The Impact of Point-of-Care Ultrasound-Guided Resuscitation on Clinical Outcomes in Patients With Shock: A Systematic Review and Meta-Analysis.
Basmaji J, Arntfield R, Desai K, Lau VI, Lewis K, Rochwerg B, Fiorini K, Honarmand K, Slessarev M, Leligdowicz A, Park B, Prager R, Wong MYS, Jones PM, Ball IM, Orozco N, Meade M, Thabane L, Guyatt G. | Crit Care Med. 2024 Nov 1;52(11):1661-1673
DOI: https://doi.org/10.1097/ccm.0000000000006399  | Télécharger l'article au format  
Keywords: Aucun

FEATURE ARTICLE

Introduction : To determine the impact of point-of-care ultrasound (POCUS)-guided resuscitation on clinical outcomes in adult patients with shock.

Méthode : We searched MEDLINE, Embase, and unpublished sources from inception to December 2023.
Study selection: We included randomized controlled trials (RCTs) that examined the use of POCUS to guide resuscitation in patients with shock.
Data extraction: We collected data regarding study and patient characteristics, POCUS protocol, control group interventions, and outcomes

Résultats : We identified 18 eligible RCTs. POCUS slightly influences physicians' plans for IV fluid (IVF) and vasoactive medication prescription (moderate certainty), but results in little to no changes in the administration of IVF (low to high certainty) or inotropes (high certainty). POCUS may result in no change in the number of CT scans performed (low certainty) but probably reduces the number of diagnostic echocardiograms performed (moderate certainty). POCUS-guided resuscitation probably reduces 28-day mortality (relative risk [RR] 0.88; 95% CI, 0.78-0.99), the duration of vasoactive medication (mean difference -0.73 d; 95% CI, -1.16 to -0.30), and the need for renal replacement therapy (RRT) (RR 0.80; 95% CI, 0.63-1.02) (low to moderate certainty evidence), and lactate clearance (high certainty evidence). POCUS-guided resuscitation may results in little to no difference in ICU or hospital admissions, ICU and hospital length of stay, and the need for mechanical ventilation (MV) (low to moderate certainty evidence). There is an uncertain effect on the risk of acute kidney injury and the duration of MV or RRT (very low certainty evidence).

Conclusion : POCUS-guided resuscitation in shock may yield important patient and health system benefits. Due to lack of sufficient evidence, we were unable to explore how the thresholds of operator competency, frequency, and timing of POCUS scans impact patient outcomes.

Conclusion (proposition de traduction) : La réanimation échoguidée au point d'intervention en cas d'état de choc peut apporter d'importants bénéfices aux patients et au système de santé. Faute de preuves suffisantes, nous n'avons pas été en mesure d'étudier l'impact des seuils de compétence de l'opérateur, de la fréquence et du moment des échographies au point d'intervention sur le devenir des patients.

High risk and low incidence diseases: Massive hemoptysis.
Pirotte M, Pirotte A, Koyfman A, Long B. | Am J Emerg Med. 2024 Sep 10;85:179-185. Am J Emerg Med. 2024 Sep 10;85:179-185
DOI: https://doi.org/10.1016/j.ajem.2024.09.013
Keywords: Airway; Asphyxia; Bleeding; Bronchial; Hemoptysis; Hemorrhage; Massive hemoptysis; Pulmonary; Pulmonology; Respiratory; Severe hemoptysis.

Article

Introduction : Massive hemoptysis (MH) is a serious condition that carries with it a high rate of morbidity and mortality.

Méthode : This review highlights the pearls and pitfalls of massive hemoptysis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Discussion : MH is a rare but deadly condition. It is defined clinically as any bleeding from the tracheobronchial tree that compromises respiratory or circulatory function. The bronchial artery system is the primary source in the majority of cases of MH. The most common cause is tuberculosis worldwide, but bronchiectasis, bronchogenic carcinoma, and mycetoma are more common causes in the U.S. Patients with MH require rapid assessment and management, as decompensation can be rapid. Patients with altered mental status, inability to clear their sections, respiratory distress, or hemodynamic compromise require emergent airway intervention. The imaging modality of choice is computed tomography angiography with pulmonary arterial phase contrast. A reasonable order or sequence of management includes initial stabilization; assessment for the need for airway intervention; reversal of any coagulopathy; advanced imaging; and emergent consultation of pulmonary, cardiothoracic surgery, and interventional radiology. Ongoing resuscitation including blood products may be required in some patients with MH until definitive hemostasis is achieved.

Conclusion : An understanding of MH can assist emergency clinicians in diagnosing and managing this dangerous disease. Providing a prompt evaluation, obtaining intravenous access, pursuing advanced imaging, providing reversal of coagulopathy, supporting hemodynamics, and appropriate consultation are key interventions in MH.

Conclusion (proposition de traduction) : Une bonne compréhension de l'hémoptysie massive peut aider les médecins urgentistes à diagnostiquer et à prendre en charge cette maladie dangereuse. Une évaluation rapide, l'obtention d'un accès intraveineux, la réalisation d'une imagerie spécialisée, la réversion de la coagulopathie, le support de l'hémodynamique et une consultation appropriée sont des interventions clés dans l'hémoptysie massive.

Commentaire :  Algorithme hémoptysie massive