Prehospital Ultrasound Use to Guide Emergent Pericardiocentesis: A Case Report.

Point-of-care ultrasound (POCUS) has been shown to be a valuable tool in the management of acutely ill patients in the prehospital setting. POCUS not only has utility from a diagnostic perspective but also has been shown to reduce the rate of complications from otherwise traditionally "blind" procedures, such as pericardiocentesis. This case report highlights the utility of POCUS in the prehospital setting to guide emergent pericardiocentesis to treat cardiac tamponade. The applicability of various approaches to ultrasound-guided pericardiocentesis is also discussed.

Prehospital Cardiac Ultrasound to Confirm Mechanical Capture in Emergency Transcutaneous Pacing: A Case Report.

Point-of-care ultrasound (POCUS) is a safe diagnostic tool that clinicians use to rapidly evaluate critically ill patients.1 POCUS has expanded into the prehospital setting and has been demonstrated to be accurate, feasible, and helpful in guiding clinical decision making.2-4 Additionally, the American College of Emergency Physicians recommends the use of echocardiography to evaluate for ventricular activity in the setting of cardiac arrest.5 There is minimal evidence regarding the use of POCUS to confirm mechanical capture in patients undergoing transcutaneous pacing. This case report highlights the use of POCUS in a patient with bradyasystolic cardiac arrest requiring transcutaneous pacing. Despite electrical capture, the patient had absent central pulses; however, POCUS demonstrated ventricular contractions, indicating mechanical capture. This suggests a role for POCUS for the evaluation of mechanical capture in patients undergoing cardiac pacing.

The Effect of Fluid Resuscitation Timing in Early Sepsis Resuscitation.

PURPOSE: The dose and timing of early fluid resuscitation in sepsis remains a debated topic. The objective of this study is to evaluate the effect of fluid timing in early sepsis management on mortality and other clinical outcomes. METHODS: Single-center, retrospective cohort study of emergency-department-treated adults (>18 years, n = 1032) presenting with severe sepsis or septic shock. Logistic regression evaluating the impact of 30 mL/kg crystalloids timing and mortality-versus-time plot controlling for mortality in emergency department sepsis score, lactate, antibiotic timing, obesity, sex, systemic inflammatory response syndrome criteria, hypotension, and heart and renal failures. This study is a subanalysis of a previously published investigation. RESULTS: Mortality was 17.1% (n = 176) overall and 20.4% (n = 133 of 653) among those in septic shock. 30 mL/kg was given to 16.9%, 32.2%, 16.2%, 14.5%, and 20.3% of patients within ≤1, 1 ≤ 3, 3 ≤ 6, 6 ≤ 24, and not reached within 24 h, respectively. A 24-h plot of adjusted mortality versus time did not reach significance, but within the first 12 h, the linear function showed a per-hour mortality increase (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.02-1.67) which peaks around 5h, although the quadratic function does not reach significance (P = .09). When compared to patients receiving 30 mL/kg within 1 h, increased mortality was observed when not reached within 24 h (OR 2.69, 95% CI 1.37-5.37) but no difference when receiving this volume between 1 and 3 (OR 1.11, 95% CI 0.62-2.01), 3 and 6 (OR 1.83, 95% CI 0.97-3.52), or 6 and 24 h (OR 1.51, 95% CI 0.75-3.06). Receiving 30 mL/kg between 1 and 3 versus <1 h increased the incidence of delayed hypotension (OR 1.83, 95% CI 1.23-2.72) but did not impact need for intubation, intensive care unit admission, or vasopressors. CONCLUSIONS: We observed weak evidence that supports that earlier is better for survival when reaching fluid goals of 30 mL/kg, but benefits may wane at later time points. These findings should be viewed as hypothesis generating.

The Effect of Fluid Initiation Timing on Sepsis Mortality: A Meta-Analysis.

