Use of Midodrine in Heart Failure: Two Case Reports and a Review of the Literature.

Hypotension in patients with heart failure is much more frequent in daily clinical practice than the 10-15% reported in clinical trials. In patients with heart failure with reduced ejection fraction (HFrEF), hypotension frequently limits the initiation and up-titration of guideline-directed medical therapy (GDMT). Midodrine is a peripheral alpha-1 agonist and a vasopressor anti-hypotensive agent approved for the treatment of orthostatic hypotension. We describe two cases where midodrine was prescribed in patients with HFrEF and hypotension. LEARNING POINTS: Hypotension in patients with systolic heart failure is a frequent presentation and can limit the initiation and optimization of guideline-directed medical therapy.Midodrine is a peripheral alpha-1 agonist and anti-hypotensive agent approved for the treatment of orthostatic hypotension.Midodrine may be used off-label in patients with heart failure with reduced ejection fraction (HFrEF) and symptomatic hypotension to allow optimization of medical therapy.

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.

Double heart - chronic large missed pseudoaneurysm of left ventricle.

Myocardial infarction is considered the most common cause of left ventricular pseudoaneurysm. Large missed pseudoaneurysm of the left ventricle incidentally diagnosed and treated conservatively.

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.

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.

Point-of-Care Ultrasound Can Suggest COVID-19.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the World Health Organization (WHO) declared it a pandemic on 11 March 2020. Point-of-care ultrasound (POCUS) is a real-time bedside tool used by physicians to guide rapid, focused and accurate evaluation in order to identify or rule out various pathologies. We describe the case of an elderly man who had fallen at home 3 days previously and was hypoxic at presentation to the emergency department (ED). POCUS in the ED helped to identify a combination of lung and vascular involvement that indicated COVID-19 infection, which was confirmed by a laboratory test. LEARNING POINTS: COVID-19 is a contagious disease caused by SARS-CoV-2 that attacks endothelial cells and most organs, resulting in different manifestations and clinical scenarios.Point-of-care ultrasound in the emergency room including lung ultrasound (LUS) and focused echocardiography (FECHO) can be useful in identifying pulmonary and vascular manifestations of COVID-19 disease during the current pandemic.Characteristic LUS signs suggesting bilateral interstitial pneumonia in addition to signs of acute right ventricular strain suggesting pulmonary embolism on FECHO raised the suspicion of COVID-19 infection in our patient.

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.

It Is Always Early with Point-of-Care Ultrasound.

A 56-year-old male was admitted to the emergency department for acute pulmonary edema and septic shock, yet no clear source of infection was noted upon physical examination. Due to his unstable condition, bedside ultrasound was performed. A heterogeneous mass in the liver was noted; hence, a tentative diagnosis of liver abscess was made. The abscess was confirmed by abdominal magnetic resonance imaging. Drainage of the abscess was attempted and guided by early ultrasound. This case highlights that point-of-care ultrasound, when performed by an ultrasound-capable critical care physician, can significantly decrease the time to diagnosis for septic patients.