A prospective analysis of the correlation between ultrasonic B-lines, cardiac tissue doppler signals and left ventricular end-diastolic pressure in patients with severe aortic stenosis.

BACKGROUND: The development of heart failure is a turning point in the natural course of aortic stenosis (AS). Pulmonary oedema and elevated left ventricular pressure (LVP) are cardinal features of heart failure. Evaluating pulmonary oedema by lung ultrasound involves taking the upper hand with a bedside noninvasive tool that may reflect LVP. AIM: We sought to assess the correlation between sonographic pulmonary congestion, invasive LV pre-A pressure, and echocardiographic LV end-diastolic pressure (LVEDP) in symptomatic AS patients receiving transcatheter aortic valve replacement. METHODS: Forty-eight consecutive patients with severe AS and planned transcatheter aortic valve implantation (TAVI) were enrolled. LVEDP was estimated to be normal or elevated using the ASE/EACVI algorithm and transmitral Doppler indices, the E/A ratio, the E/e', and the left atrial volume index. Invasive LV pre-A pressure was used as a reference, with > 12 mm Hg defined as elevated. RESULTS: Forty-eight patients (25 women (52%), mean age 75 years, standard deviation (SD) ± 7.7 years) were enrolled in the study. We detected severe B-lines (≥ 30) in 13 (27%) patients and moderate B-lines (15-30) in 33 (68.6%) patients. The number of B-lines increased significantly with the severity of New York Heart Association (NYHA) functional classes (Fig. 1). The B-line count was 14 ± 13 in NYHA class I patients, 20 ± 20 in class II patients, and 44 ± 35 in class III patients (p < 0.05, rho = 0.384). The number of B-lines was correlated with the E/E' ratio (R = 0.664, p < 0.0001) and the proBNP level (R = 0. 882, p < 0.008). We found no significant correlation with the LVEDP or LVEF. The LVEDP correlated well with the E/E' ratio (R = 0.491, p < 0.001) but not at all with E/A, DT, or LAVI. All patients had an elevated LVEDP > 12, with a mean pressure of 26 mmHg, a minimum of 13 mmHg, and a maximum of 45 mmHg, with an SD of 7.85. CONCLUSION: Assessing lung ultrasonic B-lines is a straightforward and practical approach to identifying pulmonary oedema in AS patients. The number of B-lines correlated with the E/E' ratio and the functional status of patients but did not correlate with invasive LVEDP or LVEF. All patients had elevated LVEDP that correlated with E/E'.

Tirzepatide-Induced Ketoacidosis in Non-Diabetic Patients.

Background: Tirzepatide is a novel glucagon-like peptide 1/glucose-dependent insulinotropic peptide (GLP-1/GIP) receptor agonist. It was recently approved for diabetes control and weight reduction in non-diabetic patients. Case description: We report the first case of ketoacidosis after the use of tirzepatide in an obese non-diabetic patient, secondary to the possibility of starvation ketoacidosis and insulin resistance. Conclusion: The dual-acting GLP-1 and GIP receptor agonists, tirzepatide, can induce ketoacidosis in obese non-diabetic patients. LEARNING POINTS: The dual-acting GLP-1 and GIP receptor agonists can cause ketoacidosis in obese non-diabetic patients.Ketoacidosis induced by tirzepatide is serious, and physicians should be aware of this complication and be alert to early symptoms, check serum and urine ketone levels, and stop medication.

Hypocalcemia in Patients With Osteoporosis and Normal Renal Function, Treated With Denosumab, a Retrospective Analysis.

