ClinicalTrials.gov; No.: NCT01995448; URL: www.clinicaltrials.gov.
Study Objective: We evaluated the early hemodynamic profile of patients presenting with acute circulatory failure to the Emergency Department (ED) using focused echocardiography performed by emergency physicians after a dedicated training program. Methods: Patients presenting to the ED with an acute circulatory failure of any origin were successively examined by a recently trained emergency physician and by an expert in critical care echocardiography. Operators independently performed and interpreted online echocardiographic examinations to determine the leading mechanism of acute circulatory failure. Results: Focused echocardiography could be performed in 100 of 114 screened patients (55 with sepsis/septic shock and 45 with shock of other origin) after a median fluid loading of 500 mL (interquartile range: 187–1,500 mL). A hypovolemic profile was predominantly observed whether the acute circulatory failure was of septic origin or not (33/55 [60%] vs. 23/45 [51%]: P = 0.37). Although a vasoplegic profile associated with a hyperkinetic left ventricle was most frequently identified in septic patients when compared with their counterparts (17/55 [31%] vs. 5/45 [11%]: P = 0.02), early left or right ventricular failure was observed in 31% of them. Hemodynamic profiles were adequately appraised by recently trained emergency physicians, as reflected by a good-to-excellent agreement with the expert's assessment (Κ: 0.61–0.85). Conclusions: Hypovolemia was predominantly identified in patients presenting to the ED with acute circulatory failure. Although vasoplegia was more frequently associated with sepsis, early ventricular dysfunction was also depicted in septic patients. Focused echocardiography seemed reliable when performed by recently trained emergency physicians without previous experience in ultrasound.
Approximately two-thirds of patients admitted to the intensive care unit (ICU) for coronavirus disease-19 (COVID-19) pneumonia present with the acute respiratory distress syndrome (ARDS) [1]. COVID-19-associated acute cardiac injury is frequently reported based on troponin and electrocardiographic changes [2], but its impact on cardiac function is yet unknown [3]. Accordingly, we sought to describe cardiovascular phenotypes identified using transesophageal echocardiography (TEE) in ventilated COVID-19 patients with ARDS and to compare them to those of patients with flu-induced ARDS.All patients with confirmed COVID-19 who were mechanically ventilated for ARDS in our medical-surgical ICU underwent prospectively a TEE assessment during the first 3 days and whenever required by clinical events during ICU stay, as a standard of care. Similarly, all patients ventilated for flu-associated ARDS who underwent a TEE assessment over the last 2 years were retrospectively analyzed for comparison. Cardiovascular phenotypes were identified using previously reported TEE criteria [4]. Same applied for acute cor pulmonale (ACP) [5]. TEE studies were read by two independent experts who had no access to the cause of ARDS and examination date. Results are expressed as medians and 25th-75th percentiles. Friedman ANOVA was used to compare quantitative parameters over time in COVID-19 patients, while Mann-Whitney U test and Fisher's exact test were used for comparison of continuous and categorical variables, respectively, with flu patients. No use of previous value or interpolation rule was used in the presence of missing data.Eighteen consecutive COVID-19 patients and 23 flu patients (21 A-H1N1) were studied. COVID-19 patients were significantly older (70 [57-75] vs. 58 [49-64] years, p = 0.006), less severe , p = 0.015; SOFA 4 [2-4] vs. 6 [4-9], p < 0.001), required less vasopressor support (2/18 [11%] vs. 10/23 [43%], p = 0.038), and had longer time lag between first symptoms and ICU admission, tracheal intubation, and TEE examination when compared to flu patients (Table 1).
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