Improving echographic monitoring of hemodynamics in critically ill patients: Validation of right cardiac output measurements through the modified subcostal window.

OBJECTIVE: We aimed to assess the usefulness of using the right ventricle outflow tract (RVOT) velocity-time integral (VTI) for echocardiographic monitoring of cardiac output compared to the gold standard, the VTI along the left ventricle outflow tract (LVOT). DESIGN: Prospective observational study. SETTING: A tertiary intensive care unit. PATIENTS: 100 consecutive patients. INTERVENTIONS: echocardiographic monitoring in critically ill patients. MAIN VARIABLES OF INTEREST: We used intraclass correlation coefficients (ICC) to compare echocardiographic measurements of LVOT VTI through apical window with RVOT VTI through the parasternal and modified subcostal windows and to assess interobserver reproducibility. Preplanned post hoc analyses compared the ICC between ventilated and nonventilated patients. RESULTS: At the time of echocardiography, 44 (44%) patients were mechanically ventilated and 28 (28%) were receiving vasoactive drugs. Good-quality measurements were obtained through the parasternal short-axis and/or apical views in 81 (81%) patients and in 100 (100%) patients through the subcostal window. Consistency with LVOT VTI was moderate for RVOT VTI measured from the modified subcostal view (ICC 0.727; 95%CI: 0.62-0.808) and for RVOT VTI measured from the transthoracic view (0.715; 95%CI: 0.59-0.807). CONCLUSIONS: Measurements of RVOT VTI are moderately consistent with measurements of LVOT VTI. Adding the modified subcostal window allows monitoring RVOT VTI in all the patients of this selected cohort, even those under mechanical ventilation.

Clinical Consensus Recommendations Regarding Non-Invasive Respiratory Support in the Adult Patient with Acute Respiratory Failure Secondary to SARS-CoV-2 infection. / Recomendaciones de consenso respecto al soporte respiratorio no invasivo en el paciente adulto con insuficiencia respiratoria aguda secundaria a infección por SARS-CoV-2.

Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent coronavirus, that was first recognized in Wuhan, China, in December 2019. Currently, the World Health Organization (WHO) has defined the infection as a global pandemic and there is a health and social emergency for the management of this new infection. While most people with COVID-19 develop only mild or uncomplicated illness, approximately 14% develop severe disease that requires hospitalization and oxygen support, and 5% require admission to an intensive care unit. In severe cases, COVID-19 can be complicated by the acute respiratory distress syndrome (ARDS), sepsis and septic shock, and multiorgan failure. This consensus document has been prepared on evidence-informed guidelines developed by a multidisciplinary panel of health care providers from four Spanish scientific societies (Spanish Society of Intensive Care Medicine [SEMICYUC], Spanish Society of Pulmonologists [SEPAR], Spanish Society of Emergency [SEMES], Spanish Society of Anesthesiology, Reanimation, and Pain [SEDAR]) with experience in the clinical management of patients with COVID-19 and other viral infections, including SARS, as well as sepsis and ARDS. The document provides clinical recommendations for the noninvasive respiratory support (noninvasive ventilation, high flow oxygen therapy with nasal cannula) in any patient with suspected or confirmed presentation of COVID-19 with acute respiratory failure. This consensus guidance should serve as a foundation for optimized supportive care to ensure the best possible chance for survival and to allow for reliable comparison of investigational therapeutic interventions as part of randomized controlled trials.

[Phonomechanocardiographic study of innocent murmurs in children]. / Estudio fonomecanocardiográfico de los soplos inocentes en niños.

At the National Institute of Pediatrics DIF (formerly IMAN), a comparative study was performed in 157 healthy children. Ninety four (59.8%), had an innocent cardiac murmur, and 63 children (40.1%) had no heart murmur detectable. The presence of innocent murmurs was more frequent in pre-school and school age; murmurs of basal location were predominant. The murmurs were brief midsystolic and of the ejective type. All of them had the characteristics of a vibratory murmur of sinusoidal type, with diagonal radiation and low frequency. One more dynamic of pharmacological tests were performed in 60 children. In 88.5% of the cases, the murmur showed left behavior during the Valsalva monouver. Only in 15.7% during the Azoulay maneuver suggested right origin of the murmur. In 70% the murmur decreased with orthostatism and in the children who inhaled amyl nitrite, the murmur showed a behavior suggestive of aortic ejective origin. The comparison between the groups with and without murmurs showed that the heart rate was lower for those children with murmurs (P less than 0.05), the left ventricle ejection time was shorter in children with murmurs (P less than 0.01), but instead the preejection period was longer in children with murmurs (P less than 0.05). These differences let us point out that in children with murmurs the blood flow during the early systole is higher than in those without murmurs. This conditions probably a determinant in the origin of the innocent murmur.

[Chronocardiometry in healthy children. II. Diastolic time intervals]. / Cronodinocardiometría en niños sanos. Segunda parte: Tiempos diastólicos.

At the National Institute of Pediatrics DIF (called before IMAN) a prospective study of diastole time intervals (DTI) was performed on 138 healthy children by phonomechanocardiography. The correlation of the DTI with age and heart rate (HR) was studied. Also the relationship of the DTI with systolic times intervals (STI) was studied. The age of children did not show significant correlation with the DTI. Isovolumic relaxation phase (IVRP), tachydiastolic phase (TDP) and presystolic phase (PSP) were slightly modified by HR and obviously, without significance. But instead, the bradidiastolic phase (BDP), effective diastole (ED) or the time on which the mitral valve is opened and total diastole (D) showed directly proportional relation with R-R interval of the ECG (P less than 0.001). The left ventricular ejection time (LVET) was longer according to the ED duration (r = 0.818). The ejection fraction (EF) showed proportional increase to the ED duration, but without statistics significance. The influence of the DTI that have upon STI is important.

Cronodinocardiometria en ninos sanos.Segunda parte : tiempos diastolicos. / Chronodynocardiometry in healthy children. Part II: diastolic time intervals

En el Instituto Nacional de Pediatria DIF (antes IMAN) se efectuo un estudio propesctivo de los tiempos diastolicos, por medio de fonomecanocardiografia, en 138 ninos sanos.Se analizo la correlacion de las fases diastolicas con la edad y la frecuencia cardiaca (FC) de los ninos. Se estudio la relacion que tiene la duracion de la diastole con los eventos sitolicos. No se encontro correlacion significativa entre la edad y las fases diastolicas. Las fases de relajacion isovolumetrica (FRIVD), taquidiastolica (FTD) y presistolica (FPS) poco se modificaron con la FC y en forma no significativa. En cambio la fase bradidiastolica (FBD), la diastole efectiva (DE) o tiempo que permanece abierta la valvula mitral y la diastole total (D) mostraron relacion directamente proporcional con la duracion del espacio R-R del ECG (P<0.001) La duracion del periodo expulsivo (PE) fue mayor de acuerdo con la duracion de la DE (r= 0.818). La fraccion de eyeccion (FE) mostro aumento proporcional a la duracion de la DE, pero con poca significacion estadistica. Se concluye que es importante la influencia que tiene la duracion de las fases de la diastole en el comportamiento de los tiempos sistolicos