Objective: The reported hypocalcemia in postmenopausal women with osteoporosis who received Denosumab was low (0.05%-1.7% to 7.4%). The major prediction factors were vitamin D and calcium levels and renal function. The objective is to evaluate the incidence of hypocalcemia in patients with osteoporosis, normal renal function, and vitamin D who received Denosumab. Method: A retrospective analysis was conducted using the medical records (2022-2023). We looked for hypocalcemia (albumin-adjusted calcium lower than 2.2 mmol/L). Results: Two hundred one postmenopausal women diagnosed with osteoporosis and received denosumab treatment were included. All patients received vitamin D3 capsules and calcium supplementation. The mean age of the patient was 75.7 ± 7.0 years (56-91 years). Hypocalcemia was observed in 46 (23%) patients following a subcutaneous dose of Denosumab 60 mg. Median calcium was 2.25 mmol/L (minimum: 0.890 mmol/L, maximum: 2.6 mmol/L). Fourteen (30.4%) patients had severe hypocalcemia (<1.8 mmol/L) and required parenteral correction. A comparison between hypocalcemia and patients with normal calcium indicated that the significant predictor of hypocalcemia was pretreatment parathyroid hormone levels (9.9 ± 11.8vs 7.6 ± 2.56 pmol/L, respectively; P < .005). The prognostic role of parathyroid hormone for the denosumab-associated hypocalcemia was assessed using ROC curve analysis. For the cut-off value of Parathyroid hormone = 6.8 pmol/L, giving serum parathyroid measurement an AUC of 0.668 (0.599-0.737) - P = .0007; sensitivity 85%; specificity 52%. Conclusion: Hypocalcemia induced by the denosumab treatment is more prevalent than previously shown in patients with osteoporosis receiving adequate calcium and vitamin D supplements. An elevated parathyroid hormone predicts hypocalcemia related to denosumab therapy in patients with normal calcium and vitamin D levels.

Necrotizing fasciitis following gastrostomy tube placement, detected by point-of-care ultrasound, case report.

INTRODUCTION: Necrotizing fasciitis is a recognized rare complication of gastrostomy tube replacement, but if it occurs and is not discovered early, a lethal outcome is possible. CASE PRESENTATION: We present a woman in her 80s who was known to have chronic atrial fibrillation with ischemic heart disease. She was fed through percutaneous endoscopic gastrostomy after brain injury. Erythema was observed around the stoma of the gastrostomy tube, which was later removed, and erythema extended to the left anterior abdomen. The patient was diagnosed with cellulitis. Point-of-care ultrasound examination suspected necrotizing fasciitis and, confirmed later by computerized tomography of the abdomen. The case was managed surgically. DISCUSSION: Patients with a high clinical suspicion of necrotizing fasciitis should undergo early surgical debridement with antibiotic administration. Necrotizing fasciitis starts with a clinical picture indistinguishable from other skin infections, such as cellulitis, and imaging modalities are important for confirmation and early diagnosis. We present a case of necrotizing fasciitis after gastrostomy tube replacement for which point-of-care ultrasound played a pivotal role in confirming the diagnosis early. CONCLUSION: Point-of-care ultrasound is a useful adjunct tool for clinical evaluation and assessment in diagnosing early critically ill patients with life-threatening necrotizing infections.

Caseous Calcification of the Mitral Annulus: Mimicking A Cardiac Mass.

Mitral annulus calcification is a common incidental finding in echocardiography examination of predisposed populations. On the other hand, caseous calcification of the mitral annulus is a rare variant that challenges the physician to differentiate it from different causes of cardiac masses. We describe a case of incidentally discovered caseous calcification confirmed with CT cardiac and cardiac magnetic resonance. LEARNING POINTS: Caseous calcification of the mitral annulus is a rare condition.An important differential diagnosis is cardiac tumours and myocardial abscesses.Cardiac computed tomography and cardiac magnetic resonance imaging are important in confirming the diagnosis, and assessing the extent and location of annular calcium.

Sodium-glucose cotransporter-2 inhibitors induced euglycemic diabetic ketoacidosis: Two case reports and a review of the literature.

If not detected early, euglycemic diabetic ketoacidosis can be a serious adverse effect of sodium-glucose cotransporter-2 (SGLT2) inhibitors. Unfortunately, euglycemic diabetic ketoacidosis is underreported in recent trials and missed because of normal blood sugar levels and nonspecific symptoms on presentation. We present two patients with type 2 diabetes mellitus who developed dapagliflozin-associated euglycemic diabetic ketoacidosis followed by hyperglycemic ketoacidosis. The second patient had euglycemic ketoacidosis twice despite instructions to stop using the medication dapagliflozin.

