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To summarize the evidence of the hemodynamic effects and vasopressor requirements of adult cardiac surgery patients with vasoplegic shock treated with hydroxocobalamin or methylene blue. Systematic review and meta-analysis. Multi-institutional. Adult cardiac surgery patients with vasoplegic shock. Administration of hydroxocobalamin or methylene blue. A total of 263 patients in four retrospective observational studies were included in a pooled analysis. There was no significant difference in the primary outcome, vasopressor requirement at 1 hour (mean difference [MD]: 0.00 mcg/kg/min norepinephrine equivalent [NEE], 95% confidence interval [CI]: –0.09 to 0.08). Hydroxocobalamin was associated with a significant improvement in mean arterial pressure at 1 hour (MD: 5.30 mmHg, 95% CI: 2.98 to 7.62), total vasopressor dose at 1 hour (MD: –0.13 mcg/kg/min NEE, 95% CI: –0.25 to –0.01), total vasopressor at 6 hours (MD: –0.15 mcg/kg/min NEE, 95% CI: –0.21 to –0.08). No differences were observed in systemic vascular resistance or mortality between groups. Three studies were deemed at moderate risk of bias and one at serious risk. Hydroxocobalamin has been shown to have a beneficial effect on hemodynamics and vasopressor requirements in vasoplegic cardiac surgery patients compared with methylene blue, although evidence is limited, and further well-powered randomized controlled trials are required. [ABSTRACT FROM AUTHOR]

Thiamine is an essential micronutrient for energy metabolism. Thiamine deficiency is frequently observed in critically ill patients. However, the effect of thiamine administration is unclear in critically ill patients. We conducted a systematic review and meta-analysis. To identify randomized controlled trials on the effect of thiamine administration in critically ill patients, a literature search was conducted in MEDLINE, CENTRAL, and ICHUSHI databases from inception to April 2023. Pooled effect estimates were calculated about mortality as the primary outcome and shock duration, lactate level, Sequential Organ Failure Assessment (SOFA) score, delirium, length of mechanical ventilation, length of intensive care unit (ICU) stay, infection rate, all adverse events, and Short-Form Health Survey (SF-36) as the secondary outcomes. The certainty of evidence (CoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. Overall, 35 studies (3494 patients) were included. Evidence suggested that thiamine administration resulted in little to no difference in mortality (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.75 to 1.06; Low CoE); however, thiamine administration may reduce shock duration (mean difference [MD], −11.43 h; 95% CI, −20.16 to −2.69 h; Low CoE), lactate level (MD, −0.34 mmol/L; 95% CI, −0.63 to −0.05 mmol/L; Low CoE), and SOFA score (MD, −1.29; 95% CI, −1.91 to −0.66; Low CoE). Conversely, thiamine administration resulted in a slight increase in the length of ICU stay (MD, 0.40 days; 95% CI, 0.01–0.79 days; High CoE). Although thiamine administration may reduce shock state, it may not reduce mortality, and slightly increases the length of ICU stay. [ABSTRACT FROM AUTHOR]

Shock is a life-threatening clinical condition that arises when there is inadequate oxygen metabolism at a cellular level. It can occur in a wide range of clinical conditions and without prompt identification and management it has a high morbidity and mortality. Treatment focuses on both correcting the cause and managing the abnormal physiology associated with shock. Clinicians use a number of tools including clinical examination, biochemical markers and haemodynamic monitoring to both identify and treat shock. In this article we will review the normal physiology of oxygen delivery, the aetiology and pathophysiology of shock and how haemodynamic monitoring is used to manage patients presenting with shock. [ABSTRACT FROM AUTHOR]

