Optimizing the value of measuring inferior vena cava diameter in shocked patients

Advances in the application of ultrasonographic parameters for fluid management in obstetric anesthesia

Ultrasound provides a valuable non-invasive approach for fluid management in obstetric anesthesia. Ultrasonographic parameters assist anesthesiologists to effectively assess the fluid status of parturients and reduce related complications. In addition to conventional parameters, which have been widely validated in clinical practice, we provide new insights into arterial parameters such as peak velocity, velocity-time integral, corrected flow time, and vein-related parameters, including the internal jugular vein and its collapsibility index, the inferior vena cava and its collapsibility index, as well as subclavian vein and its collapsibility index. These parameters can potentially enhance fluid management in obstetric anesthesia.

Surgical and critical care management of earthquake musculoskeletal injuries and crush syndrome: A collective review

Earthquakes are unpredictable natural disasters causing massive injuries. We aim to review the surgical management of earthquake musculoskeletal injuries and the critical care of crush syndrome. We searched the English literature in PubMed without time restriction to select relevant papers. Retrieved articles were critically appraised and summarized. Open wounds should be cleaned, debrided, receive antibiotics, receive tetanus toxoid unless vaccinated in the last 5 years, and re-debrided as needed. The lower limb affected 48.5% (21.9%-81.4%) of body regions/patients. Fractures occurred in 31.1% (11.3%-78%) of body regions/patients. The most common surgery was open reduction and internal fixation done in 21% (0%-76.6%), followed by plaster of Paris in 18.2% (2.3%-48.8%), and external fixation in 6.6% (1%-13%) of operations/patients. Open fractures should be treated with external fixation. Internal fixation should not be done until the wound becomes clean and the fractured bones are properly covered with skin, skin graft, or flap. Fasciotomies were done in 15% (2.8%-27.2%), while amputations were done in 3.7% (0.4%-11.5%) of body regions/patients. Principles of treating crush syndrome include: (1) administering proper intravenous fluids to maintain adequate urine output, (2) monitoring and managing hyperkalemia, and (3) considering renal replacement therapy in case of volume overload, severe hyperkalemia, severe acidemia, or severe uremia. Low-quality studies addressed indications for fasciotomy, amputation, and hyperbaric oxygen therapy. Prospective data collection on future medical management of earthquake injuries should be part of future disaster preparedness. We hope that this review will carry the essential knowledge needed for properly managing earthquake musculoskeletal injuries and crush syndrome in hospitalized patients.

Accuracy of Pocket-sized Ultrasound Devices to Evaluate Inferior Vena Cava Diameter and Variability in Critically Ill Patients

Purpose

By using inferior vena cava (IVC) measurements, clinicians can detect fluid status and responsiveness and find out the etiology of hypotension, acute heart failure, and sepsis easier. Pocket-sized ultrasound devices (PSUD) may take this advantage a few steps further by their lower costs, user-friendly interface, and easily applicable structure.In this study, we aimed to determine the diagnostic value of a PSUD compared with a standard ultrasound device (SD) for the measurement of IVC diameter (IVCD) and its respiratory variability.

Materials and methods

We measured the inspiratory, expiratory diameters of IVC, and calculated the inferior vena cava collapsibility index (IVCCI). We investigated 42 intensive care unit (ICU) patients.

Results

There was no difference in inspiratory (PSUD: 1.34 ± 0.67 cm; SD: 1.35 ± 0.68 cm) and expiratory (PSUD: 1.98 ± 0.53 cm; SD: 2.01 ± 0.49 cm) IVCD among measurements with PSUD and SD (p > 0.05). There was also no difference between IVCCI's measured with PSUD (39 ± 20%) and SD (39 ± 20%) (p > 0.05). The Bland-Altman analysis revealed that the width of 95% limits of agreement were similar for both devices. There was a good inter-device agreement among PSUD and SD for measurements of IVCD, and there was no difference between IVCCI's measured using both ultrasound devices.

Conclusion

We support that the idea of a PSUD is as reliable as a SD for IVC measurements.

How to cite this article

Inci K, Gürsel G. Accuracy of Pocket-sized Ultrasound Devices to Evaluate Inferior Vena Cava Diameter and Variability in Critically Ill Patients. Indian J Crit Care Med 2024;28(4):369-374.