Detecting spontaneous retroperitoneal hemorrhage using a modified RUSH protocol: a case report.

INTRODUCTION: Bleeding in the retroperitoneal space is a serious complication. Hypovolemia and shock develop late after losing a large volume of blood. However, point of care ultrasound (POCUS) examinations in adult patients with shock do not include the retroperitoneal space. CASE PRESENTATION: We present the case of a 74-year-old male with ischemic heart disease on dual antiplatelet. He developed vague abdominal pain and hemoglobin drop without overt bleeding source until he developed shock. Modified POCUS examination that included the retroperitoneal space detected the bleeding source and confirmed later by computerized tomography of the abdomen. The case was managed conservatively. CLINICAL DISCUSSION: The risk factors associated with the formation of spontaneous retroperitoneal hematomas are age above 70 years and dual antiplatelet therapy. The initial integration of point-of-care ultrasound into the assessment of shocked patients leads to an earlier and accurate initial diagnosis with a clear patient care plan. POCUS should include the retroperitoneal space examination in every patient presenting with shock. CONCLUSION: In patients with unexplained hemorrhagic shock, a modified POCUS protocol could help by including an examination of the retroperitoneal space in the assessment.

Modified BLUE protocol ultrasonography can diagnose thrombotic complications of COVID-19 with normal lung ultrasound.

The BLUE protocol provides an excellent step-by-step approach for diagnosis of acute dyspnea. Adding FECHO (Focused Echocardiography) to the BLUE protocol completes the picture and helps make solid diagnoses, especially in submassive and massive PE (Pulmonary embolism). COVID-19 infection can present with thrombotic manifestations like DVT (Deep vein thrombosis) and PE with no ultrasonographic evidence of lung parenchymal affection.

Appropriateness of lung ultrasound for the diagnosis of COVID-19 pneumonia.

BACKGROUND: Chest radiography (CXR) and computerized tomography (CT) are the standard methods for lung imaging in diagnosing COVID-19 pneumonia in the intensive care unit (ICU), despite their limitations. This study aimed to assess the performance of bedside lung ultrasound examination by a critical care physician for the diagnosis of COVID-19 pneumonia during acute admission to the ICU. METHOD: This was an observational, prospective, single-center study conducted in the intensive care unit of Adan General Hospital from April 10, 2020, to May 26, 2020. The study included adults with suspicion of COVID-19 Infection who were transferred to the ICU. Patients were admitted to the ICU directly from the ED after reverse transcriptase-polymerase chain reaction (RT-PCR) swabs were sent to the central virology laboratory in Kuwait, and the results were released 16 to 24 hours after the time of admission. A certified intensivist in critical care ultrasound performed the lung ultrasound within 12 hours of the patient's admission to the ICU.The treating physician confirmed the diagnosis of COVID-19 pneumonia based on a set of clinical features, inflammatory markers, biochemical profile studies, RT-PCR test results, and CXR. RESULTS: Of 77 patients with suspected COVID-19 pneumonia, 65 (84.4%) were confirmed. The median age of the patients was 48 (31-68) years, and 51 (71%) were men.In the group of patients with confirmed COVID-19 pneumonia, LUS revealed four signs suggestive of COVID-19 pneumonia in 63 patients (96.9%) (sensitivity 96.9%, CI 85%-99.5%). Two patients presented with unilateral lobar pneumonia without other ultrasonic signs of COVID-19 pneumonia but with positive RT-PCR results. Among patients in the group without COVID-19 pneumonia who had negative RT-PCR results, 11 (91.7%) were LUS negative for COVID-19 pneumonia (specificity 91.7%, 95% CI 58.72%-99.77%). CONCLUSIONS: During the COVID-19 outbreak, LUS allows the identification of early signs of interstitial pneumonia. LUS patterns that show a combination of the four major signs offer high sensitivity and specificity compared to nasopharyngeal RT-PCR.