• In those with cardiac amyloidosis and heart failure-related cardiogenic shock, there was significant augmentation of cardiac index after intra-aortic balloon pump (IABP) and significant decreases in left ventricular and right ventricular filling pressures. • Predictors of lack of response to IABP by cardiac index were a smaller baseline left ventricular end-diastolic diameter size per centimeter and higher pre-IABP systemic vascular resistance. • Most patients with Society for Cardiovascular Angiography and Interventions stage C heart failure-related cardiogenic shock were stabilized successfully and bridged to advanced therapies with IABP alone. In those with heart failure-related cardiogenic shock (HF-CS), an intra-aortic balloon pump (IABP) may improve hemodynamics and be useful as a bridge to advanced therapies. We explore whether those with cardiac amyloidosis and HF-CS might experience hemodynamic improvement and describe the hemodynamic response after IABP. We retrospectively identified consecutive patients with a diagnosis of cardiac amyloid, either light chain or transthyretin, who were admitted to our intensive care unit with HF-CS. Patients were excluded if an IABP was placed during heart transplant or for shock related to acute myocardial infarction. Invasive hemodynamics before and after IABP placement were assessed. We identified 23 patients with cardiac amyloid who had an IABP placed for HF-CS. The 1-year survival rate was 74% and most (65%) were bridged to heart transplant, although 1 patient was bridged to destination left ventricular assist device. After IABP, the mean arterial pressure, cardiac index, and cardiac power index were significantly increased, whereas mean right atrial pressure, mean pulmonary artery pressure, and pulmonary capillary wedge pressure were all significantly decreased. A smaller left ventricular end-diastolic diameter (per cm) was associated with a higher likelihood of a cardiac index of <2.2 L/min/m2 after IABP (odds ratio 0.16, 95% confidence interval 0.01–0.93, P =.04). IABP significantly improved cardiac index while decreasing right atrial pressure, mean pulmonary artery pressure, and pulmonary capillary wedge pressure in cardiac amyloidosis patients with HF-CS. [Display omitted] [ABSTRACT FROM AUTHOR]

The list of standard abbreviations for JDS is available at adsa.org/jds-abbreviations-24. Nonstandard abbreviations are available in the Notes. Virtual fencing technology provides an opportunity to rethink the management of intensive grazing systems in general, yet most studies have used products developed and applied to more extensive livestock systems. This research aimed to assess the application of a virtual fencing technology developed for the intensive pastoral dairy industry. The Halter system uses 2 primary cues (sound and vibration) and one aversive secondary cue (a low-energy electrical pulse) to confine cows to a pasture allocation and remotely herd cows. We studied 2 groups of 40 mid-lactation multiparous dairy cows (Bos taurus , predominantly Friesian and Friesian × Jersey, parity 1–8). Cows were milked twice per day and provided 9 kg of pasture DM/d in a 24-h allocation, supplemented with 7 kg of silage and 6 kg of grain DM/d. Training to the Halter system occurred over 10 d, after which cows were managed with the technology for a further 28 d. The type and time of cues delivered were recorded by each collar and communicated via a base station to cloud data storage. Cows took less than a day to start responding to the sound cues delivered while held on a pasture allocation and were moving to the milking parlor without human intervention by d 4 of training. On training d 1, at least 60% of sound cues resulted in an electrical pulse. Across training d 2 to 10, 6.4% of sound cues resulted in a pulse. After the 10-d training period, 2.6% of sound cues resulted in a pulse. During the management period, 90% of cows spent ≤1.7 min/d beyond the virtual fence, received ≤0.71 pulses/d in the paddock and received ≤1 pulse/d during virtual herding to the parlor. By the final week of the management period, 50% of cows received 0 pulses/week in the paddock and 35% received 0 pulses/week during virtual herding. The number of pulses delivered per day and the pulse/sound cue ratio was lower in this study than that previously reported using other virtual fencing technologies. We conclude that the Halter technology is successful at containing lactating dairy cows in an intensive grazing system as well as at remotely herding animals to the milking parlor. [ABSTRACT FROM AUTHOR]

Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states. [ABSTRACT FROM AUTHOR]

Abdominal compartment syndrome (ACS) is typically attributed to critically unwell patients with trauma, burns, post surgery, and massive ascites. A rare but fatal cause of ACS is bulimia nervosa (BN), which is an eating disorder characterized by bingeing, followed by methods to avoid weight gain, including purging. We present a case of a 20-year-old woman who presented with abdominal pain and distension after consuming a large quantity of food the previous night and was unable to purge. She was initially managed conservatively and discharged home, but returned subsequently on the same day with clinical features of ACS secondary to acute gastric distension. Decompression resulted in life-threatening reperfusion injury with critical electrolyte abnormalities and fatal cardiac arrest in the operating theatre. A systematic review of the literature found only 11 case reports of ACS secondary to BN, of which only 6 patients survived due to early diagnosis and decompression. Inability to purge and lower limb ischemia appeared to be associated with increased mortality. As BN is a common emergency presentation, the case and systematic review highlights the need to consider ACS as a potentially life-threatening complication of binge eating, particularly when there is unsuccessful purging. [ABSTRACT FROM AUTHOR]

