Integrated ultrasonographic approach to evaluate fluid responsiveness in critically ill patients.

In patients with acute circulatory failure, we tested the feasibility of the evaluation of the fluid-responsiveness (FR) by a combined approach with echocardiography and lung ultrasound. We enrolled 113 consecutive patients admitted to the Emergency Department High-Dependency Unit of Careggi University-Hospital from January 2015 to June 2020. We assessed: (1) inferior vena cava collapsibility index (IVCCI); (2) the variation of aortic flow (VTIAo) during the passive leg raising test (PLR); (3) the presence of interstitial syndrome by lung ultrasound. FR was defined as an increase in the VTIAo > 10% during PLR or IVCCI ≥ 40%. FR patients were treated with fluid and those non-FR with diuretics or vasopressors. The therapeutic strategy was reassessed after 12 h. The goal was to maintain the initial strategy. Among 56 FR patients, at lung ultrasound, 15 patients showed basal interstitial syndrome and 4 all-lung involvement. One fluid bolus was given to 51 patients. Among 57 non-FR patients, 26 patients showed interstitial syndrome at lung ultrasound (basal fields in 14, all lungs in 12). We administered diuretics to 21 patients and vasopressors to 4 subjects. We had to change the initial treatment plan in 9% non-FR patients and in 12% FR patients (p = NS). In the first 12 h after the evaluation, non-FR patients received significantly less fluids compared to those FR (1119 ± 410 vs 2010 ± 1254 ml, p < 0.001). The evaluation of the FR based on echocardiography and lung ultrasound was associated with the reduction in fluid administration for non-FR patients compared with those FR.

The presentations/physician ratio predicts door-to-physician time but not global length of stay in the emergency department: an Italian multicenter study during the SARS-CoV-2 pandemic.

To investigate the effects of the dramatic reduction in presentations to Italian Emergency Departments (EDs) on the main indicators of ED performance during the SARS-CoV-2 pandemic. From February to June 2020 we retrospectively measured the number of daily presentations normalized for the number of emergency physicians on duty (presentations/physician ratio), door-to-physician and door-to-final disposition (length-of-stay) times of seven EDs in the central area of Tuscany. Using the multivariate regression analysis we investigated the relationship between the aforesaid variables and patient-level (triage codes, age, admissions) or hospital-level factors (number of physician on duty, working surface area, academic vs. community hospital). We analyzed data from 105,271 patients. Over ten consecutive 14-day periods, the number of presentations dropped from 18,239 to 6132 (- 67%) and the proportion of patients visited in less than 60 min rose from 56 to 86%. The proportion of patients with a length-of-stay under 4 h decreased from 59 to 52%. The presentations/physician ratio was inversely related to the proportion of patients with a door-to-physician time under 60 min (slope - 2.91, 95% CI - 4.23 to - 1.59, R2 = 0.39). The proportion of patients with high-priority codes but not the presentations/physician ratio, was inversely related to the proportion of patients with a length-of-stay under 4 h (slope - 0.40, 95% CI - 0.24 to - 0.27, R2 = 0.36). The variability of door-to-physician time and global length-of-stay are predicted by different factors. For appropriate benchmarking among EDs, the use of performance indicators should consider specific, hospital-level and patient-level factors.

Prediction of Mortality With the Use of Noninvasive Ventilation for Acute Respiratory Failure.

