The caval index:an adequate non-invasive ultrasound parameter to predict fluid responsiveness in the emergency department?

Background: Fluid therapy is the first important step in patients with signs of shock but assessment of the volume status is difficult and invasive measurements are not readily available in the emergency department. We have investigated whether the respiratory variation in diameter of the inferior vena cava is a reliable parameter to predict fluid responsiveness in spontaneous breathing emergency department patients with signs of shock. Methods: All patients admitted to the emergency department during a 15 week period were screened for signs of shock. If the attending physician planned to give a fluid challenge, the caval index was determined by transabdominal ultrasonography in supine position. Immediately afterwards 500 ml NaCl 0.9% was administered in 15 minutes and the clinical response was observed. An adequate response was defined as an increase in systolic blood pressure of at least 10 mm Hg. Based on this definition patients were divided into responders and non-responders. Results: After selection a total number of 45 patients was included. A low caval index (<36.5%) in patients with signs of shock reliably predicted the absence of an adequate response to fluid therapy (negative predictive value 92%). The positive predictive value of a high caval index was much lower (48%) despite the fact that responders had a significantly higher pre-infusion caval index than non-responders (48.7% vs 31.8%, p 0.014). Conclusions: In spontaneously breathing patients with signs of shock in the emergency department, a high caval index (>36.5%) does not reliably predict fluid responsiveness in our study, while a low caval index (<36.5%) makes fluid responsiveness unlikely. An explanation for the absence of a blood pressure response in the group of patients with a low high caval index might be that these patients represent a group requiring more volume therapy than 500 ml

The value of the clinical impression in recognizing and treating sepsis patients in the emergency department

Objectives Immediate bedside recognition of sepsis in the emergency department (ED) enables early treatment. This study aims to investigate whether the clinical impression score of different health care providers (a) is a good predictor of the severity of sepsis, (b) is mutually agreed, and (c) correlates with the treatment provided in the ED. Methods We performed a prospective observational study in the ED of a tertiary teaching hospital over a 3-month period. The vital signs of all patients of at least 18 years presenting with suspected infection or sepsis were measured on arrival at the ED. In patients with at least one of the 'Systemic Inflammatory Response Syndrome' criteria, the nurse, resident, and attending physician assigned a clinical impression score for the degree of acute illness, ranging from 1 (not ill) to 10 (extremely ill). Additional information collected included demographic and treatment data. Results We included 123 patients with sepsis and 11 patients with a (suspected) infection with one 'Systemic Inflammatory Response Syndrome' criterion. The clinical impression scores of all health care providers increased significantly between the infection without sepsis, mild sepsis, and severe sepsis groups. The agreement between the health care providers ranged from moderate to good (weighted kappa 0.54-0.62). The clinical impression score correlated with time to antibiotics (R = -0.33, P = 0.001), amount of volume therapy (R=0.61-0.64, P Conclusion The clinical impression score is associated with the severity of sepsis, is mutually agreed between the different health care providers and is correlated with sepsis treatment provided in the ED. European Journal of Emergency Medicine 19:373-378 (C) 2012 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins

Pseudolithiasis after recent use of ceftriaxone:an unexpected diagnosis in a child with abdominal pain

<p>Ceftriaxone is a widely prescribed third-generation broad spectrum cephalosporin, often used for treatment of severe bacterial infections in children. It is known that ceftriaxone can cause sonographic biliary abnormalities in children. However, in only a minority of these cases, it will be accompanied with the clinical relevant symptoms and biochemical abnormalities seen in gallbladder disease. Ceftriaxone-associated cholelithiasis has a highly reversible nature and is thus called pseudolithiasis. Apart from stopping or converting the ceftriaxone treatment, no other therapy is indicated. Awareness of this phenomenon is important in preventing unnecessary treatment.</p>

Ultrasound and NICOM in the assessment of fluid responsiveness in patients with mild sepsis in the emergency department: A pilot study

Objective We investigated whether combining the caval index, assessment of the global contractility of the heart and measurement of stroke volume with Noninvasive Cardiac Output Monitoring (NICOM) can aid in fluid management in the emergency department (ED) in patients with sepsis. Setting A prospective observational single-centre pilot study in a tertiary care centre. Primary and secondary outcomes Ultrasound was used to assess the caval index, heart contractility and presence of B-lines in the lungs. Cardiac output and stroke volume were monitored with NICOM. Primary outcome was increase in stroke volume after a fluid bolus of 500mL, while secondary outcome included signs of fluid overload. Results We included 37 patients with sepsis who received fluid resuscitation of at least 500mL saline. The population was divided into patients with a high (>36.5%, n=24) and a low caval index ( Conclusions Our small pilot study suggests that at least 1000mL saline is needed to induce a significant response in stroke volume in patients with sepsis and a high caval index. This amount seems to be safe, not leading to the development of fluid overload. Therefore, combining ultrasound and NICOM is feasible and may be valuable tools in the treatment of patients with sepsis in the ED. A larger trial is needed to confirm these results