Adrenal insufficiency (AI) is one of the most life-threatening disorders resulting from adrenal cortex dysfunction. Symptoms and signs of AI are often nonspecific, and the diagnosis can be missed and lead to the development of AI with severe hypotension and hypovolemic shock. We report the case of a 13-year-old child admitted for cardiac arrest following severe hypovolemic shock. The patient initially presented with isolated mild abdominal pain and vomiting together with unexplained hyponatremia. He was discharged after an initial short hospitalization with rehydration but with persistent hyponatremia. After discharge, he had persistent refractory vomiting, finally leading to severe dehydration and extreme asthenia. He was admitted to pediatric intensive care after prolonged hypovolemic cardiac arrest with severe anoxic encephalopathy leading to brain death. After re-interviewing, the child's parents reported that he had experienced polydipsia, a pronounced taste for salt with excessive consumption of pickles lasting for months, and a darkened skin since their last vacation 6 months earlier. A diagnosis of autoimmune Addison's disease was made. Primary AI is a rare life-threatening disease that can lead to hypovolemic shock. The clinical symptoms and laboratory findings are nonspecific, and the diagnosis should be suspected in the presence of unexplained collapse, hypotension, vomiting, or diarrhea, especially in the case of hyponatremia. [ABSTRACT FROM AUTHOR]

Septic shock is the progression of sepsis, defined as cardiovascular dysfunction during systemic infection, and it has a mortality rate of 40 %–80 %. Loss of vascular tone is an important pathophysiological feature of septic shock. Diastolic blood pressure (DBP) was reported to be associated with vascular tone. This study aimed to identify the associations of several hemodynamic indices, especially DBP, with outcome in pediatric septic shock to allow for timely interventions. Children with persistent catecholamine-resistant shock had a pulse index continuous cardiac output (PiCCO®) system implanted for invasive hemodynamic monitoring and were enrolled in the current study. Serial cardiac index, systemic vascular resistance index (SVRI), systolic blood pressure (SBP), mean arterial pressure (MAP), and DBP were recorded during the first 24 h following PiCCO® initiation. All hemodynamic parameters associated with 28-day mortality were further analyzed using receiver operating characteristic curve analysis. Thirty-three children with persistent catecholamine-resistant shock were enrolled. The median age was 12 years and the youngest children were 5 years old. Univariate analysis noted that SVRI, SBP, MAP, and DBP were significantly higher, and shock index was significant lower, in survivors compared with non-survivors (p < 0.05). In the multivariate analysis, only SVRI and DBP remained independent predictors of 28-day mortality. DBP had the best correlation with SVRI (r = 0.718, n = 219, p < 0.001). The area under the receiver operating characteristic curves of SVRI and DBP for predicting 28-day mortality during the first 24 h of persistent catecholamine-resistant shock were >0.75, indicating a good prediction for mortality. DBP correlated well with SVRI and it can serve as a predictor for mortality in pediatric septic shock. Furthermore, DBP was a superior discriminator of mortality when compared with SBP and MAP. A lower DBP was an independent hemodynamic factor associated with 28-day mortality. [ABSTRACT FROM AUTHOR]

Modern resin hemoadsorption/hemoperfusion for calcium channel blocker overdose is yet to be reported. The characteristics of calcium channel blockers make them unamenable to removal by hemodiafiltration or charcoal hemoperfusion; however, elimination, using styrene bead adsorption in an ex vivo model, has been demonstrated. Its clinical use is described. A man in his 20s was admitted with shock into the Intensive Care Unit (ICU) after an overdose of amlodipine and risperidone. Resuscitation and supportive care were administered, but hypotension did not resolve despite the administration of intravenous fluids, infusions of calcium, adrenaline, and hyperinsulinemic-euglycemic therapy. Methylene blue was then administered to maintain the mean arterial pressures. However, the hemodynamic effect did not allow the weaning of the adrenaline. Drug clearance using hemoadsorption/hemoperfusion was attempted using a styrene resin filter (Jafron HA230; Jafron Biomedical Co., Ltd., Guangdong, China). During the two hemoperfusion sessions (6 h duration each, and 18 h apart) the patient had successfully weaned off all supportive measures, with lactate levels returning to normal and was later discharged home. At the end of each session, significant amlodipine concentrations were detected in blood aspirated from both filters, suggesting enhanced clearance. Our case illustrates a temporal relationship between resin hemoperfusion therapy, resolution of hemodynamic instability, and shock without proving causation. Significant amlodipine elimination was suggested by high concentrations found in blood from the filter. At the same time, shock resolution after initiation of hemoperfusion occurred in less than one elimination half-life of amlodipine. [ABSTRACT FROM AUTHOR]