OBJECTIVE: Current guidelines suggest the immediate initiation of crystalloid for sepsis-induced hypoperfusion but note that supporting evidence is low quality. The aim of this study is to examine the effect of timing of fluid initiation on mortality for adults with sepsis. DATA SOURCES: Two authors independently reviewed relevant articles and extracted study details from PubMed, Scopus, Cochrane, Google Scholar, and previous relevant systematic reviews from 1-1-2000 to 1-6-2022. Registered with PROSPERO (CRD42021245431) and bias assessed using CLARITY. STUDY SELECTION: A minimum of severe sepsis (Sepsis-2) or sepsis (Sepsis-3) for patients ≥18 years old. Fluid initiation timing ranging from prehospital to 120 min within sepsis onset defined as "early" initiation. DATA EXTRACTION: Included studies providing mortality-based odds ratios (or comparable) adjusting for confounders or prospective trials. DATA SYNTHESIS: From 1643 citations, five retrospective cohort studies were included (n = 20,209) with in-hospital mortality of 21.8%. A pooled analysis (odds ratio = OR [95% CI]) did not observe an impact on mortality for the early initiation of fluids among all patients, OR = 0.79 [0.62-1.02]; heterogeneity: I2 = 86% [70-94%], but when studies analyzed cases of hypotension where available, a survival benefit was observed, OR = 0.74 [0.61-0.90]. Initiation of fluids in two prehospital studies did not impact mortality, OR = 0.82 [0.27-2.43]. However, both prehospital cohorts observed benefit among hypotensive patients individually, although heterogenous results precluded significance when pooled, OR = 0.50 [0.21-1.18]. Three hospital-based studies with initiation stratified at 30, 100, and 120 min, observed survival benefit both individually and when pooled, OR = 0.78 [0.63-0.97]. No differences were observed between prehospital versus hospital subgroups. CONCLUSION: This meta-analysis supports the guideline recommendations for early fluid initiation once sepsis is recognized, especially in cases of hypotension. Findings are limited by the small number, heterogeneity, and retrospective nature of available studies. Further retrospective investigations may be worthwhile as randomized studies on fluid initiation are unlikely.

The Effect of Body Mass Index and Weight-Adjusted Fluid Dosing on Mortality in Sepsis.

PURPOSE: The Surviving Sepsis Campaign guidelines recommend 30 mL/kg of fluids within 3 hours (30by3) of sepsis-induced hypoperfusion, but a national mandate released an allowance for dosing based on ideal instead of actual body weight (IBW/ABW) for obese patients. This study aims to determine the dose-effect of 30by3 for patients with severe sepsis or septic shock (SS/SS) with respect to body mass index (BMI) categories and secondarily, examine the clinical impact of IBW vs. ABW-based dosing. METHODS: Retrospective cohort study of adults (≥18 years; n = 1,032) with SS/SS presenting to an urban, tertiary-care emergency department. Models include MEDS score, antibiotic timing, lactate, renal and heart failure, among others. RESULTS: The cohort was 10.2% underweight and 28.7% obese. Overall mortality was 17.1% with 20.4% shock mortality. An exponential increase in mortality was observed for each 5 mL/kg under 30by3 for underweight (p = 0.02), but not obese patients. ABW vs IBW-30by3 dosing was reached in 80.0 vs 52.4% (underweight), 56.4 vs 56.9% (normal/overweight), and 23.3 vs 46.0% (obese). Across all BMI categories, there was increased mortality for not reaching ABW-based 30by3 dosing (OR 1.78, 95% CI 1.18-2.69) with no significant impact for IBW (OR 1.28, 95% CI 0.87 -1.91). The increased mortality for failing to reach ABW-dosed 30by3 remained for underweight patients ABW (OR 5.82, 95% CI 1.32-25.57) but not obese patients. Longer ICU stays were observed for not reaching 30by3 based on ABW (ß = 2.40, 95% CI 0.84-3.95) and IBW dosing (ß = 1.58, 95% CI 0.07-3.08) overall. This effect remained for obese and underweight (except IBW dosing) patients. CONCLUSIONS: An exponential, dose-effect increase in mortality was observed for underweight patients not receiving 30by3. Therefore, the mortality impact of under-dosing may be amplified using ABW for underweight patients. Fluid dosing did not impact mortality for obese patients, but we caution against deviation from guidelines without further studies.

The effect of delays in second-dose antibiotics on patients with severe sepsis and septic shock.