BACKGROUND: In actuality, it is difficult to obtain an early prognostic stratification for patients with acute respiratory failure treated with noninvasive ventilation (NIV). We tested whether an early evaluation through a predictive scoring system could identify subjects at risk of in-hospital mortality or NIV failure. METHODS: This was a retrospective study, which included all the subjects with acute respiratory failure who required NIV admitted to an emergency department-high-dependence observation unit between January 2014 and December 2017. The HACOR (heart rate, acidosis [by using pH], consciousness [by using the Glasgow coma scale], oxygenation [by using [Formula: see text]/[Formula: see text]], respiratory rate) score was calculated before the NIV initiation (T0) and after 1 h (T1) and 24 h (T24) of treatment. The primary outcomes were in-hospital mortality and NIV failure, defined as the need for invasive ventilation. RESULTS: The study population included 644 subjects, 463 with hypercapnic respiratory failure and an overall in-hospital mortality of 23%. Thirty-six percent of all the subjects had NIV as the "ceiling" treatment. At all the evaluations, nonsurvivors had a higher mean ± SD HACOR score than did the survivors (T0, 8.2 ± 4.9 vs 6.1 ± 4.0; T1, 6.6 ± 4.8 vs 3.8 ± 3.4; T24, 5.3 ± 4.5 vs 2.0 ± 2.3 [all P < .001]). These data were confirmed after the exclusion of the subjects who underwent NIV as the ceiling treatment (T0, 8.2 ± 4.9 vs 6.1 ± 4.0 [P = .002]; T1, 6.6 ± 4.8 vs 3.8 ± 3.4; T24, 5.3 ± 4.5 vs 2.0 ± 3.2 [all P < .001]). At T24, an HACOR score > 5 (Relative Risk [RR] 2.39, 95% CI 1.60-3.56) was associated with an increased mortality rate, independent of age and the Sequential Organ Failure Assessment score. CONCLUSIONS: Among the subjects treated with NIV for acute respiratory failure, the HACOR score seemed to be a useful tool to identify those at risk of in-hospital mortality.

Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED.

BACKGROUND: Acute dyspnea is a common symptom in the ED. The standard approach to dyspnea often relies on radiologic and laboratory results, causing excessive delay before adequate therapy is started. Use of an integrated point-of-care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis, while maintaining an acceptable safety profile. METHODS: Consecutive adult patients presenting with dyspnea and admitted after ED evaluation were prospectively enrolled. The gold standard was the final diagnosis assessed by two expert reviewers. Two physicians independently evaluated the patient; a sonographer performed an ultrasound evaluation of the lung, heart, and inferior vena cava, while the treating physician requested traditional tests as needed. Time needed to formulate the ultrasound and the ED diagnoses was recorded and compared. Accuracy and concordance of the ultrasound and the ED diagnoses were calculated. RESULTS: A total of 2,683 patients were enrolled. The average time needed to formulate the ultrasound diagnosis was significantly lower than that required for ED diagnosis (24 ± 10 min vs 186 ± 72 min; P = .025). The ultrasound and the ED diagnoses showed good overall concordance (κ = 0.71). There were no statistically significant differences in the accuracy of PoCUS and the standard ED evaluation for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax, and dyspnea from other causes. PoCUS was significantly more sensitive for the diagnosis of heart failure, whereas a standard ED evaluation performed better in the diagnosis of COPD/asthma and pulmonary embolism. CONCLUSIONS: PoCUS represents a feasible and reliable diagnostic approach to the patient with dyspnea, allowing a reduction in time to diagnosis. This protocol could help to stratify patients who should undergo a more detailed evaluation.

Can non-invasive ventilation modify central venous pressure? Comparison between invasive measurement and ultrasonographic evaluation.

Central venous pressure (CVP) is primarily measured to assess intravascular volume status and heart preload. In clinical practice, the measuring device most commonly used in emergency departments and intensive care units, is an electronic transducer that interconnects a central venous catheter (CVC) with a monitoring system. Non-invasive ventilation (NIV) consists in a breathing support that supplies a positive pressure in airways through a mask or a cask though not using an endotracheal prosthesis. In emergency settings, non-invasive ultrasonography evaluation of CVP, and hence of intravascular volume status entail the measurement by a subxiphoid approach of inferior vena cava diameter and its variations in relation to respiratory activity. In the literature, there are many studies analyzing the ability to estimate CVP through ultrasonography, rating inspiratory and expiratory vena cava diameters and their ratio, defined as inferior vena cava collapsibility index (IVC-CI). At the same time, the effects of invasive mechanical ventilation on blood volume and the correlation during ventilation between hemodynamic invasive measurement of CVP and inferior vena cava diameters have already been demonstrated. Nevertheless, there are no available data regarding the hemodynamic effects of NIV and the potential correlations during this kind of ventilation between invasive and non-invasive CVP measurements. Therefore, this study aims to understand whether there exists or not an interrelationship between the values of CVP assessed invasively through a CVC and non-invasively through the IVC-CI in patients with severe respiratory distress, and above all to evaluate if these means of assessment can be influenced using NIV.