Prehospital management of earthquake crush injuries: A collective review

Earthquakes are natural disasters which can destroy the rural and urban infrastructure causing a high toll of injuries and death without advanced notice. We aim to review the prehospital medical management of earthquake crush injuries in the field. PubMed was searched using general terms including rhabdomyolysis, crush injury, and earthquake in English language without time restriction. Selected articles were critically evaluated by three experts in disaster medicine, emergency medicine, and critical care. The medical response to earthquakes includes: (1) search and rescue; (2) triage and initial stabilization; (3) definitive care; and (4) evacuation. Long-term, continuous pressure on muscles causes crush injury. Ischemia-reperfusion injury following the relieving of muscle compression may cause metabolic changes and rhabdomyolysis depending on the time of extrication. Sodium and water enter the cell causing cell swelling and hypovolemia, while potassium and myoglobin are released into the circulation. This may cause sudden cardiac arrest, acute extremity compartment syndrome, and acute kidney injury. Recognizing these conditions and treating them timely and properly in the field will save many patients. Majority of emergency physicians who have worked in the field of the recent Kahramanmaraş 2023, Turkey, earthquakes, have acknowledged their lack of knowledge and experience in managing earthquake crush injuries. We hope that this collective review will cover the essential knowledge needed for properly managing seriously crushed injured patients in the earthquake field.

Reduction of motorcycle-related deaths over 15 years in a developing country

BACKGROUND

There have been major improvements in the trauma system and injury prevention in Al-Ain City. We aimed to study the impact of these changes on the incidence, pattern, injury severity, and outcome of hospitalized motorcycle-related injured patients in Al-Ain City, United Arab Emirates.

METHODS

This is a retrospective analysis of two separate periods of prospectively collected data which were retrieved from Al-Ain Hospital Trauma Registry (March 2003 to March 2006 compared with January 2014 to December 2017). All motorcycle-injured patients who were admitted to Al-Ain Hospital for more than 24 h or died in the Emergency Department or after hospitalization were studied.

RESULTS

The incidence of motorcycle injuries dropped by 37.1% over the studied period. The location of injury was significantly different between the two periods (p = 0.02, Fisher's exact test), with fewer injuries occurring at streets/highways in the second period (69.1% compared with 85.3%). The anatomical injury severity of the head significantly increased over time (p = 0.03), while GCS on arrival significantly improved (p < 0.0001), indicating improvements in both prehospital and in-hospital trauma care. The mortality of the patients significantly decreased (0% compared with 6%, p = 0.002, Fisher's exact test).

CONCLUSIONS

The incidence of motorcycle injuries in our city dropped by almost 40% over the last 15 years. There was a significant reduction in the mortality of hospitalized motorcycle-injured patients despite increased anatomical severity of the head injuries. This is attributed to improvements in the trauma care system, including injury prevention, and both prehospital and in-hospital trauma care.

Inferior vena cava assessment in term pregnant women using ultrasound: A comparison of the subcostal and right upper quadrant views

Point-of-care ultrasound can be used at the bedside to assess the haemodynamic status and fluid responsiveness of a pregnant woman. Previous studies demonstrated that views from the apical and parasternal windows are readily obtainable in labouring women. However, using the subcostal window to assess the inferior vena cava can be challenging because of the gravid uterus. A potential alternative is the right upper quadrant transhepatic window. We sought to compare visualisation of the inferior vena cava via the subcostal and right upper quadrant windows, in full-term pregnant women. This was a prospective pilot study carried out in a tertiary academic obstetric centre. Thirty pregnant non-labouring women at full term were recruited. In each patient, the inferior vena cava was visualised through both the subcostal and the right upper quadrant windows. Time to acquire each image, acquisition success rates and ease of obtaining images were compared for both approaches. Image quality was then reviewed and rated by two independent expert reviewers. There was a significant difference in the time required to obtain each view; subcostal median (interquartile range): 52 (35-59) seconds, right upper quadrant median (interquartile range): 23 (11-55) seconds (P=0.0045). Operator-defined successful image acquisition was 100% for the right upper quadrant window compared to 80% for the subcostal window. Ease of obtaining the view, as rated by the operator, was significantly easier in the right upper quadrant window compared to the subcostal window (P <0.0001). Both reviewers independently rated image adequacy to be significantly greater in the right upper quadrant window (73% and 57%) compared to the subcostal window (40% and 10%) (P=0.0213 and P=0.0005, respectively). Inter-rater agreement ranged between good (Cohen's kappa coefficient 0.64) for right upper quadrant windows to fair (Cohen's kappa coefficient 0.29) for subcostal windows. Inferior vena cava visualisation in term pregnant patients may take less time, be easier and provide better quality images when the right upper quadrant window is used compared to the subcostal window.