BACKGROUND: Early antibiotics are fundamental to sepsis management. Second-dose antibiotic delays were associated with increased mortality in a recent study. Study objectives include: 1) determine factors associated with delays in second-dose antibiotic administration; 2) evaluate if delays influence clinical outcomes. METHODS: ED-treated adults (≥18 years; n = 1075) with severe sepsis or septic shock receiving ≥2 doses of intravenous antibiotics were assessed, retrospectively, for second-dose antibiotic delays (dose time > 25% of recommended interval). Predictors of delay and impact on outcomes were determined, controlling for MEDS score, 30 mL/kg fluids and antibiotics within three hours of sepsis onset, lactate, and renal failure, among others. RESULTS: In total, 335 (31.2%) patients had delayed second-dose antibiotics. A total of 1864 second-dose antibiotics were included, with 354 (19.0%) delays identified by interval (delayed/total doses): 6-h (36/67) = 53.7%; 8-h (165/544) = 30.3%; 12-h (114/436) = 26.1%; 24-h (21/190) = 8.2%; 48-h (0/16) = 0%. In-hospital mortality in the timely group was 15.5% (shock-17.6%) and 13.7% in the delayed group (shock-16.9%). Increased odds of delay were observed for ED boarding (OR 2.54, 95% 1.81-3.55), shorter dosing intervals (6/8-h- OR 2.99, 95% CI 1.95-4.57; 12-h- OR 2.46, 95% CI 1.72-3.51), receiving 30 mL/kg fluids by three hours (OR 1.42, 95% CI 1.06-1.90), and renal failure (OR 2.57, 95% CI 1.50-4.39). Delays were not associated with increased mortality (OR 0.87, 95% CI 0.58-1.29) or other outcomes. CONCLUSIONS: Factors associated with delayed second-dose antibiotics include ED boarding, antibiotics requiring more frequent dosing, receiving 30 mL/kg fluid, and renal failure. Delays in second-dose administration were not associated with mortality or other outcomes.

Prehospital Echocardiogram Use in Identifying Massive Pulmonary Embolism in Unidentified Respiratory Failure.

Medical transport teams often handle cases of complex, critically ill patients and are in need of rapid, bedside assessments to guide clinical decision making. The use of point-of-care ultrasound (POCUS) as a diagnostic indicator has gained increased acceptance in emergency medicine. Ultrasound devices have become increasingly portable, and numerous studies have demonstrated that use in the prehospital setting is feasible, accurate, and can have a dramatic impact on the care of patients. In this case report, we highlight the use of handheld ultrasound in the identification of right heart dilation in an unstable patient with respiratory failure in a rural emergency department, concerning for massive pulmonary embolism. The patient was given thrombolytic therapy with dramatic clinical improvement, ultimately surviving transport to the intensive care unit at a nearby tertiary care center.

Evaluation and Predictors of Fluid Resuscitation in Patients With Severe Sepsis and Septic Shock.

OBJECTIVES: Rapid fluid resuscitation has become standard in sepsis care, despite "low-quality" evidence and absence of guidelines for populations "at risk" for volume overload. Our objectives include as follows: 1) identify predictors of reaching a 30 mL/kg crystalloid bolus within 3 hours of sepsis onset (30by3); 2) assess the impact of 30by3 and fluid dosing on clinical outcomes; 3) examine differences in perceived "at-risk" volume-sensitive populations, including end-stage renal disease, heart failure, obesity, advanced age, or with documentation of volume "overload" by bedside examination. DESIGN: Retrospective cohort study. All outcome analyses controlled for sex, end-stage renal disease, heart failure, sepsis severity (severe sepsis vs septic shock), obesity, Mortality in Emergency Department Sepsis score, and time to antibiotics. SETTING: Urban, tertiary care center between January 1, 2014, and May 31, 2017. PATIENTS: Emergency Department treated adults (age ≥18 yr; n = 1,032) with severe sepsis or septic shock. INTERVENTIONS: Administration of IV fluids by bolus. MEASUREMENTS AND MAIN RESULTS: In total, 509 patients received 30by3 (49.3%). Overall mortality was 17.1% (n = 176), with 20.4% mortality in the shock group. Patients who were elderly (odds ratio, 0.62; 95% CI, 0.46-0.83), male (odds ratio, 0.66; CI, 0.49-0.87), obese (odds ratio, 0.18; CI, 0.13-0.25), or with end-stage renal disease (odds ratio, 0.23; CI, 0.13-0.40), heart failure (odds ratio, 0.42; CI, 0.29-0.60), or documented volume "overload" (odds ratio, 0.30; CI, 0.20-0.45) were less likely to achieve 30by3. Failure to meet 30by3 had increased odds of mortality (odds ratio, 1.52; CI, 1.03-2.24), delayed hypotension (odds ratio, 1.42; CI, 1.02-1.99), and increased ICU stay (~2 d) (ß = 2.0; CI, 0.5-3.6), without differential effects for "at-risk" groups. Higher fluid volumes administered by 3 hours correlated with decreased mortality, with a plateau effect between 35 and 45 mL/kg (p < 0.05). CONCLUSIONS: Failure to reach 30by3 was associated with increased odds of in-hospital mortality, irrespective of comorbidities. Predictors of inadequate resuscitation can be identified, potentially leading to interventions to improve survival. These findings are retrospective and require future validation.

