The ability of renal ultrasound and ureteral jet evaluation to predict 30-day outcomes in patients with suspected nephrolithiasis.

STUDY OBJECTIVE: We sought to identify findings on bedside renal ultrasound that predicted need for hospitalization in patients with suspected nephrolithiasis. METHODS: A convenience sample of patients with suspected nephrolithiasis was prospectively enrolled and underwent bedside ultrasound of the kidneys and bladder to determine the presence and degree of hydronephrosis and ureteral jets. Sonologists were blinded to any other laboratory and imaging data. Patients were followed up at 30 days by phone call and review of medical records. RESULTS: Seventy-seven patients with suspected renal colic were included in the analysis. Thirteen patients were admitted. Reasons for admission included intractable pain, infection, or emergent urologic intervention. All 13 patients requiring admission had hydronephrosis present on initial bedside ultrasound. Patients with moderate hydronephrosis had a higher admission rate (36%) than those with mild hydronephrosis (24%), P<.01. Of patients without hydronephrosis, none required admission within 30 days. The sensitivity and specificity of hydronephrosis for predicting subsequent hospitalization were 100% and 44%, respectively. Loss of the ipsilateral ureteral jet was not significantly associated with subsequent hospital admission and did not improve the predictive value when used in combination with the degree of hydronephrosis. CONCLUSIONS: No patients with suspected renal colic and absence of hydronephrosis on bedside ultrasound required admission within 30 days. Ureteral jet evaluation did not help in prediction of 30-day outcomes and may not be useful in the emergency department management of renal colic.

Diagnosis of near-fatal pulmonary embolus-in-transit with focused echocardiography.

BACKGROUND: Among patients who die from pulmonary embolus (PE), approximately two-thirds succumb within an hour of presentation. Computed tomography can provide a definitive diagnosis but is associated with practical limitations. Echocardiography can increase diagnostic certainty of PE by visualizing signs of acute right ventricular (RV) strain. This case highlights a potentially lethal finding associated with PE and the role of clinician-performed bedside echocardiography in the timely management of this disease. OBJECTIVE: To describe a case of PE-in-transit diagnosed by clinician-performed focused echocardiography. CASE REPORT: A 78-year-old man with lymphoma presented to the Emergency Department with shortness of breath. His blood pressure was 95/53 mm Hg; his oxygen saturation was 84% on room air. A focused echocardiogram showed a highly mobile elongated mass traversing the right atrium and right ventricle, consistent with a PE-in-transit. Anticoagulation was initiated and Cardiovascular Surgery was consulted for emergent thrombectomy. Minutes after reviewing the ultrasound with the surgeons, the patient was transported to the operating room. Just before surgery, the patient had a cardiac arrest. Exploration of his heart failed to reveal thrombus; however, extensive clot burden was removed from the pulmonary arteries, with subsequent return of spontaneous circulation. CONCLUSION: The clinician performed a focused echocardiogram to evaluate the cause of the patient's critical state. PE-in-transit, a rare entity associated with large PEs, was identified, which obviated the need for further diagnostic evaluation and led to immediate aggressive therapy. Increased familiarity with the uses of bedside sonography in the evaluation of shock and respiratory distress may allow clinicians to become more proficient in managing these patients.

Continuous addition of adenosine with a micropump system improves warm whole blood cardioplegia.

BACKGROUND: Micropump additive systems allow for continuous modification of cardioplegia composition during heart surgery. Although the use of such systems in warm heart surgery is theoretically desirable, the role of the systems has been clinically limited by coronary vasoreactivity with higher potassium concentration and unreliable mechanical arrest at lower potassium concentration. Adenosine, a potent coronary vasodilator and arresting agent, has the potential to reduce the potassium concentration required for arrest and to improve distribution of cardioplegia. However, clinical use of adenosine has been limited by a short half-life in blood and difficulty in titrating the dose. This study tested the hypothesis that continuous addition of adenosine with an in-line linear micropump system would facilitate whole blood hyperkalemic perfusion for cardiac surgery. METHODS: Canine hearts (n = 9) were randomized to 20 minutes of arrest with whole blood cardioplegia or cardioplegia with adenosine at either low (0.5 M) or high (8 M) concentration. Potassium was supplemented at an arresting dose (24 mEq/L) for 5 minutes and then at a maintenance dose (6 mEq/L) for an additional 15 minutes. Coronary flow was held constant (4 mL/kg per minute), and aortic root pressure was measured. Myocardial performance was assessed by measurement of the end-diastolic pressure to stroke volume relationship at constant afterload. Myocardial tissue perfusion was evaluated with colored microspheres. RESULTS: During the initial period of high-concentration potassium arrest, coronary resistance rose progressively regardless of adenosine addition. Coronary resistance remained elevated during the period of low potassium perfusion, except when high-concentration adenosine was added. With addition of 8 M adenosine, coronary resistance returned to baseline, and left ventricular endocardial perfusion was augmented. Electromechanical quiescence improved with adenosine perfusion and was complete with high-dose adenosine addition. Function was preserved in all hearts. CONCLUSION: Use of a modern micropump system allowed for continuous addition of adenosine and potassium to whole blood cardioplegia. Adenosine minimized potassium-induced coronary vasoconstriction and improved endocardial perfusion and mechanical quiescence. These findings supported addition of adenosine to the perfusate during warm whole blood cardioplegia.