Hepatic portal vein gas detected by point of care ultrasound.

INTRODUCTION: Portal venous gas is a rare finding in adults and is typically associated with underlying intestinal ischemia. Portal venous gas can be detected by a bedside point of care ultrasound (POCUS) examination in adult patients in critical care units (CCU). Findings include echogenic bubbles flowing centrifugally throughout the portal venous system. CASE PRESENTATION: We present the case of a 73-year-old female with advanced ischemic cardiomyopathy and cardiorenal syndrome who was managed in the CCU. She developed vague abdominal pain and respiratory depression requiring intubation and dialysis during her course of treatment in the CCU. Her findings were consistent with portal venous gas upon POCUS, prompting computed tomography of her abdomen and surgical consultation. She was ultimately found to have nonobstructive mesenteric ischemia. CLINICAL DISCUSSION: PVG is an ominous radiological sign and reflects intestinal ischemia in up to 72% of cases. Acute mesenteric ischemia of the small bowel could be due to occlusive or nonocclusive obstruction of the arterial blood supply or obstruction of venous outflow. Nonocclusive obstruction accounts for 5% to 15% of patients with acute mesenteric ischemia. CONCLUSION: With the increasing use of POCUS, critical care physicians should be aware of findings consistent with portal venous gas as a bedside tool for directing the treating physician toward an ominous diagnosis in patients with shock.

Conflicting clinical and radiological management decisions.

Gliosis with hemorrhagic transformation is a late reported complication of stroke. Sometimes there is a big discrepancy between clinical and radiological diagnosis, and clinical decisions must be multi-aspect decisions and not dependent on a single discrepant investigation result.

Specific situations may require different relative indications.

In specific situations such as patient with severely dilated left ventricle (LV) and spontaneous echo contrast (SEC) who suffered an ischemic stroke previously may be an acceptable indication for oral anticoagulation to prevent further TE events.

Point-of-Care Ultrasound for COVID-19 Pneumonia Patients in the ICU.

BACKGROUND: There is scarce literature on point-of-care ultrasound (POCUS) assessment characteristics in coronavirus disease 2019 (COVID-19) pneumonia with hypoxic respiratory failure. METHODS: This study was an observational, prospective, single-center study, including adults suspected to have COVID-19 who were transferred to the intensive care unit (ICU). An intensivist in critical care ultrasound performed lung ultrasound (LUS) and echocardiology within 12 hours of patients' admission to the ICU. We calculated the trans mitral E/A ratio, E/e', left ventricular ejection fraction (EF), inferior vena cava (IVC) diameter, right ventricle (RV) size and systolic function. RESULTS: In the group of patients with confirmed COVID-19 pneumonia, echocardiographic findings revealed normal E/e', deceleration time (DT), and transmittal E/A ratio compared to those in the non-COVID-19 patients (p = 0.001, 0.0001, and 0.0001, respectively). IVC diameter was < 2 cm with > 50% collapsibility in 62 (81%) patients with COVID-19 pneumonia; a diameter of > 2 cm and < 50% collapsibility was detected among those with non-COVID-19 pneumonia (p-value of 0.001). In patients with COVID-19 pneumonia, there were 3 cases of myocarditis (3.9%) with poor EF, severe RV systolic dysfunction was seen in 9 cases (11.6%), and 3 cases exhibited RV thrombus. Lung US revealed 4 signs suggestive of COVID-19 pneumonia in 77 patients (98.6%) (sensitivity 96.9%; confidence interval, 85%-99.5%) when compared with reverse transcriptase-polymerase chain reaction results. CONCLUSIONS: POCUS plays an important role in the bedside diagnosis, hemodynamic assessment and management of patients with acute hypoxic respiratory and circulatory failure with COVID-19 pneumonia.

Carbamazepine-induced Stevens-Johnson syndrome in a patient with history of methotrexate-induced mast cell activation syndrome.