High-frequency QRS analysis compared to conventional ST-segment analysis in patients with chest pain and normal ECG referred for exercise tolerance test.

BACKGROUND: The novel analysis of high-frequency QRS components (HFQRS-analysis) has been proposed in patients with chest pain (CP) and normal electrocardiography (ECG) referred for exercise tolerance test (ex-ECG). The aim of the study was to compare the diagnostic value of ex-ECG with ex-HFQRS-analysis. METHODS: Patients with CP and normal ECG, troponin, and echocardiography were considered. All patients underwent ex-ECG for conventional ST-segment-analysis and ex-HFQRS-analysis. A decrease ≥ 50% of the HFQRS signal intensity recorded in at least 2 contiguous leads was considered an index of ischemia, as ST-segment depression ≥ 2 mm or ≥ 1 mm and CP on ex-ECG. Exclusion criteria were: QRS duration ≥ 120 ms and inability to exercise. End-point: The composite of coronary stenosis ≥ 70% or acute coronary syndrome, revascularization, cardiovascular death at 3-month follow-up. RESULTS: Three-hundred thirty-seven patients were enrolled (age 60 ± 15 years). The percent-age of age-adjusted maximal predicted heart rate was 89 ± 10 beat per minute and the maximal systolic blood pressure was 169 ± 23 mm Hg. Nineteen patients achieved the end-point. In multivariate analysis, both ex-ECG and ex-HFQRS were predictors of the end-point. The ex-HFQRS-analysis showed higher sensitivity (63% vs. 26%; p < 0.05), lower specificity (68% vs. 95%; p < 0.001), and comparable negative predictive value (97% vs. 96%; p = 0.502) when compared to ex-ECG-analysis. Receiver operator characteristics analysis showed the incremental diagnostic value of HFQRS (area: 0.655, 95% CI 0.60-0.71) over conventional ex-ECG (0.608, CI 0.55-0.66) and CP score (0.530, CI 0.48-0.59), however without statistical significance in pairwise comparison by C-statistic. CONCLUSIONS: In patients with CP submitted to ex-ECG, the novel ex-HFQRS-analysis shows a valuable incremental diagnostic value over ST-segment-analysis.

Quality of life after mild to moderate trauma.

INTRODUCTION: To evaluate potential reduction in health-related quality of life (HRQOL) after a mild to moderate trauma. MATERIALS AND METHODS: Follow-up study of a cohort of 153 trauma patients admitted to the High Dependency Unit of the Emergency Department of the University-Hospital of Florence from July 2008 to February 2012. After 6 months from the event, a telephone interview using the Physical (PCS) and Mental (MCS) Health Composite Score (SF12) was conducted. Patients reported their HRQOL both at present and before trauma. Scores ≥ 50 represent no disability; 40-49, mild disability; 30-39, moderate disability; and below 30, severe disability. RESULTS: Before the event 143 (93%) subjects reported a normal PCS and MCS. After the events, a significantly lower proportion of patients maintained a normal PCS and MCS values (52 and 68%, all p<0.01). One, two, three and four PCS items worsened in 14%, 15%, 18% and 38% of the study population, while one, two, three or four MCS dimensions worsened in 12%, 19%, 19% and 24%. We identified 109 subjects (N+), which showed normal PCS and MCS values before trauma, in the absence of any pre-existing medical condition. After the event, we observed a significant PCS (before: 54, standard deviation, SD 6; after 43, SD 11, p<0.0001) and MCS (before: 55, SD 7; after 47, SD 11, p<0.0001) worsening among N+ subjects. Distribution across the four disability categories was 52, 24, 17 and 6% for MCS score and 38, 25, 27 and 11% for PCS score: overall 8 (7%) patients reported a moderate disability and 5 (5%) reported a severe disability in both dimensions. Compared with subjects with preserved values, patients with an abnormal (<39) HRQOL were older, showed a higher prevalence of female gender and pre-existing medical conditions and a worst Sequential Organ Failure Assessment score. An advanced age (OR 1.033, 95% CI 1.010-1.057, p=0.005) and a higher SOFA T1 score (OR 1.500, 95% CI 1.027-2.190, p=0.036) were independently associated with a worsening PCS. CONCLUSIONS: After a mild trauma, we evidenced a relevant reduction in HRQOL; an advanced age and a higher degree of organ dysfunction were independently associated with HRQOL deterioration.