Point-of-care ultrasound (POCUS) practices in the helicopter emergency medical services in Europe: results of an online survey

Background

The extent to which Point-of-care of ultrasound (POCUS) is used in different European helicopter EMS (HEMS) is unknown. We aimed to study the availability, perception, and future aspects of POCUS in the European HEMS using an online survey.

Method

A survey about the use of POCUS in HEMS was conducted by a multinational steering expert committee and was carried out from November 30, 2020 to December 30, 2020 via an online web portal. Invitations for participation were sent via email to the medical directors of the European HEMS organizations including two reminding notes.

Results

During the study period, 69 participants from 25 countries and 41 different HEMS providers took part in the survey. 96% (n = 66) completed the survey. POCUS was available in 75% (56% always when needed and 19% occasionally) of the responding HEMS organizations. 17% were planning to establish POCUS in the near future. Responders who provided POCUS used it in approximately 15% of the patients. Participants thought that POCUS is important in both trauma and non-trauma-patients (73%, n = 46). The extended focused assessment sonography for trauma (eFAST) protocol (77%) was the most common protocol used. A POCUS credentialing process including documented examinations was requested in less than one third of the HEMS organizations.

Conclusions

The majority of the HEMS organizations in Europe are able to provide different POCUS protocols in their services. The most used POCUS protocols were eFAST, FATE and RUSH. Despite the enthusiasm for POCUS, comprehensive training and clear credentialing processes are not available in about two thirds of the European HEMS organizations. Due to several limitations of this survey further studies are needed to evaluate POCUS in HEMS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00933-y.

Inferior Vena Cava Collapsibility Index: Clinical Validation and Application for Assessment of Relative Intravascular Volume

Accurate assessment of relative intravascular volume is critical to guide volume management of patients with acute or chronic kidney disorders, particularly those with complex comorbidities requiring hospitalization or intensive care. Inferior vena cava (IVC) diameter variability with respiration measured by ultrasound provides a dynamic noninvasive point-of-care estimate of relative intravascular volume. We present details of image acquisition, interpretation, and clinical scenarios to which IVC ultrasound can be applied. The variation in IVC diameter over the respiratory or ventilatory cycle is greater in patients who are volume responsive than those who are not volume responsive. When 2 recent prospective studies of spontaneously breathing patients (n = 214) are added to a prior meta-analysis of 181 patients, for a total of 7 studies of 395 spontaneously breathing patients, IVC collapsibility index (CI) had a pooled sensitivity of 71% and specificity of 81% for predicting volume responsiveness, which is similar to a pooled sensitivity of 75% and specificity of 82% for 9 studies of 284 mechanically ventilated patients. IVC maximum diameter <2.1 cm, that collapses >50% with or without a sniff is inconsistent with intravascular volume overload and suggests normal right atrial pressure (0-5 mmHg). Inferior vena cava collapsibility (IVC CI) < 20% with no sniff suggests increased right atrial pressure and is inconsistent with overt hypovolemia in spontaneously breathing or ventilated patients. These IVC CI cutoffs do not appear to vary greatly depending on whether patients are breathing spontaneously or are mechanically ventilated. Patients with lower IVC CI are more likely to tolerate ultrafiltration with hemodialysis or improve cardiac output with ultrafiltration. Our goal for IVC CI generally ranges from 20% to 50%, respecting potential biases to interpretation and overriding clinical considerations. IVC ultrasound may be limited by factors that affect IVC diameter or collapsibility, clinical interpretation, or optimal visualization, and must be interpreted in the context of the entire clinical situation.

Role of Inferior Vena Cava Parameters as Predictors of Fluid Responsiveness in Pediatric Septic Shock: A Prospective Study

Fluid 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.

