Timing of pericardiocentesis and clinical outcomes: Is earlier pericardiocentesis better?

BACKGROUND: Pericardial tamponade is critical clinical diagnosis that requires prompt management and intervention. However, it is unknown if early pericardiocentesis is associated with better or worse patient outcomes. METHODS: A retrospective chart review was performed on all emergency department patients from two large academic hospitals with pericardial tamponade who underwent pericardiocentesis during the index hospitalization between March 2015-August 2020. We included only those who underwent pericardiocentesis within 24 h of their ED presentations. Subjects were stratified based on the time of pericardiocentesis, with early intervention defined as pericardiocentesis within <12 h and late intervention as those 12-24 h. Clinical outcomes of interest were; procedural complications, intensive care unit (ICU) admission, hospital length of stay (LOS), in hospital mortality, 30-day and first year survival. The effect of early vs. late intervention on survival was analyzed using log-rank tests for univariate analyses, Cox proportional hazard models for multivariable analyses and propensity matching. RESULTS: 205 patients with a mean age of 60 years, and 53.2% female were included. The median door-to-pericardiocentesis time for the early and late group were 5.0 h [interquartile range (IQR) 3.3-7.4] and 18.5 h (IQR 15.9-21.0), respectively. Transthoracic echocardiography (TTE) in patients in the early group more frequently demonstrated right atrial collapse (78.7% vs 58.6%) and exaggerated mitral inflow velocity variances (84.8% vs 70.0%). Early pericardiocentesis was associated with a hazard ratio of 2.909 (95% CI: 0.926-9.137, p = 0.067) for 30-day survival and 3.124 (95% CI, 1.648-5.924, p < 0.001) for 1-year survival. CONCLUSION: Early pericardiocentesis was associated with decreased 1-year survival. Future prospective analysis adjusting for patients' complexities is required.

Pericardial tamponade: a new perspective on echocardiographic features and application of a prediction score.

Few clinical decision rules have been used to guide clinical management and predict outcomes in patients with pericardial tamponade. The objectives of this study are to identify the echocardiographic features associated with adverse outcomes in patients with pericardial effusions requiring pericardiocentesis and to apply a previously described four-point clinical and echocardiographic score to predict clinical outcomes over 24-hr, 30-day, and 1-year intervals. We performed a retrospective cohort review of patients who had transthoracic echocardiogram (TTE) performed and underwent pericardiocentesis within 48 h of emergency department presentation at two large tertiary care institutions. We constructed different stepwise logistic regression models and examined the associations of TTE characteristics and clinical features with ICU admission, hospital length of stay (h-LOS), and survival. The data set was then employed against a previously proposed scoring system to predict factors associated with clinical outcomes over 24 hr, 30 days, and 1 year. Two hundred thirty-nine patients were included in the final analysis. Echocardiographic characteristics of patients with pericardial tamponade who underwent pericardiocentesis are as follows: 69.1% right ventricular (RV) diastolic collapse, 62.3% exaggerated mitral valve (MV) inflow velocities, 56.4% inferior vena cava (IVC) plethora, and 53.4% right atrial (RA) systolic collapse. Increase in systolic blood pressure and increased variation in MV inflow velocity were associated with reduced ICU admission [OR: 0.94 (CI 0.90, 0.99), 0.28 (CI 0.09, 0.89), respectively]. In addition, a history of malignancy increased the length of hospital stay by about 3.89 days (CI 1.43-6.35, p < 0.01) and prior pericardiocentesis history was associated with 4.82-day increase in hospital stay (CI 1.19-8.45, p = 0.01). In utilizing the previously published prediction score, we found no statistically significant correlation in predicting survival. RV diastolic collapse and exaggerated MV inflow velocity were the most common echocardiographic findings in patients requiring pericardiocentesis. Contrary to prior studies, exaggerated MV inflow velocity was associated with reduced ICU admission. In addition, a previously described prediction score did not correlate with decreased survival in this cohort.

Accuracy of "TICS" ultrasound protocol in detecting simple and complicated diverticulitis: A prospective cohort study.

BACKGROUND: Point-of-care ultrasound (US) has been suggested as the primary imaging in evaluating patients with suspected diverticulitis. Discrimination between simple and complicated diverticulitis may help to expedite emergent surgical consults and determine the risk of complications. This study aimed to: (1) determine the accuracy of an US protocol (TICS) for diagnosing diverticulitis in the emergency department (ED) setting and (2) assess the ability of TICS to distinguish between simple and complicated diverticulitis. METHODS: Patients with clinically suspected diverticulitis who underwent a diagnostic computed tomography (CT) scan were identified prospectively in the ED. Emergency US faculty and fellows blinded to the CT results performed and interpreted US scans. The presence of simple or complicated diverticulitis was recorded after each US evaluation. The diagnostic ability of the US was compared to CT as the criterion standard. Modified Hinchey classification was used to distinguish between simple and complicated diverticulitis. RESULTS: A total of 149 patients (55% female, mean ± SD age 58 ± 16 years) were enrolled and included in the final analyses. Diverticulitis was the final diagnosis in 75 of 149 patients (50.3%), of whom 53 had simple diverticulitis and 22 had perforated diverticulitis (29.4%). TICS protocol's test characteristics for simple diverticulitis include a sensitivity of 95% (95% confidence interval [CI] 87%-99%), specificity of 76% (95% CI 65%-86%), positive predictive value of 80% (95% CI 71%-88%), and negative predictive value of 93% (95% CI 84%-98%). TICS protocol correctly identified 12 of 22 patients with complicated diverticulitis (sensitivity 55% [95% CI 32%-76%]) and specificity was 96% (95% CI 91%-99%). Eight of 10 missed diagnoses of complicated diverticulitis were identified as simple diverticulitis, and two were recorded as negative. CONCLUSIONS: In ED patients with suspected diverticulitis, US demonstrated high accuracy in ruling out or diagnosing diverticulitis, but its reliability in differentiating complicated from simple diverticulitis is unsatisfactory.

Global point-of-care ultrasound education and training in the age of COVID-19.

The COVID-19 pandemic has disrupted traditional global point-of-care ultrasound (POCUS) education and training, as a result of travel restrictions. It has also provided an opportunity for innovation using a virtual platform. Tele-ultrasound and video-conferencing are alternative and supportive tools to augment global POCUS education and training. There is a need to support learners and experts to ensure that maximum benefit is gained from the use of these innovative modalities.