Prognosis and health-related quality of life in elderly patients after a mild to moderate trauma.

The aims of this study were to compare outcome after a mild to moderate trauma in three subgroups of patients of increasing age (A1: <50, A2: 50-74, A3: >74 years) and to assess potential health-related quality of life (HRQOL) impairment. This is a follow-up study of a cohort of 418 trauma patients admitted to the High Dependency Unit of the Emergency Department of the University Hospital of Florence from July 2008 to February 2012. Six months after the event, a telephone interview using the Physical component summary (PCS) and Mental component summary (MCS) Health Composite Score (SF12) was conducted. Patients reported their QOL both at present and before trauma. In-hospital mortality was 10 of 418 (2.3 %); overall mortality was 27 of 244 (11 %) patients found at follow-up. No death was observed among A1 patients; overall mortality was (6/76) 7 % in A2 and (21/71) 30 % in A3 patients (p < 0.05 A1 vs A2, A1 vs A3 and A2 vs A3). Before the event, respectively, 94 and 96 % patients reported a normal MCS and PCS score (>39); after the event, the proportion of patients with a normal score value was significantly lower (MCS 70 %, p = 0.002; PCS 58 %, p < 0.0001). All subgroups showed a highly significant reduction in the scores' value due to the trauma. After the event, the proportion of patients with normal scores was significantly lower (all p < 0.0001, except for MCS score in A1 subgroup, who showed p = 0.013) within all subgroups. Elderly patients' prognosis was significantly worse compared with the younger counterpart; despite young patients' optimal outcome, HRQOL was uniformly reduced across all age groups.

Prognostic value of emergency physician performed echocardiography in patients with acute pulmonary thromboembolism.