Stevens-Johnson syndrome (SJS) is serious conditions that happen as a result of infection, side effects to medications, or unknown etiology. Carbamazepine is one of the common medications that can cause SJS. Good history taking is crucial if treatment with carbamazepine is clinically indicated. We would like to alert all physicians that carbamazepine should be avoided in any patient with a previous history of drug reaction such as mast cell activation syndrome.

The use of point-of-care ultrasound to guide clinical management in intra-abdominal hypertension.

INTRODUCTION: The Abdominal Compartment Society (WSACS) developed a medical management algorithm with a stepwise approach to keep intra-abdominal pressure (IAP) ≤ 15 mm Hg. The role of point-of-care ultrasound (POCUS) as a bedside modality in the critical care patients is not well studied in relation to the intra-abdominal hypertension (IAH) management algorithm. AIM: To test the role of point-of-care ultrasound (POCUS) in the medical management of patients with intra-abdominal hypertension (IAH). METHOD: We conducted a prospective observational study. Those who met the inclusion criteria were assigned to undergo POCUS and small bowel ultrasound as adjuvant tools in their IAH management. RESULTS: A total of 22 patients met the inclusion criteria and were included in the study. The mean age of the study participants was 65 ± 22.6 years, 61% were men, and the most frequent admission diagnoses were hepatic encephalopathy and massive ascites (five cases). Ultrasound and abdominal X-rays were comparable in confirming correct NGT position, but the ultrasound was superior in determining the gastric content (fluid vs. solid) and diagnoses of gastric paresis in two cases. Small bowel obstruction was present in four patients and confirmed with abdominal CT; two of the patients underwent surgical intervention for mesenteric vessel occlusion and transmesenteric internal hernia. Enema treatment was found to empty the bowel incompletely 72%, 56%, and 42% of the time on days 1, 2, and 3, respectively. Four patients with cirrhosis admitted with upper gastrointestinal bleeding and hepatic encephalopathy (out of a total of 8) were found to have large amounts of ascites, and US-guided paracentesis was performed. CONCLUSION: POCUS can be used in the nonoperative management of IAH. It is an important tool in the diagnosis and treatment of patients with IAH.

Lung Ultrasound and Sonographic Subpleural Consolidation in COVID-19 Pneumonia Correlate with Disease Severity.

INTRODUCTION: One of the ultrasonic features of COVID-19 pneumonia is the presence of subpleural consolidation (SPC), and the number of SPCs varies among patients with COVID-19 pneumonia. AIM: To examine the relationship between disease severity and the number of SPCs on admission. Methodology. This observational, prospective, single-center study included patients with suspected COVID-19 infection who had been transferred to the ICU. A specialized intensivist in critical care ultrasound performed lung ultrasound (LUS) and echocardiography within 12 hours of a patient's admission to the ICU. The aeration score was calculated, and the total number of SPCs was quantified in 12 zones of the LUS. RESULTS: Of 109 patients with suspected COVID-19 pneumonia, 77 (71%) were confirmed. The median patient age was 53 (82-36) years, and 81 of the patients (73.7%) were men. The aeration score and the counts of subpleural consolidation in each zone were significantly higher in patients with COVID-19 pneumonia (P=0.018 and P < 0.0001, respectively). There was an inverse relationship between PO2/FiO2, the aeration score, and the number of subpleural consolidations. The higher the number of SPCs, the worse the PO2/FiO2 will be. CONCLUSIONS: Sonographic SPC counts correlate well with the severity of COVID-19 pneumonia and PO2/FiO2. The number of SPCs should be considered when using LUS to assess disease severity.

White lung with milky effusion.

Thoracic duct injury is a rare complication of dorsal spine operations. Ultrasound chest plays an important tool for rapid diagnosis of acute dyspnea, drainage of massive effusion, and daily follow-up. Conservative treatment of postoperative chylous with measures to decrease chylous formation can lead to a resolution of chylothorax.

Bariatric Surgery can Lower the Efficacy of DOACs.

