The Role of Diastolic Dysfunction in the Diagnosis and Treatment of Shock: The Rapid Ultrasound for Shock and Hypotension Protocol with a Diastolic Parameter

Yıl 2022, Cilt: 5 Sayı: 1, 13 - 19, 09.03.2022

Adnan Yamanoğlu

https://doi.org/10.54996/anatolianjem.1015103

Öz

Aim: Numerous bedside ultrasound protocols have been developed for the evaluation of critically ill patients with bedside ultrasound. The most widely known of these protocols is the "Rapid Ultrasound for Shock and Hypotension (RUSH)’’ protocol. Diastolic dysfunction is the cause of nearly half of left ventricular dysfunctions, but no ultrasound protocol includes diastolic dysfunction. The aim of this study is to evaluate the contribution of the addition of diastolic assessment to the RUSH protocol to the diagnosis and treatment of critically ill patients.

Material and Methods: This prospective, observational study was conducted in a tertiary training and research hospital emergency medicine clinic critical care area for 1 year. Non-traumatic non-pregnant adult patients with systolic blood pressure below 90 mmHg or shock index >1 with signs of circulatory disorder were included in the study. Complaints, clinical findings, and vital signs of all patients included in the study were recorded. With the primary evaluation of the patients, the RUSH protocol was applied, and the findings were recorded. All clinical, laboratory, imaging, and consultation procedures of the patients, as well as the type of shock and its treatment were planned. After the diagnosis of the patients, a second cardiac ultrasound was performed maximum 2 hours later, and diastolic parameters were evaluated and recorded. Whether there was a difference between the diagnoses and treatments of the patients before and after the diastolic parameters were measured, was compared with McNemar and paired T test.

Results: A total of 69 patients with a mean age of 67 ± 13 years were included in the study, 54% of whom were females. Before the diastolic parameters of the patients were evaluated, distributive shock was detected in 20.3%, hypovolemic shock in 18.8%, obstructive-type shock in 8.7% and mixed type shock in 40.6% of the patients and their treatment was arranged accordingly. After evaluating the diastolic dysfunction parameters, distributive shock was found in 15.9% of the patients, hypovolemic shock in 18.8%, obstructive-type shock in 5.7% and mixed type shock in 47.8%. However, this change in diagnoses was not statistically significant (p=0.135). On the other hand, the treatment plans were changed in a total of 13 patients by re-adjusting the volume status due to the determination of the diastolic parameter in those patients, and the change was statistically significant (p<0.001).

Conclusion: Evaluation of the diastolic parameters may not be necessary in determining the shock type in patients with shock. However, the evaluation of the diastolic parameters is effective in adjusting the treatment and volume status of critically ill patients and may need to be evaluated as soon as possible.

Anahtar Kelimeler

Emergency medicine, echocardiography, heart failure, bedside ultrasound, critical care

Teşekkür

Acknowledgments We are greatly indebted to Assistant Professor Dr. Sadık Volkan Emren from our university cardiology department for his invaluable support for this study. We are also most grateful to all the consultant physicians from the internal diseases, chest diseases, anesthesia, and cardiology departments for their support.

Şok Tanı ve Tedavisinde Diyastolik Disfonksiyonun Rolü: Diyastolik Yetmezlik Parametresiyle Birlikte Şok ve Hipotansiyon İçin Hızlı Ultrason Protokolü

Öz

Amaç: Kritik hastaların yatakbaşı ultrasonla değerlendirilmesi için çok sayıda yatakbaşı ultrason protokolü geliştirilmiştir. Bu protokollerden en yaygın bilineni “Şok ve Hipotansiyon için Hızlı Ultrason protokolü: “Rapid Ultrasound for Shock and Hypotension’’ (RUSH) protokolüdür. Sol ventrikül disfonksiyonlarının yarıya yakın nedenini diyastolik disfonksiyon içerir ve hiçbir ultrason protokolü diyastolik disfonksiyon yer almamaktadır. Bu çalışmanın amacı RUSH protokolüne diyastolik değerlendirmenin eklenmesinin kritik hastaların tanı ve tedavilerine katkılarını belirlemektir.