INTRODUCTION: Pulmonary embolism (PE) is a life-threatening illness with high morbidity and mortality. Echocardiography (ECG) plays an important role in the early identification of right ventricular (RV) dysfunction, making it a helpful tool in identifying hemodynamically stable patients affected by PE with a higher mortality risk. The purpose of this study was to evaluate if one or more ECG indexes could predict a short-term evolution towards RV dysfunction. METHODS: We selected all patients consecutively admitted to the Careggi Hospital Emergency Department with the clinical suspicion of PE, confirmed by computed tomography angiography prior to enrollment. Subsequently, properly trained emergency physicians acquired a complete ECG to measure RV morphological and functional indices. For each patient, we recorded if he or she received a fibrinolytic treatment, a surgical embolectomy or heparin therapy during the emergency department (ED) stay. Then, every patient was re-evaluated with ECG, by the same physician, after 1 week in our intensive observation unit and 1 month as outpatient in our ED regional referral center for PE. RESULTS: From 2002 to 2007, 120 consecutive patients affected by PE were evaluated by echocardiography at the Careggi Hospital ED. Nine patients (8%) were treated with thrombolytic therapy. Six died within 1 week and 4 abandoned the study, while the remaining 110 survived and were re-evaluated by ECG after 1 week and 1 month. The majority of the echocardiographic RV indexes improve mostly in the first 7 days: Acceleration Time (AT) from 78±14 ms to 117±14 ms (p<0.001), Diameter of Inferior Vena Cava (DIVC) from 25±6 mm to 19±5 mm (p<0.001), Tricuspid Annular Plane Systolic Excursion (TAPSE) from 16±6 mm to 20±6 mm (p<0.001). Pulmonary Artery Systolic Pressure (PASP) showed a remarkable decrease from 59±26 mmHg to 37±9 mmHg, (p<0.001). The measurements of the transverse diameters of both ventricles and the respective ratio showed a progressive normalization with a reduction of RV diameter, an increase of Left Ventricular (LV) diameter and a decrease of RV/LV ratio over time. To evaluate the RV function, the study population was divided into 3 groups based on the TAPSE and PASP mean values at the admission: Group 1 (68 patients) (TAPSE+/ PASP-), Group 2 (12 patients) (TAPSE-/PASP-), and Group 3 (30 patients) (TAPSE-/PASP+). Greater values of AT, minor RV diameter, greater LV diameter and a lesser RV/LV ratio were associated with a short-term improvement of TAPSE in the Group 2. Instead, in Group 3 the only parameter associated with short-term improvement of TAPSE and PASP was the treatment with thrombolytic therapy (p<0.0001). CONCLUSION: Greater values of AT, minor RV diameter, greater LV diameter and a lesser RV/LV ratio were associated with a short-term improvement of TAPSE-/PASP- values. Patients with evidence of RV dysfunction (TAPSE-/PASP+), may benefit from thrombolytic therapy to improve a short- term RV function. After 1 month, also a decreased DIVC predicted improved RV function.

Verification of correct central venous catheter placement in the emergency department: comparison between ultrasonography and chest radiography.

In 210 consecutive patients undergoing emergency central venous catheterization, we studied whether an ultrasonography examination performed at the bedside by an emergency physician can be an alternative method to chest X-ray study to verify the correct central venous catheter placement, and to identify mechanical complications. A prospective, blinded, observational study was performed, from January 2009 to December 2011, in the emergency department of a university-affiliated teaching hospital. Ultrasonography interpretation was completed during image acquisition; ultrasound scan was performed in 5 ± 3 min, whereas the time interval between chest radiograph request and its final interpretation was 65 ± 74 min p < 0.0001. We found a high concordance between the two diagnostic modalities in the identification of catheter position (Kappa = 82 %, p < 0.0001), and their ability to identify a possible wrong position showed a high correlation (Pearson's r = 0.76 %, p < 0.0001) with a sensitivity of 94 %, a specificity of 89 % for ultrasonography. Regarding the mechanical complications, three iatrogenic pneumothoraces occurred, all were correctly identified by ultrasonography and confirmed by chest radiography (sensitivity 100 %). Our study showed a high correlation between these two modalities to identify possible malpositioning of a catheter resulting from cannulation of central veins, and its complications. The less time required to perform ultrasonography allows earlier use of the catheter for the administration of acute therapies that can be life-saving for the critically ill patients.

Usefulness of chest ultrasonography in detecting pulmonary embolism in patient with chronic obstructive pulmonary disease and chronic renal failure: a case report.

We describe the case of a 75-year-old man affected by a chronic obstructive pulmonary disease and chronic renal failure admitted to our emergency department for dyspnea and interscapular stabbing pain. Chest radiography showed diffuse parenchymal consolidation in the lower right lung with bronchiectasis, but the treatment for infection disease did not improve the clinical conditions of the patient. According to Wells score indicating an intermediate risk for pulmonary embolism, we performed a chest ultrasonography that showed ultrasonographic patterns of thromboembolism. Because the presence of chronic renal failure limited the execution of a helical computed tomographic pulmonary angiography, a pulmonary scintigraphy was performed confirming the diagnosis of pulmonary embolism. Our case suggested that chest ultrasonography can be a valuable tool for early detection of pulmonary embolism and to establish immediately an appropriate therapy.