Correlation and concordance of carotid Doppler ultrasound and echocardiography with invasive cardiac output measurement in critically ill patients.

BACKGROUND: Critical care management heavily relies on accurate cardiac output (CO) measurement. Echocardiography has been a mainstay in non-invasive cardiac monitoring; however, its comparability to invasive methods warrants further exploration. Recent studies have suggested the potential of carotid Doppler measurements as a promising approach to estimate CO. Despite this potential, the literature presents mixed outcomes regarding its reliability and accuracy. This study aims to evaluate the correlation and concordance between carotid Doppler ultrasonography and invasive hemodynamic monitoring in estimating CO in critically ill patients. Furthermore, it assesses the concordance and correlation between echocardiography CO and the standard invasive CO measurements. METHODS: This concordance study involved critically ill adults requiring invasive CO measurement. Patients with arrhythmias, severe valvulopathy, pregnancy, and poor acoustic window were excluded. Statistical analyses comprised univariate analysis, Wilcoxon signed-rank test, Spearman correlation, and intraclass correlation coefficient. Ethical approval was granted by the institution's ethics committee. RESULTS: A total of 49 critically ill patients were included, predominantly male (63.27%), with a median age of 57 years. Diagnoses included subarachnoid hemorrhage (53.06%) and heart failure (8.16%). Mean cardiac index was 3.36 ± 0.81 L/min/m2 and mean cardiac output was 5.98 ± 1.47 L/min. Spearman correlation coefficient between echocardiography and invasive CO measurements was 0.58 (p-value = p < 0.001), with an ICC of 0.59 for CO and 0.52 for cardiac index. Carotid measurements displayed no significant correlation with invasive CO. CONCLUSION: There is a moderate correlation and concordance between echocardiography and invasive CO measurements. There is no significant correlation between carotid variables and invasive CO, underscoring the necessity for cautious interpretation and application, particularly in patients with distinctive cerebral blood flow dynamics.

Bleeding Complications in Uremic Patients After Ultrasound-Guided Central Venous Catheter Placement.

Introduction: Bleeding associated with elevated blood urea nitrogen (BUN) is a known complication. Patients with uremia require a central venous catheter insertion by dialysis. The relation between BUN and bleeding complications during central venous catheter insertion is not yet clear. Objective: We described the frequency of complications associated with central venous catheter implantation in uremic patients and evaluated the statistical relationship between bleeding complications and catheter type, number of punctures, and catheter insertion site. Also, we determined if any value of BUN is associated with bleeding complications. Methods: We included patients with a serum value of BUN >70 mg/dl that required insertion of a central venous catheter. The quantitative variables were expressed through the measure of central tendency. A bivariate analysis and a ROC curve were performed. Results: A total of 273 catheters were included in this study. Bleeding complications were detected in 69 cases (25.3%), and local bleeding was the most frequent complication in 51/69 cases. Statistically significant association was not established. We did not find a specific cut-off value directly related to BUN levels and the rate of complications. Conclusion: Bleeding complications associated with the insertion of central venous catheter and the suspected disorder of hemostasis given by BUN levels >70 mg/dl are common. It was not possible to determine a BUN cut-off value to predict complications. The association analysis was not conclusive. High BUN levels should not be considered a high-risk condition for central venous cannulation under ultrasound guidance performed by trained personnel.

An 80-Year-Old Woman with Alzheimer Disease and Accidental Poisoning with Pyrethroid Pesticide Successfully Treated with Intravenous Lipid Emulsion.

BACKGROUND Pesticides are commonly used in the agricultural industry. Overdose can be lethal due to its effects generating closure of the voltage-gated sodium channels in the axonal membranes. Most case reports of toxicity refer to skin exposure and there are very few that refer to effects due to its oral intake. CASE REPORT We report the case of an elderly woman with Alzheimer disease who accidentally swallowed 50 g of Lambda Cyhalothrin (GOLPE 5 M E®), a pyrethroid of medium toxicity containing a cyano group. It severely harmed the woman's health, causing severe central nervous system depression and refractory vasodilated shock requiring the use of vasopressors. Its management was challenging, requiring orotracheal intubation, vasopressors, and admission to the Intensive Care Unit (ICU). The emergency care team decided to use intravenous lipid emulsion, which clearly helped with the recovery and successful discharge of the patient. CONCLUSIONS The use of intravenous lipid emulsion for the treatment of pyrethroid poisoning can lead to successful outcomes, as described in this case report.

Successful Outcome Following Intravenous Lipid Emulsion Rescue Therapy in a Patient with Cardiac Arrest Due to Amitriptyline Overdose.

BACKGROUND The management of patients with tricyclic antidepressant drug overdose can be a challenge for the emergency department physician. Tricyclic antidepressants block alpha-adrenergic receptors and the anticholinergic effects may lead to cardiotoxicity, resulting in arrhythmias and hypotension that can lead to patient mortality. This report is of a case of a 28-year-old woman who presented with cardiac arrest due to amitriptyline overdose and who responded to intravenous lipid emulsion (ILE) therapy. CASE REPORT A 28-year-old woman was admitted to the emergency department with amitriptyline overdose. She suffered a cardiac arrest followed by cardiovascular and neurological complications. Hypotension and lack of a pulse did not respond to treatment with high-dose sodium, but she stabilized following treatment with ILE. The prompt response from the emergency team guaranteed rapid intervention that may have influenced the successful results. CONCLUSIONS Despite the frequency and severity of poisoning with tricyclic antidepressants, there is little consensus among physicians regarding patient management. This case showed the successful use of ILE as rescue therapy in a patient in cardiac arrest following amitriptyline overdose. However, the successful outcome obtained in this case is not a recommendation for the use of ILE as a first-line treatment for the management of patients with tricyclic antidepressant drug overdose. Controlled clinical studies are required to evaluate the safety and efficacy of ILE in the management of tricyclic antidepressant drug overdose.

