Doppler Interrogation of the Femoral Vein in the Critically Ill Patient: The Fastest Potential Acoustic Window to Diagnose Right Ventricular Dysfunction?

OBJECTIVES: To report the use of common femoral vein Doppler interrogation as a simple technique to diagnose right ventricular dysfunction. DESIGN: Case report. SETTING: Cardiac surgical ICU. PATIENTS: Postoperative cardiac surgical patients. INTERVENTIONS: Common femoral pulsed-wave and color Doppler examination associated with hepatic, portal, and renal venous Doppler measurement were obtained in both patients and before and after treatment in patient number 1. In addition, right ventricular pressure waveform examination was obtained in patient number 2. MEASUREMENTS AND MAIN RESULTS: The technique to obtain common femoral venous Doppler is described. Two cases of patients presenting with right ventricular dysfunction and fluid overload with portal and renal venous congestion in the perioperative period undergoing complex multivalvular cardiac surgery are presented. Hemodynamic waveform monitoring was performed alongside echocardiographic, hepatic, and renal venous flow Doppler assessment, and spectral Doppler profiles of the common femoral veins were examined. Those findings were useful in confirming our diagnosis and guiding our response to treatment. An algorithm was developed and tested on two additional hemodynamically unstable patients. CONCLUSIONS: Doppler examination of the common femoral vein is a simple, fast, and noninvasive technique that could be useful to rule in the presence of right ventricular dysfunction with venous congestion and help guide the management of such patients.

Does the full-time presence of an intensivist lead to better outcomes in the cardiac surgical intensive care unit?

OBJECTIVE: The study objective was to compare clinical outcomes in a dedicated adult cardiac surgery intensive care unit before and after the implementation of 24-hour intensivist coverage. METHODS: Between 2008 and 2016, 16,454 consecutive adult patients were admitted to the cardiac surgery intensive care unit after cardiac surgery. During this period, postoperative patients in the cardiac surgery intensive care unit were managed by intensivists during the day (group A); in July 2010, the nighttime coverage was transferred from the hands of residents and fellows to intensivists (group B). Postoperative outcomes before and after this change using 1-to-1 propensity score matching were examined. Patients were stratified a priori into low- and high-risk (<5% and ≥5% predicted mortality) based on the European System for Cardiac Operative Risk Evaluation II. RESULTS: Matched patients in group A had significantly higher cardiac surgery intensive care unit (2.1% vs 1.4%, P = .01) and in-hospital (2.7% vs 1.8%, P = .008) mortality. This higher mortality was only observed among high-risk group A patients who had significantly higher rates of cardiac surgery intensive care unit mortality (6.8% vs 4.1%, P = .01) and in-hospital mortality (8.5% vs 5.3%, P = .01) compared with the high-risk group B. The median duration of mechanical ventilation (5.8 vs 4.3 hours, P < .0001) and the risk of prolonged ventilation greater than 48 hours (5.3% vs 4%, P = .008) were significantly higher among group A patients; this higher rate of respiratory adverse events was observed in all strata of preoperative risk. CONCLUSIONS: In this large cohort of patients admitted to a dedicated adult cardiac surgery intensive care unit, 24-hour intensivist coverage was associated with reduced mortality among patients with an expected operative mortality 5% or greater. These data suggest that preoperative risk stratification and adaptive cardiac surgery intensive care unit physician staffing may result in improved clinical outcomes and optimized hospital resource use.

Digital Imaging and Communications in Medicine Whole Slide Imaging Connectathon at Digital Pathology Association Pathology Visions 2017.

As digital pathology systems for clinical diagnostic work applications become mainstream, interoperability between these systems from different vendors becomes critical. For the first time, multiple digital pathology vendors have publicly revealed the use of the digital imaging and communications in medicine (DICOM) standard file format and network protocol to communicate between separate whole slide acquisition, storage, and viewing components. Note the use of DICOM for clinical diagnostic applications is still to be validated in the United States. The successful demonstration shows that the DICOM standard is fundamentally sound, though many lessons were learned. These lessons will be incorporated as incremental improvements in the standard, provide more detailed profiles to constrain variation for specific use cases, and offer educational material for implementers. Future Connectathon events will expand the scope to include more devices and vendors, as well as more ambitious use cases including laboratory information system integration and annotation for image analysis, as well as more geographic diversity. Users should request DICOM features in all purchases and contracts. It is anticipated that the growth of DICOM-compliant manufacturers will likely also ease DICOM for pathology becoming a recognized standard and as such the regulatory pathway for digital pathology products.

Transthoracic echocardiographic evaluation of the heart and great vessels.

PURPOSE: Transthoracic examination of the heart and great vessels is an essential skill that allows the anesthesiologist to evaluate cardiac function. In this article, we describe a pragmatic technique to obtain the essential views to evaluate normal or abnormal cardiac function and to appreciate great vessel anatomy and physiology. PRINCIPAL FINDINGS: The cardiac anatomy and function can be described using standard parasternal, apical, and subcostal views. These windows can also be used to assess the aorta, pulmonary artery, and vena cavae; however, other transthoracic and abdominal windows can be used to complete the evaluation of the great vessels. CONCLUSIONS: The integration of the echocardiographic information particularly from the heart and great vessels with the case story, physical examination, laboratory data, and other relevant clinical information should become the way of the future, and this will benefit the patients under our care.