Early Recognition and Treatment of Sepsis After the Addition of Lactate to the Laboratory's Critical Result Call List.

PURPOSE: Screening of patients with sepsis is needed to increase recognition and allow for earlier interventions. There is no consensus on whether the addition of lactate to the critical result laboratory's call list should be a standard practice. MATERIALS AND METHODS: This was a retrospective cohort study that compared management and outcomes of patients with sepsis having lactate ≥4 mmol/L before (group 1) and after (group 2) the addition of a critical result threshold of lactate of ≥4 mmol/L to the critical result laboratory's call list and its effects on time to antibiotics and intravenous fluids (IVFs). RESULTS: One hundred twenty-one patients were included. Lactate was higher in group 1 (7.0 ± 4.3 vs 5.6 ± 2.0, P = 0.03). More patients in group 2 received hydrocortisone (1.9% vs 22.4%, P = .001). Hospital mortality, 30-day mortality, and 90-day mortality were significantly lower in group 2 (59.3% vs 32.8%, P = .003; 68.5% vs 37.3%, P ≤ .001; 68.5% vs 41.8%, P = .002). There were no significant differences in total volume of IVFs (2400.8 ± 1720.0 vs 2483.7 ± 2155.7, P = 0.83), time to start IVFs (184.0 ± 283.2 vs 115.6 ± 190.5, P = 0.27), or antibiotics (184.8 ± 187.1 vs 133.7 ± 137.4, P = 0.16). CONCLUSION: Addition of lactate to the critical result laboratory's call list did not lead to a statistically significant improvement in time to IVFs or antibiotics, although the average time to antibiotics and IVFs decreased by 51.1 and 68.4 minutes, respectively. Hospital mortality, 30-day mortality, and 90-day mortality were lower in group 2, which may be, in part, due to increased recognition of severe sepsis by critical result notification and earlier intervention.

Escalation to High-Dose Defibrotide in Patients with Hepatic Veno-Occlusive Disease.

Hepatic veno-occlusive disease (VOD) is a serious complication of high-dose chemotherapy regimens, such as those used in hematopoietic cell transplantation recipients. Defibrotide is considered a safe and effective treatment when dosed at 25 mg/kg/day. However, patients who develop VOD still have increased mortality despite the use of defibrotide. Data are limited on the use of doses above 60 mg/kg/day for persistent VOD. In this prospective clinical trial 34 patients received escalating doses of defibrotide. For patients with persistent VOD despite doses of 60 mg/kg/day, doses were increased to a maximum of 110 mg/kg/day. Increased toxicity was not observed until doses rose beyond 100 mg/kg/day. Patients receiving doses between 10 and 100 mg/kg/day experienced an average of 3 bleeding episodes per 100 days of treatment, whereas those receiving doses >100 mg/kg/day experienced 13.2 bleeding episodes per 100 days (P = .008). Moreover, dose reductions due to toxicity were needed at doses of 110 mg/kg/day more often than at lower doses. Defibrotide may be safely escalated to doses well above the current standard without an increase in bleeding risk. However, the efficacy of this dose-escalation strategy remains unclear, because outcomes were similar to published cohorts of patients receiving standard doses of defibrotide for VOD.

Use of Point-of-Care Ultrasound in the Pediatric and Neonatal Emergency Transport Realm.

Point-of-care ultrasound (POCUS) is a tool often used by clinical providers in the care of critically ill or acutely injured patients. POCUS can be used to evaluate for potentially harmful conditions during transport and to optimize downstream management. Although available literature primarily focuses on adults in the prehospital, critical care, and austere environment realm, more literature supporting POCUS use during pediatric and neonatal transport has emerged over the last few years. What is currently available is often from diverse operators and a wide variety of applications. The goal of this article is to describe current pediatric and neonatal POCUS applications and to identify its barriers and limitations in the transport realm. [Pediatr Ann. 2021;50(10):e432-e436.].