A 39-year-old woman who was taking the contraceptive pill was admitted with right leg deep venous thrombosis (DVT). She was started on apixaban tablets, but after 8 days developed proximal progression of the DVT and pulmonary embolism. Her medical history later showed a history of sleeve gastrectomy. The patient responded to a vitamin K antagonist after heparin. The failure of the antithrombotic drug shed light on the efficacy and changed pharmacodynamics of direct oral anticoagulants (DOACs) after bariatric surgery in the absence of commercially available blood monitoring tests. LEARNING POINTS: Bariatric surgery causes complicated changes in the pharmacodynamics of direct oral anticoagulants (DOACs).The absence of clinical data on the efficacy of DOACs after various bariatric procedures makes it difficult to justify their use after bariatric surgery.

Right atrial thrombus in a patient with COVID-19 pneumonia: a case report.

BACKGROUND: Significant coagulopathy and hyperinflammation are found in patients with coronavirus disease 2019 (COVID-19). Expert consensus has recommended prophylactic anticoagulation in COVID-19 patients due to the risk of thrombo-embolism. However, the use of therapeutic anticoagulation in these patients is still a matter of debate. CASE SUMMARY: We describe a patient with COVID-19 pneumonia and a clinical hyperinflammatory state. He developed early respiratory depression and required ventilation, and he subsequently developed haemodynamic instability. Point-of-care echocardiography demonstrated a right atrial thrombus and right ventricular dysfunction suggestive of acute massive pulmonary embolism. He was managed with veno-arterial extracorporeal membrane oxygenation and local thrombolysis. DISCUSSION: Critical cases of COVID-19 pneumonia are associated with hypercoagulation, and these patients should be monitored closely for complications. Therapeutic anticoagulation may play a role in the management and prevention of thrombo-embolism.

The Forgotten Hemodynamic (PCO2 Gap) in Severe Sepsis.

BACKGROUND: Central venous-arterial carbon dioxide difference (PCO2 gap) can be a marker of cardiac output adequacy in global metabolic conditions that are less affected by the impairment of oxygen extraction capacity. We investigated the relation between the PCO2 gap, serum lactate, and cardiac index (CI) and prognostic value on admission in relation to fluid administration in the early phases of resuscitation in sepsis. We also investigated the chest ultrasound pattern A or B. METHOD: We performed a prospective observational study and recruited 28 patients with severe sepsis and septic shock in a mixed ICU. We determined central venous PO2, PCO2, PCO2 gap, lactate, and CI at 0 and 6 hours after critical care unit (CCU) admission. The population was divided into two groups based on the PCO2 gap (cutoff value 0.8 kPa). RESULTS: The CI was significantly lower in the high PCO2 gap group (P=0.001). The high PCO2 gap group, on admission, required more administered fluid and vasopressors (P=0.01 and P=0.009, respectively). There was also a significant difference between the two groups for low mean pressure (P=0.01), central venous O2 (P=0.01), and lactate level (P=0.003). The mean arterial pressure was lower in the high PCO2 gap group, and the lactate level was higher, indicating global hypoperfusion. The hospital mortality rate for all patients was 24.5% (7/28). The in-hospital mortality rate was 20% (2/12) for the low gap group and 30% (5/16) for the high gap group; the odds ratio was 1.6 (95% CI 0.5-5.5; P=0.53). Patients with a persistent or rising PCO2 gap larger than 0.8 kPa at T = 6 and 12 hours had a higher mortality change (n = 6; in-hospital mortality was 21.4%) than patients with a PCO2 gap of less than 0.8 kPa at T = 6 (n = 1; in-hospital mortality was 3%); this odds ratio was 5.3 (95% CI 0.9-30.7; P=0.08). The PCO2 gap had no relation with the chest ultrasound pattern. CONCLUSION: The PCO2 gap is an important hemodynamic variable in the management of sepsis-induced circulatory failure. The PCO2 gap can be a marker of the adequacy of the cardiac output status in severe sepsis. A high PCO2 gap value (>0.8 kPa) can identify situations in which increasing CO can be attempted with fluid resuscitation in severe sepsis. The PCO2 gap carries an important prognostic value in severe sepsis.