Cistitis hemorrágica por Enterococo: reporte de un caso y revisión de la literatura / Enterococcus hemorrhagic cystitis: a case report and literature review

La hematuria macroscópica es un síntoma y signo clínico más que una enfermedad por sí misma, dado que detrás de ésta siempre habrá una enfermedad responsable. La hematuria macroscópica, a diferencia de la microscópica, siempre obliga al médico a estudiarla exhaustivamente puesto que múltiples enfermedades pueden ser la posible etiología y, a su vez, pudiera generarse gran morbilidad para el paciente en caso de no ser rápidamente identificadas y tratadas. La historia clínica y el examen físico del paciente son el pilar fundamental para guiar el enfoque paraclínico inicial de los pacientes. Este último debe ser iniciado con el uroanálisis y según su resultado, se deben continuar los estudios necesarios para corroborar o confirmar las sospechas diagnósticas generadas en el interrogatorio y el examen clínico inicial. Se presenta un caso inusual de una paciente de 12 años con hematuria macroscópica franca, quien llega al servicio de urgencias pediátricas sin antecedentes claros que guiaran a un diagnóstico inicial, motivo por lo cual se le realizan varios paraclínicos para descartar enfermedades frecuentemente asociadas a este motivo de consulta. Finalmente se llega a un diagnóstico inusual de cistitis hemorrágica por Enterococcus Sp., del cual no se encontraron casos reportados previamente en la literatura. Este caso inusual permite hacer una revisión de la literatura respecto a la hematuria macroscópica en la población pediátrica, con el fin de puntualizar yaclarar el enfoque diagnóstico.

Gross hematuria is more a symptom and clinical sign than a disease by itself, because behind this there is always a disease that is responsible for it. Gross hematuria always obligates to be studied because many potentially complicated diseases might generate some morbidity for patient. Clinical history and physical examination are fundamental for guiding initial laboratory approach in our patients, which should be started with an urinalysis and continued as necessary for corroborating suspected diagnosis by clinical history and physical examination. We present an unusual case of 12 years old patient with gross hematuria that comes to emergency department, some laboratories test were taken looking for the most frequent pathologies, but we made the diagnosis of a very unusual case of enterococcal hemorrhagic cystitis, about what there are no previous reports in medical literature. This unusual case allows a review of literature on macroscopic haematuria in paediatric population in order to clarify the diagnostic approach in this type of symptomatology, as was done in this patient.

Intoxicación aguda por hierro / Acute iron poisoning

Los pacientes intoxicados representan un reto en el enfoque diagnóstico y terapéutico en los serviciosde urgencias. La intoxicación por hierro es una condición médica relativamente frecuente en los pacientes pediátricos y gestantes, dada la fácil adquisición de este mineral en los suplementosvitamínicos, que son corrientemente formulados en las consultas médicas de promoción y prevención y en los programas de control prenatal. La intoxicación aguda por hierro representa un alto potencialletal y para llegar a dicho estado se requieren dosis extremadamente altas como 200 a 250 mg/kg de hierro elemental, aunque recientemente se describe con valores mayores de 150 mg/kg y otros con 75 mg/kg; sin embargo, se empiezan a observar manifestaciones de toxicidad con ingestas mayores de 15 a 20 mg/kg. En el presente artículo se hace una revisión de la intoxicación aguda por hierro desde su metabolismo básico, pasando por los mecanismos existentes para la regulación de las sobrecargasférricas agudas y tomando conceptos necesarios para la comprensión de los procesos fisiopatológicosde las manifestaciones de toxicidad, según el órgano blanco potencialmente lesionado. Se hace una reseña de las modalidades diagnósticas y terapéuticas establecidas, así como los aportes de algunas investigaciones para la posible identificación de antídotos distintos a la deferoxamina. Por último, sepresenta un algoritmo diagnóstico y terapéutico en base a la revisión hecha.

Poisoned patients represent a challenge at the diagnostic and therapeutic approach in theemergency department. Iron poisoning is a relativelycommon medical condition in pregnantand pediatric patients due the easy acquisition of the mineral in supplements often prescribedin medical consultations and prenatal care programs. This poisoning has a high lethal potential,however to reach that state are required extremely high doses as 200 to 250 mg/kg of elementaliron, but recently it´s describe doses of 150 mg/kg and some authors reports of 75 mg/Kg,but are beginning to show signs of toxicity with intakes of 15 - 20 mg/kg. In this paper, we madea review of acute iron poisoning, from basic metabolism, through existing mechanisms for theregulation of acute iron overload and taking concepts for understanding the pathophysiologicalprocesses. This review provides an overview of established diagnostic and therapeutic modalities,as well as input from some research forthe possible identification of various antidotes different to deferoxamine. Finally, it presents a diagnostic and therapeutic algorithm based on the review done.