Gereç ve Yöntemler: Prospektif gözlemsel olarak planlanan bu çalışma 1 yıl boyunca üçüncü basamak bir eğitim araştırma hastanesi acil tıp kliniği kritik bakım alanında yürütülmüştür. Çalışmaya dolaşım bozukluğu bulguları olan, sistolik kan basıncı 90 mmHg altında veya şok indeksi >1 olan, nontravmatik, gebe olmayan erişkin hastalar dahil edildi. Çalışmaya alınan bütün hastaların şikayetleri, klinik bulguları, vital bulguları kaydedildi. Hastaların primer değerlendirilmesiyle beraber RUSH protokolü uygulandı ve bulguları kaydedildi. Hastaların tüm klinik, laboratuvar, görüntüleme ve konsültasyon işlemleri ile şok tipi ve şok tedavisi planlandı. Hastaların tanı almasını takiben maksimum 2 saat sonra ikinci defa kardiyak ultrason yapılarak diyastolik parametreler değerlendirildi ve kaydedildi. Hastaların diyastolik parametreler bilinmeden önce ve sonraki tanıları ve tedavileri arasında fark olup olmadığı McNemar ve Eşleştirilmiş T testi ile karşılaştırıldı.

Bulgular: Çalışmaya yaş ortalaması 67±13 olan ve %54’ü kadın olan toplam 69 hasta dahil edildi. Hastaların diyastolik parametreleri değerlendirilmeden önce %20.3’ünde distribütif tip şok, %18.8’inde hipovolemik şok, %8.7’sinde obstrüktif tip şok ve %40.6’sında da miks tip şok tespit edilerek bu yönde tedavileri düzenlendi. Diyastolik yetmezlik parametreleri değerlendirildikten sonra hastaların %15.9’unda distribütif tip şok %18.8’inde hipovolemik şok, %5.7’sinde obstrüktif tip şok ve %47.8’inde de miks tip şok tespit edildi ancak tanılarda meydana gelen bu değişiklik istatistiksel olarak anlamlı değildi (p=0.135). Tedaviler ise ağırlıklı olarak hastalarda diyastolik kusurun tespit edilmesine bağlı volüm durumunun yeniden ayarlanması şeklinde değişmiş olup, toplam 13 hastanın tedavisinde değişiklik oldu ve bu değişiklik istatistiksel olarak anlamlı idi (p<0.001).

Sonuç: Hastalarda şok tipinin belirlenmesinde diyastolik parametrenin değerlendirilmesi gerekli olmayabilir. Ancak kritik hastaların tedavi ve volüm durumlarının ayarlanmasında diyastolik parametrenin değerlendirilmesi etkindir ve en kısa zamanda değerlendirilmesi gerekli olabilir.

Anahtar Kelimeler

Acil tıp, ekokardiyografi, kalp yetmezliği, yatakbaşı ultrason, kritik hasta bakımı