Point-of-care ultrasound for the acute abdomen in the primary health care

Point-of-care ultrasound (POCUS) is a focused examination, which is performed and interpreted at the bedside by the treating physician answering a specific clinical question. It is currently utilized as an essential adjunct to physical examination in many medical specialties. Recent advances in technology have made POCUS machines portable, affordable, and could be used with minimal training even by nonradiologists. This review aims to cover the fundamental physics of POCUS and its applications for diagnosing the acute abdomen in the primary health care including the most common causes encountered by family physicians. These are acute appendicitis, acute cholecystitis, renal colic, ectopic pregnancy, acute diverticulitis, bowel obstruction, and abdominal aortic aneurysm. We hope to encourage primary care physicians to incorporate POCUS in their routine clinical practice. We also highlight challenges encountered when using POCUS in the primary health care including limited availability and the need for proper training. Furthermore, we review the POCUS results when performed by primary health-care physicians. Integrating POCUS in primary health care empowers primary health-care physicians to provide high-quality, safe, and cost-effective care to the patients.

Kunafa knife and play dough is an efficient and cheap simulator to teach diagnostic Point-of-Care Ultrasound (POCUS)

Background

Point-of-Care Ultrasound (POCUS) is a useful diagnostic tool. Nevertheless, it needs proper training to reach its required level of competency. Educators who work in low-income countries find it difficult to purchase expensive training computer-based simulators. We aim in this communication to describe the methods to build up and use an efficient, simple, and cheap simulator which can be used for teaching POCUS globally.

Methods

It took our group 2 years to develop the simulator to its current form. The required material for the simulator includes a Kunafa knife, a carton gift box and its cover and colored play dough. The Kunafa knife with its blade is an excellent simulator for the small print convex array probe (3–5 MHz) and its ultrasound sections. It is useful to teach two important principles. First, the three basic hand movements used to control the ultrasound probe (fanning, tilting, and shifting). Second, the thin blade of the knife (1 mm thick) simulates the shape of the two-dimensional ultrasound images. The play dough is used to simulate different organs to be cut in different directions like the aorta and inferior vena cava.

Results

The simulator was used to teach 88 fifth year medical students during the period of November 2017 to November 2018 at the College of Medicine and Health Sciences, UAE University. The simulator was valid, simple, portable, and sustainable. The students greatly enjoyed its use. The cost of the simulator is less than 10 US dollars.

Conclusions

Surgical educators who work in low-income countries are encouraged to develop their educational tools that are tailored to their own needs. Our simulator can help our colleagues who want to teach POCUS and cannot purchase expensive mannequins and computer-based simulators.

Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced

The use of point-of-care ultrasound (POCUS) by non-radiologists has dramatically increased. POCUS is completely different from the routine radiological studies. POCUS is a Physiological, On spot, extension of the Clinical examination, that is Unique, and Safe. This review aims to lay the basic principles of using POCUS in diagnosing intestinal pathologies so as to encourage acute care physicians to learn and master this important tool. It will be a useful primer for clinicians who want to introduce POCUS into their clinical practice. It will cover the basic physics, technical aspects, and simple applications including detection of free fluid, free intraperitoneal air, and bowel obstruction followed by specific POCUS findings of the most common intestinal pathologies encountered by acute care physicians including acute appendicitis, epiploic appendagitis, acute diverticulitis, pseudomembranous colitis, intestinal tuberculosis, Crohn’s disease, and colonic tumours. Deep understanding of the basic physics of ultrasound and its artefacts is the first step in mastering POCUS. This helps reaching an accurate POCUS diagnosis and avoiding its pitfalls. With increased skills, detailed and accurate POCUS findings of specific intestinal pathologies can be achieved and properly correlated with the clinical picture. We have personally experienced and enjoyed this approach to a stage that an ultrasound machine is always accompanying us in our clinical on calls and rounds.

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Background

Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups.

Methods

The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion.

Recommendations

Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention.

Discussion

This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.

Bowel injury following gynecological laparoscopic surgery

Background

Bowel injury remains a serious complication of gynecological laparoscopic surgery. We aimed to review the literature on this topic, combined with personal experiences, so as to give recommendations on how to avoid and manage this complication.

Methods

We performed a narrative review on bowel injury following gynecological laparoscopic surgery using PubMed covering prevention, diagnosis, and management. Search terms used were laparoscopy, gynaecology, injury, bowel, prevention, treatment.

