassessed directly after administration of a fluid bolus of 10 mL/kg over 10 minutes. Fluid responsiveness was considered adequate when there was ≥ 10% increase in SV after fluid bolus. Minimal IVC diameter indexed to body surface area and its distensibility index can be predictors of fluid responsiveness at all times: 1 hour (area under curve [AUC] = 0.88; 95% confidence interval [CI] = 0.77–0.96), 6 hours (AUC = 0.86; 95% CI = 0.67–0.97), and 24 hours (AUC = 0.77; 95% CI = 0.6–0.95). IVC distensibility index can also predict fluid responsiveness at 1 hour (AUC= 0.87; 95% CI = 0.74–0.95), 6 hours (AUC = 0.86; 95% CI = 0.73–0.94), and 24 hours (AUC = 1; 95% CI = 0.77–1). The cutoff points of each parameter differed from time to time (contradicts with previous statement that says it is predictor at all times). The maximum IVC diameter could not predict fluid responsiveness at any time from admission. Minimal IVC diameter and its distensibility index were feasible noninvasive surrogates of fluid responsiveness in pediatric septic shock at different times from admission.
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Affiliation(s)
- Ahmed Ahmed EL-Nawawy
- Pediatric Intensive Care Unit, Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt
| | - Omneya Magdy Omar
- Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt
| | - Hadir Mohamed Hassouna
- Pediatric Intensive Care Unit, Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt
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Baloch K, Rehman Memon A, Ikhlaq U, Umair M, Ansari MI, Abubaker J, Salahuddin N. Assessing the Utility of End-Tidal Carbon Dioxide as a Marker for Fluid Responsiveness in Cardiogenic Shock. Cureus 2021; 13:e13164. [PMID: 33692926 PMCID: PMC7938016 DOI: 10.7759/cureus.13164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Preventing end-organ failure in patients with shock requires rapid and easily accessible measurements of fluid responsiveness. Unlike septic shock, not all patients in cardiogenic shock are preload responsive. We conducted this study to determine the discriminant power of changes in end-tidal carbon dioxide (ETCO2), systolic blood pressure (SBP), inferior vena cava (IVC) collapsibility index (IVC-CI), and venous to arterial carbon dioxide (Pv-aCO2) gap after a fluid challenge and compared it to increases in cardiac output. Methodology In a prospective, quasi-experimental design, mechanically ventilated patients in cardiogenic shock were assessed for fluid responsiveness by comparing improvement in cardiac output (velocity time integral) with changes in ETCO2, heart rate, SBP, Pv-aCO2 gap, IVC-CI after a fluid challenge (a crystalloid bolus or passive leg raise). Results Out of 60 patients, with mean age 61.3 ± 14.8 years, mean acute physiology and chronic health evaluation (APACHE) score 14.82 ± 7.49, and median ejection fraction (EF) 25% (25-35), 36.7% (22) had non ST-segment elevation myocardial infarction (NSTEMI) and 60% (36) were ST-segment elevation myocardial infarction (STEMI). ETCO2 was the best predictor of fluid responsiveness; area under the curve (AUC) 0.705 (95% confidence interval (CI) 0.57-0.83), p=0.007, followed by reduction in Pv-aCO2 gap; AUC 0.598 (95% CI; 0.45-0.74), p= 0.202. Changes in SBP, mean arterial pressure (MAP), IVC-CI weren’t significant; 0.431 (p=0.367), 0.437 (p=0.410), 0.569 (p=0.367) respectively. The discriminant value identified for ETCO2 was more than equal to 2 mmHg, with sensitivity 58.6%, specificity 80.7%, positive predictive value 73.9% [95% CI; 56.5% to 86.1%], negative predictive value 69.7% [95% CI; 56.7% to 76.9%]. Conclusions Change in ETCO2 is a useful bedside test to predict fluid responsiveness in cardiogenic shock.
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Affiliation(s)
- Komal Baloch
- Critical Care Medicine, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Aziz Rehman Memon
- Critical Care Medicine, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Urwah Ikhlaq
- Critical Care Medicine, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Madiha Umair
- Critical Care Medicine, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Muhammad Imran Ansari
- Critical Care Medicine, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Jawed Abubaker
- Internal Medicine, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Nawal Salahuddin
- Critical Care Medicine, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
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Wood C. Fluid management: An update for perioperative practitioners. J Perioper Pract 2021; 31:71-79. [PMID: 33472531 DOI: 10.1177/1750458920964174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An interprofessional team approach is required to achieve optimum fluid balance for patients during the perioperative period. Incorrect management of fluid assessment and monitoring is associated with adverse outcomes. The scientific understanding of perioperative fluid balance has improved over recent years leading to changes in clinical practice with regard to volume and choice of intravenous fluid. It is important that perioperative practitioners have an understanding of intravenous fluid, fluid compartmentalisation, fluid mechanics and intravascular fluid control mechanisms. Optimum fluid status not only shortens hospital stay but also reduces the incidence of postoperative nausea and vomiting and complication profiles. This article aims to provide perioperative practitioners with a comprehensive overview of fluid management. It will cover important issues surrounding physiological control of fluid balance, choice of intravenous fluid therapy, methods to monitor intravascular volume and factors which influence delivery.
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El-Nawawy AA, Farghaly PM, Hassouna HM. Accuracy of Passive Leg Raising Test in Prediction of Fluid Responsiveness in Children. Indian J Crit Care Med 2020; 24:344-349. [PMID: 32728327 PMCID: PMC7358867 DOI: 10.5005/jp-journals-10071-23432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Aim To assess the accuracy of the passive leg raising (PLR) test to anticipate fluid responsiveness in critically ill children under age of 5 years. Materials and methods A prospective observational study was conducted, in a university hospital pediatric intensive care unit from June 1, 2017, to January 30, 2018. Hemodynamic parameters including stroke volume using bedside transthoracic echocardiography were assessed at baseline I (45° semi-recumbent position), after PLR, at baseline II, and following fluid challenge. Changes in the stroke volume (delta SV) and in the cardiac index (CI) were recorded after PLR and fluid challenge. Findings Delta SV of 10% after PLR was an excellent discriminator of the fluid responsiveness with an area under ROC (AUC) of 0.81 (95% CI 0.68-0.9) with a sensitivity of 65.38% and a specificity of 100%. The change in CI of 8.7% after PLR was a significant discriminator of fluid responsiveness with an AUC of 0.7 (95% CI 0.56-0.81) with 57.78% sensitivity and 91.67% specificity. Conclusion Passive leg raising can identify nonresponders among seriously ill children under the age of 5 years but it cannot identify all responders with certainty. Clinical significance Passive leg raising is reliable test in under 5 year-old-children if performed appropriately using bedside echocardiography for the measurement of its transient effect. How to cite this article El-Nawawy AA, Farghaly PM, Hassouna HM, Accuracy of Passive Leg Raising Test in Prediction of Fluid Responsiveness in Children. Int J Clin Pediatr Dent 2020;24(5):344-349.
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Affiliation(s)
- Ahmed A El-Nawawy
- Pediatric Department (PICU), Faculty of Medicine, Alexandria University, Egypt
| | - Passant M Farghaly
- Pediatric Department (PICU), Faculty of Medicine, Alexandria University, Egypt
| | - Hadir M Hassouna
- Pediatric Department (PICU), Faculty of Medicine, Alexandria University, Egypt
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