Kaynakça

• Nagre AS. Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care. Ann Card Anaesth. 2019;22(3):302-308. doi:10.4103/aca.ACA_88_18.
• Pershad J, Myers S, Plouman C, et al. Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics. 2004;114(6):e667-e671. doi:10.1542/peds.2004-0881.
• Breitkreutz R, Price S, Steiger HV, et al. Focused echocardiographic evaluation in life support and peri resuscitation of emergency patients: a prospective trial. Resuscitation. 2010;81(11):1527-1533. doi:10.1016/j.resuscitation.2010.07.013.
• Perera P, Mailhot T, Riley D, Mandavia D. Rapid ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010; 28:29–56.
• Bagheri-Hariri S, Yekesadat M, Farahmand S, et al. The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department. Emerg Radiol. 2015;22(5):517-520. doi:10.1007/s10140-015-1311-z.
• Blanco P, Aguiar FM, Blaivas M. Rapid Ultrasound in Shock (RUSH) Velocity-Time Integral: A Proposal to Expand the RUSH Protocol. J Ultrasound Med. 2015;34(9):1691-1700. doi:10.7863/ultra.15.14.08059.
• David F Gaieski, MD, Mark E Mikkelsen, MD. Definition, classification, etiology, and pathophysiology of shock in adults. Polly E Parsons (sEd), Geraldine Finlay, MD (dEd). Url. https://www.uptodate.com/contents/definition-classification-etiology-and-pathophysiology-of-shock-in-adults.
• Treatment of acute decompensated heart failure: Specific therapies Author:Wilson S Colucci, MDSection Editors: Stephen S Gottlieb, MDJames Hoekstra, MDDeputy Editor:Todd F Dardas, MD, MS, last updated: Jul 21, 2020. Retrieved December, 2021 from; https://www.uptodate.com/contents/treatment-of-acute-decompensated-heart-failure-specific-therapies.
• Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355(3):251-259. doi:10.1056/NEJMoa052256.
• Janssens U, Graf J. [Shock--what are the basics?]. Der Internist. 2004 Mar;45(3):258-266. DOI: 10.1007/s00108-003-1135-x. PMID: 14997304.
• How to diagnose diastolic heart failure. European Study Group on Diastolic Heart Failure. Eur Heart J. 1998;19(7):990-1003. doi:10.1053/euhj.1998.1057
• Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J. 2009;26(2):87-91.
• Jensen MB, Sloth E, Larsen KM, Schmidt MB. Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol. 2004;21(9):700-707. doi:10.1017/s0265021504009068.
• Ferrada P, Murthi S, Anand RJ, Bochicchio GV, Scalea T. Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients. J Trauma. 2011;70(1):56-64. doi:10.1097/TA.0b013e318207e6ee.
• Liteplo A, Noble V, Atkinson P. My patient has no blood pressure: point of care ultrasound in the hypotensive patient FAST and RELIABLE. Ultrasound. 2012;20:64–68.
• Rose JS, Bair AE, Mandavia D, Kinser DJ. The UHP ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient. American Journal of Emergency Medicine. 2001;19(4):299 302.
• Standl T, Annecke T, Cascorbi I, Heller AR, Sabashnikov A, Teske W. The Nomenclature, Definition and Distinction of Types of Shock. Dtsch Arztebl Int. 2018;115(45):757-768. doi:10.3238/arztebl.2018.0757.
• Morgan JP. Abnormal intracellular modulation of calcium as a major cause of cardiac contractile dysfunction. N Engl J Med. 1991;325:625–632.
• Hasenfuss G. Alterations of calcium-regulatory proteins in heart failure. Cardiovasc Res. 1998;37:279–289.
• Hasenfuss G, Schillinger W, Lehnart SE, Preuss M, Pieske B, Maier LS, et al. Relationship between Na+-Ca2+-exchanger protein levels and diastolic function of failing human myocardium. Circulation. 1999;99:641–648.
• Mahmood SS, Wang TJ. The epidemiology of congestive heart failure: the Framingham Heart Study perspective. Glob Heart. 2013;8(1):77-82. doi:10.1016/j.gheart.2012.12.006.
• Boyd JH, Walley KR. The role of echocardiography in hemodynamic monitoring. Curr Opin Crit Care. 2009;15(3):239-243. doi:10.1097/MCC.0b013e32832b1fd0.
• Via G, Tavazzi G. Diagnosis of diastolic dysfunction in the emergency department: really at reach for minimally trained sonologists? A call for a wise approach to heart failure with preserved ejection fraction diagnosis in the ER. Crit Ultrasound J. 2018 Oct 8;10(1):26. doi: 10.1186/s13089-018-0107-2. PMID: 30294760; PMCID: PMC6174119.
• Unlüer EE, Bayata S, Postaci N, et al. Limited bedside echocardiography by emergency physicians for diagnosis of diastolic heart failure. Emerg Med J. 2012;29(4):280-283. doi:10.1136/emj.2011.111229.
• Handy JM, Soni N. Physiological effects of hyperchloraemia and acidosis. Br J Anaesth. 2008 Aug;101(2):141-50. doi: 10.1093/bja/aen148. Epub 2008 Jun 4. PMID: 18534973.