Results

Important principles of prevention include proper pre-operative evaluation and increased laparoscopic surgical skills and knowledge. High clinical suspicion is crucial for early diagnosis. Diagnostic workup of suspected cases includes serial abdominal examination, measuring inflammatory markers, and performing imaging studies including abdominal ultrasound and CT scan. When bowel injury is recognized during the first laparoscopic procedure then laparoscopic primary suturing could be tried although laparotomy may be needed. When diagnosis is delayed, then laparotomy is the treatment of choice. The role of robotic surgery and three-dimensional laparoscopic gynecological surgery on bowel injury needs to be further assessed.

Conclusion

Early recognition of bowel injury is crucial for a favorable clinical outcome. A combined collaboration between gynecologists and general surgeons is important for timely and proper decisions to be made.

A comparison of the ultrasound measurement of the inferior vena cava obtained with cardiac and convex transducers

BACKGROUND

Ultrasound measurement of the inferior vena cava diameter and its respiratory variability are amongst the predictors of fluid volume status. The primary purpose of the present study was to compare the consistency of inferior vena cava diameter measurements and the collapsibility index, obtained with convex and cardiac transducers. A secondary aim was to assess the agreement of the patient's allocation to one of the two groups: "fluid responder" or "fluid non-responder", based on inferior vena cava collapsibility index calculation made with two different probes.

METHODS

20 experienced clinicians blinded to the purpose of the study analysed forty anonymized digital clips of images obtained during ultrasound examination of 20 patients. For each patient, one digital loop was recorded with a cardiac and the second with a convex probe. The participants were asked to determine the maximal and minimal diameters of the inferior vena cava in all presented films. An independent researcher performed a comparative analysis of the measurements conducted with both probes by all participants. The calculation of the collapsibility index and allocation to "fluid responder" or "fluid non-responder" group was performed at this stage of the study.

RESULTS

The comparison of measurements obtained with cardiac and convex probes showed no statistically significant differences in the measurements of the maximal and minimal dimensions and in the collapsibility index. We also noticed that the decision of allocation to the "fluid responder" or "non-responder" group was not probe-dependent.

CONCLUSION

Both transducers can be used interchangeably for the estimation of the studied dimensions.

Ultrasound diagnosis of fractures in mass casualty incidents

The role of point-of-care ultrasound in mass casualty incidents (MCIs) is still evolving. Occasionally, hospitals can be destroyed by disasters resulting in large number of trauma patients. CAVEAT and FASTER ultrasound protocols, which are used in MCIs, included extremity ultrasound examination as part of them. The literature supports the use of ultrasound in diagnosing extremity fractures both in hospitals and MCIs. The most recent systematic review which was reported by Douma-den Hamer et al in 2016 showed that the pooled ultrasound sensitivity and specificity for detecting distal forearm fractures was 97% and 95% respectively. Nevertheless, majority of these studies were in children and they had very high heterogeneity. The portability, safety, repeatability, and cost-effectiveness of ultrasound are great advantages when treating multiply injured patients in MCIs. Its potential in managing fractures in MCIs needs to be further defined. The operator should master the technique, understand its limitations, and most importantly correlate the sonographic findings with the clinical ones to be useful. This editorial critically reviews the literature on this topic, describes its principles and techniques, and includes the author’s personal learned lessons so that trauma surgeons will be encouraged to use ultrasound to diagnose fractures in their own clinical practice.

Respiratory Variation in Femoral Vein Diameter Has Moderate Accuracy as a Marker of Fluid Responsivity in Mechanically Ventilated Septic Shock Patients

Ultrasound (US) is considered the first step in evaluation of patients with shock; respiratory variation of the inferior vena cava (inferior vena cava collapsibility [IVCc]) is an important measurement in this scenario that can be impaired by patient condition or technical skills. The main objective of this study was to evaluate if respiratory variation of the femoral vein (femoral vein collapsibility [FVc]), which is easier to visualize, can adequately predict fluid responsiveness in septic shock patients. Forty-five mechanically ventilated septic shock patients in a mixed clinical-surgical, 30-bed intensive care unit were enrolled in this study. All patients underwent assessments of FVc, IVCc and cardiac output using a portable US device. The passive leg raising test was used to evaluate fluid responsiveness. FVc presented an area under the receiver operating characteristic curve of 0.678 (95% confidence interval: 0.519-0.837, p = 0.044) with a cutoff point of 17%, yielding a sensitivity of 62% and specificity of 65% in predicting fluid responsiveness. IVCc had greater diagnostic accuracy compared with FVc, with an area under the receiver operating characteristic curve of 0.733 (95% confidence interval: 0.563-0.903, p = 0.024) and a cutoff point of 29%, yielding a sensitivity of 47% and specificity of 86%. In conclusion, FVc has moderate accuracy when employed as an indicator of fluid responsiveness in spontaneously mechanically ventilated septic shock patients.

