Lung ultrasound in a tertiary intensive care unit population: a diagnostic accuracy study.

BACKGROUND: Evidence from previous studies comparing lung ultrasound to thoracic computed tomography (CT) in intensive care unit (ICU) patients is limited due to multiple methodologic weaknesses. While addressing methodologic weaknesses of previous studies, the primary aim of this study is to investigate the diagnostic accuracy of lung ultrasound in a tertiary ICU population. METHODS: This is a single-center, prospective diagnostic accuracy study conducted at a tertiary ICU in the Netherlands. Critically ill patients undergoing thoracic CT for any clinical indication were included. Patients were excluded if time between the index and reference test was over eight hours. Index test and reference test consisted of 6-zone lung ultrasound and thoracic CT, respectively. Hemithoraces were classified by the index and reference test as follows: consolidation, interstitial syndrome, pneumothorax and pleural effusion. Sensitivity, specificity, positive and negative likelihood ratio were estimated. RESULTS: In total, 87 patients were included of which eight exceeded the time limit and were subsequently excluded. In total, there were 147 respiratory conditions in 79 patients. The estimated sensitivity and specificity to detect consolidation were 0.76 (95%CI: 0.68 to 0.82) and 0.92 (0.87 to 0.96), respectively. For interstitial syndrome they were 0.60 (95%CI: 0.48 to 0.71) and 0.69 (95%CI: 0.58 to 0.79). For pneumothorax they were 0.59 (95%CI: 0.33 to 0.82) and 0.97 (95%CI: 0.93 to 0.99). For pleural effusion they were 0.85 (95%CI: 0.77 to 0.91) and 0.77 (95%CI: 0.62 to 0.88). CONCLUSIONS: In conclusion, lung ultrasound is an adequate diagnostic modality in a tertiary ICU population to detect consolidations, interstitial syndrome, pneumothorax and pleural effusion. Moreover, one should be careful not to interpret lung ultrasound results in deterministic fashion as multiple respiratory conditions can be present in one patient. Trial registration This study was retrospectively registered at Netherlands Trial Register on March 17, 2021, with registration number NL9344.

Thinking Out-of-the-Box: A Non-Standard Application of Standard Pulse-Oximetry and Standard Near-Infrared Spectroscopy in a COVID-19 Patient.

PURPOSE: Purpose of this report is to describe the feasibility of lingual pulse oximetry and lingual near-infrared spectroscopy (NIRS) in a COVID-19 patient to assess lingual tissue viability after several days of mechanical ventilation in the prone position. MATERIALS & METHODS: In a COVID-19 ICU-patient, the tongue became grotesquely swollen, hardened and protruding from the oral cavity after 20 h of mechanical ventilation uninterrupted in the prone position. To assess the doubtful viability of the tongue, pulse-oximetric hemoglobin O2-saturation (SpO2; Nellcor, OxiMax MAX-NI, Covidien, MA, USA) and NIRS-based, regional tissue O2-saturation measurements (rSO2; SenSmart, Nonin, MN, USA) were performed at the tongue. RESULTS: At the tongue, regular pulse-oximetric waveforms with a pulse-oximetric hemoglobin O2-saturation (SpO2) of 88% were recorded, i.e. only slightly lower than the SpO2 reading at the extremities at that time (90%). Lingual NIRS-based rSO2 measurements yielded stable tissue rSO2-values of 76-78%, i.e. values expected also in other adequately perfused and oxygenated (muscle-) tissues. CONCLUSION: Despite the alarming, clinical finding of a grotesquely swollen, rubber-hard tongue and clinical concerns on the adequacy of the tongue perfusion and oxygenation, our measurements of both arterial pulsatility (SpO2) and NIRS-based tissue oxygenation (rSO2) suggested adequate perfusion and oxygenation of the tongue, rendering non-vitality of the tongue, e.g. by lingual venous thrombosis, unlikely. To our knowledge, this is the first clinical report of lingual rSO2 measurement.

Electrocardiographic changes in therapeutic hypothermia.

INTRODUCTION: During therapeutic hypothermia (TH), electrocardiographic (ECG) abnormalities such as Osborn waves and/or ST-segment elevation have been described. However, the incidence and prognostic value of these ECG changes are uncertain given the small-scale studies that have been carried out to date. The aim of this study is to further evaluate the electrocardiographic changes during TH. METHODS: During a period of 3 years, 81 patients (age 63 ± 14 years) were included retrospectively. All patients underwent TH after being resuscitated. ECG registrations before, during and after TH were collected and analyzed. Patients were divided into two groups based on the presence or absence of transmural ischemia ST elevation on the first representative ECG upon arrival at the hospital (ST-segment elevation myocardial infarction (STEMI) and non-STEMI). RESULTS: A total of 243 ECGs were analyzed. During TH 24 patients (30%) had Osborn waves, which disappeared in 22 patients (92%) after regaining normal body temperature. The presence of Osborn waves was not associated with age, gender, average pH, electrolytes, or lactate levels and was not associated with excess in-hospital mortality. In 10 patients (12%, six non-STEMI patients) new STEMI was observed during TH, which disappeared after TH discontinuation. The STEMI group (44 patients) had significantly more Osborn waves during TH than the non-STEMI group (38.6% vs. 15.2%, odds ratio = 3.508; 95% confidence interval = 1.281 to 9.610). CONCLUSIONS: Hypothermia-induced Osborn waves are relatively common and are not associated with an unfavorable short-term outcome. TH is associated with ECG changes that may mimic STEMI.

Improvement in exercise capacity after a modified Potts shunt in an adult patient with pulmonary arterial hypertension.

For young adults with end-stage idiopathic pulmonary hypertension, a valved graft connecting the central pulmonary artery to the distal aortic arch can provide substantial palliation of symptoms and may defer lung transplantation https://bit.ly/2TvMFFC.

Systolic time intervals vs invasive predictors of fluid responsiveness after coronary artery bypass surgery.

OBJECTIVES: Haemodynamic parameters for predicting fluid responsiveness in intensive care patients are invasive, technically challenging or not universally applicable. We compared the initial systolic time interval (ISTI), a non-invasive measure of the time interval between the electrical and mechanical activities of the heart measured by impedance cardiography, with invasively measured haemodynamic parameters in predicting fluid responsiveness after cardiac surgery. METHODS: Thirty-two clinically hypovolemic patients admitted to the intensive care unit after coronary artery bypass surgery received 500 ml of gelatine solution in two volume loading steps of 250 ml at an infusion rate of 1000 ml/h. Haemodynamic and biochemical measurements were done at baseline and 15 min after each volume loading step with continuous recording of the impedance cardiogram and electrocardiogram. RESULTS: Forty-four percentage (n = 14) of patients showed a stroke volume (SV) index increase >10%. ISTI predicted fluid responsiveness with an optimum threshold of >153 ms (P = 0.023) and a sensitivity of 71% and specificity of 78%. The predictive values of ISTI did not differ from those of arterial pressure or SV at baseline. A decrease of ISTI of ≥8.3 ms predicted fluid responsiveness with the highest positive predictive value (88%, P = 0.004) among the variables, and absence thereof virtually excluded fluid responsiveness (specificity 94%). CONCLUSIONS: Non-invasively measured ISTI is able to predict and monitor fluid responsiveness after cardiac surgery non-inferiorly to invasively measured haemodynamic indices.