What every intensivist should know about the IVC.

Assessment of the IVC by point-of-care ultrasound in the context of resuscitation has been a controversial topic in the last decades. Most of the focus had been on its use as a surrogate marker for fluid responsiveness, with results being equivocal. We review its important anatomical aspects as well as the physiological rationale behind ultrasound assessment and propose a new way to do so, as well as explain its central role in the concept of fluid tolerance.

Bedside Ultrasound in the Management of Cardiorenal Syndromes: An Updated Review.

BACKGROUND: Cardiorenal syndromes constitute a spectrum of disorders involving heart and kidney dysfunction modulated by a complex interplay of neurohormonal, inflammatory, and hemodynamic derangements. The management of such patients often poses a diagnostic and therapeutic challenge to physicians owing to gaps in understanding of pathophysiology, paucity of objective bedside diagnostic tools, and individual biases. SUMMARY: In this narrative review, we discuss the role of clinician who performed bedside ultrasound in the management of patients with cardiorenal syndromes. Novel sonographic applications such as venous excess ultrasound score (VExUS) are reviewed in addition to the lung and focused cardiac ultrasound. Further, underrecognized causes of heart failure such as high-flow arteriovenous fistula are discussed. KEY MESSAGE: Bedside ultrasound allows a comprehensive hemodynamic characterization of cardiorenal syndromes.

Multiorgan evaluation of perfusion and congestion using ultrasound in patients with shock.

There is increasing evidence on the role of ultrasound in the evaluation of multiorgan hypoperfusion and congestion in patients with cardiocirculatory shock both to identify the underlying pathophysiological mechanism and to drive and monitor the treatment. The cardiac and lung ultrasound is included as an integrated multiparametric approach to the very early phase of patients with haemodynamic instability/cardiogenic shock. Splanchnic ultrasound has been mainly applied in heart failure and predominant circulatory failure. Although poorly validated in the critically ill, many ultrasound parameters have a strong physiological background to support their use in the acute setting those that apply either for heart/lung and for splanchnic organ evaluation. This review summarizes the ultrasonographic parameters that have shown evidence in literature in the diagnostic/therapeutic pathway to define the congestion/perfusion profile of the organs that are involved in the pathophysiological cascade of cardiocirculatory shock.

The Survival of the Surviving Sepsis Campaign.

Even well-intentioned policies have great potential to cause harm. This statement is vividly illustrated by the influential, yet controversial, Surviving Sepsis Campaign guidelines and subsequent CMS benchmarks. Despite low-quality evidence, tendentious industry ties, and rebuke from the Infectious Disease Society of America (IDSA), these benchmarks continue to eschew therapy driven by clinician expertise and individual patient needs in favor of mandating an arbitrary, one-size-fits-all approach that suspends clinical judgment and promotes indiscriminate use of treatments that have the potential to cause great harm.

High sensitivity troponin - Six hours is the magic number.

BACKGROUND: High sensitivity troponin assays have become widespread for emergency department evaluation of acute chest pain. We assessed if a high sensitivity troponin under the 99th percentile upper reference limit drawn at 6 h or greater from symptom onset could safely rule out acute coronary syndrome in patients who did not meet the rapid rule-out strategy. METHODS: We conducted a multicenter retrospective study examining emergency department patients with chest pain who did not meet rapid-rule out criteria and were admitted for further evaluation. Among these admitted patients, we assessed the rate of clinically relevant adverse cardiac events (death, cardiac or respiratory arrest, STEMI, or life-threatening arrhythmia) and NSTEMI in patients with high sensitivity troponin less than the 99th percentile value obtained after at least 6 h of chest pain. RESULTS: Out of 1187 patients admitted, we found 30 clinically relevant adverse cardiac events, all of which occurred in patients admitted for another compelling reason or ischemic ECG. 36 patients had an NSTEMI, of which 33 were identified with high sensitivity troponin greater than 99th percentile upper reference limit within 6 h of chest pain onset. This left 0 clinically relevant adverse cardiac events and 3 NSTEMI among the 429 patients with high sensitivity troponin less than the 99th percentile at 6 h and nonischemic ECG and no other compelling reason for admission. CONCLUSION: This study assessed patients with chest pain with high sensitivity troponin values between 3 ng/L and the 99th percentile upper reference limit after 6 h of chest pain and found that they have a low rate of clinically relevant adverse cardiac events and NSTEMI.

Airway Pressure Release Ventilation: A Field Guide for the Emergency Physician.

Airway pressure release ventilation (APRV) is a mode of ventilation that uses high airway pressures to recruit and maintain patients' lung volumes. The goal of this mode of ventilation is 2-fold: first, to maintain patients as close to their functional residual capacity as possible and second, to promote safe spontaneous breathing. APRV should essentially be viewed as continuous positive airway pressure (CPAP), with intermittent releases of that pressure to metabolically support patients who are incapable of managing their ventilatory load. As patients recruit and lungs approach the patients' natural lung volumes, their ability to breathe spontaneously and manage their own ventilatory needs improves. Eventually, patients are able to fully support their ventilatory needs and no longer require any release breaths to maintain normal CO2 levels. Now, patients can be "stretched" to CPAP.

Lowering platelet count threshold to 10,000/µL for peripherally inserted central catheter placement safely conserves blood products.

Despite the low risk of peripherally inserted central catheter (PICC) insertion-related bleeding, the practice of administering prophylactic platelets varies greatly. Limiting unnecessary blood product transfusions reduces transfusion-related adverse events, financial cost, and delays in care. We assessed the impact of lowering prophylactic platelet administration threshold on blood product utilization patterns and bleeding events. This quasi-experimental study was conducted in an urban academic tertiary medical center. The study population included patients with platelet counts ≥ 10,000/µL and < 50,000/µL undergoing PICC placement in 2018 and 2019 when the minimum platelet thresholds were 50,000/µL and 10,000/µL, respectively. The primary outcome was blood product utilization and the secondary outcome was PICC insertion-related bleeding complications. Thirty-five patients using the 10,000/µL (10 K) platelet threshold and 46 patients using the 50,000/µL (50 K) platelet threshold were enrolled. The 50 K group received more platelets before PICC insertion (0.870 ± 0.885 and 0.143 ± 0.430 pools of platelets-per-person, p < 0.001). No patients experienced clinically significant bleeding. Immediately following PICC insertion, minor bleeding occurred in five patients (two [4.3%] and three [8.6%] in the 50 K and 10 K groups, respectively). Bleeding rates between the two cohorts did not differ (p = 0.647). Lowering the minimum platelet threshold from 50,000/µL to 10,000/µL resulted in less prophylactic platelet and total blood product administration with no appreciable difference in PICC insertion-related bleeding.

Clinical applications of the venous excess ultrasound (VExUS) score: conceptual review and case series.

The importance of functional right ventricular failure and resultant splanchnic venous congestion has long been under-appreciated and is difficult to assess by traditional physical examination and standard diagnostic imaging. The recent development of the venous excess ultrasound score (VExUS) and growth of point-of-care ultrasound in the last decade has made for a potentially very useful clinical tool. We review the rationale for its use in several pathologies and illustrate with several clinical cases where VExUS was pivotal in clinical management.