Focused Real-Time Ultrasonography for Nephrologists

We propose that renal consults are enhanced by incorporating a nephrology-focused ultrasound protocol including ultrasound evaluation of cardiac contractility, the presence or absence of pericardial effusion, inferior vena cava size and collapsibility to guide volume management, bladder volume to assess for obstruction or retention, and kidney size and structure to potentially gauge chronicity of renal disease or identify other structural abnormalities. The benefits of immediate and ongoing assessment of cardiac function and intravascular volume status (prerenal), possible urinary obstruction or retention (postrenal), and potential etiologies of acute kidney injury or chronic kidney disease far outweigh the limitations of bedside ultrasonography performed by nephrologists. The alternative is reliance on formal ultrasonography, which creates a disconnect between those who order, perform, and interpret studies, creates delays between when clinical questions are asked and answered, and may increase expense. Ultrasound-enhanced physical examination provides immediate information about our patients, which frequently alters our assessments and management plans.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

On table POCUS assessment for the IVC following abdominal packing: how I do it

BACKGROUND

Some surgeons may lack proper experience in abdominal packing. Overpacking may directly compress the inferior vena cava (IVC). This reduces the venous return and possibly causes hypotension. Here, a new on table Point-of-Care Ultrasound application that has been recently used to assess the effect of abdominal packing on the IVC diameter is described. Following abdominal packing, a small print convex array probe with low frequency (2-5 MHz) is used to visualize the IVC. Using the B mode, the IVC can be directly evaluated through a hepatic window between the ribs. The ultrasound beam should be vertical to the IVC longitudinal section at its midpoint. The abdominal towels will be in front of the IVC. This will enable us to judge whether there was overpacking on the IVC.

RESULTS

Our method demonstrates that overpacking does not compress the IVC in a patient whose blood pressure has improved. The IVC diameter progressively increases on table and in the ICU with active resuscitation implying that bleeding stopped and the resuscitation was successful. Furthermore, presence of intra-peritoneal fluid can be excluded.

CONCLUSIONS

This new application of ultrasound evaluation of IVC patency after abdominal packing is simple, practical, easily reproducible, and can guide a less experienced surgeon in determining if overpacking of the abdomen is the cause of hypotension. Ultrasound findings should be correlated with the clinical picture to be useful.

Strangulated epigastric hernia in a 90-year-old man: Point-of-Care Ultrasound (POCUS) as a saving kit: Case report

INTRODUCTION

The physiological reserve of extreme elderly patients is very limited and has major impact on clinical decisions on their management. Hereby we report a 90-year-old man who presented with a strangulated epigastric hernia and who developed postoperative intra-abdominal bleeding, and highlight the value of Point-of-Care Ultrasound (POCUS) in critical decisions made during the management of this patient.

PRESENTATION OF CASE

A 90-year-old man presented with a tender irreducible epigastric mass. Surgeon-performed POCUS using colour Doppler showed small bowel in the hernia with no flow in the mesentery. Resection anastomosis of an ischaemic small bowel and suture repair of the hernia was performed. Twenty four hours after surgery, in a routine follow up using POCUS, significant intra-peritoneal fluid was detected although the patient was haemodynamically stable. The fluid was tapped under bedside ultrasound guidance and it was frank blood. During induction of anaesthesia for a laparotomy, the patient became hypotensive. Resuscitation under inferior vena cava sonographic measurement, followed by successful damage control surgery with packing, was performed. 36h later, the packs were removed, no active bleeding could be seen and the abdomen was closed without tension. The patient was discharged home 50 days after surgery with good general condition.

CONCLUSION

POCUS has a central role in the management of critically-ill elderly patients for making quick critical decisions.