Multisystem inflammatory syndrome in children (MIS-C) is a novel disease associated with COVID-19. The COVID-19 epidemic peaked in May 2022 in Taiwan, and we encountered our first case of MIS-C in late May 2022. We aimed to present patients' clinical manifestations and identify risk factors for shock. We included patients diagnosed with MIS-C at two medical centers from May 2022 to August 2022. We separated those patients into two groups according to whether they experienced shock. We collected demographic, clinical manifestation, and laboratory data of the patients and performed statistical analysis between the two groups. We enrolled 28 patients, including 13 (46 %) with shock and 15 (54 %) without shock. The median age was 6.4 years (IQR: 1.9–7.5). In single variable analysis, patients with shock tended to be older, had more neurological symptoms, more conjunctivitis and strawberry tongue, lower lymphocyte count, lower platelet counts, and higher C-reactive protein, higher procalcitonin, higher ferritin, and higher D-dimer levels than those without shock. The area under the ROC curve that used procalcitonin to be the risk factor of shock with MIS-C was 0.815 (95 % CI 0.644 to 0.987). The cutoff value obtained by ROC analysis of procalcitonin was 1.68 ng/mL. With this cutoff, the test characteristics of procalcitonin were as follows: sensitivity 77 %, specificity 93 %, positive predictive value 91 %, negative predictive value 82 %. Multivariable analysis revealed that procalcitonin was the only independent risk factor of shock with MIS-C on admission (OR, 26.00, 95 % CI, 1.01–668.89). MIS-C patients with high initial procalcitonin levels have higher risks of experiencing shock and may need ICU admission. [ABSTRACT FROM AUTHOR]

Inotropes are a group of drugs that alter myocardial contractility by increasing intracellular calcium or enhancing sensitivity to it. However, they may result in suboptimal myocardial oxygen supply demand ratios with impaired diastolic filling and greater arrhythmia risk. As shock is frequently encountered perioperatively and in the intensive care unit (ICU), an understanding of its pathophysiology and the pharmacology of inotropes and vasopressors is essential for their rational use. Until resolution of the primary issue, this heterogeneous group of drugs may be used in combination. However, knowing their mechanisms of action is necessary to minimize complications. With advances in our understanding of heart failure pathophysiology novel agents aim to enhance benefit with minimal harm. However, to date, none is in widespread use. Measurement of cardiac output is recommended to guide inotrope administration. This is frequently achieved with devices using pulse contour analysis or ultrasound. As mechanical support devices are more widely available current trends favour their earlier use. [ABSTRACT FROM AUTHOR]

The choice of fluid resuscitation in Traumatic Hemorrhagic shock (THS) remains a critical aspect of patient management. Bicarbonated Ringers solution (BRS) has shown promise due to its composition resembling human Extracellular Fluid and its potential benefits on hemodynamics. To evaluate the efficacy, mortality rates, hemodynamic effects, and adverse outcomes of Sodium Bicarbonate Ringer's Solution in the treatment of hemorrhagic shock, as compared to other relevant interventions. A comprehensive examination of the available literature was performed by conducting systematic searches in prominent databases such as Cochrane, EMBASE, MEDLINE, and PubMed. The process employed predefined criteria to extract relevant data and evaluate the quality of the studies. The outcome measures considered encompassed survival rates, mortality, mean arterial pressure (MAP), heart rate (HR), and adverse events. The meta-analysis of three studies showed that compared to the other crystalloids, the use of BRS had an odds ratio for survival of 1.86 (95% CI: 0.94, 3.71; p = 0.08; I2 = 0%), an odds ratio for total adverse events of 0.14 (95% CI: 0.06, 0.35; p < 0.0001; I2 = 22%), a mean difference in heart rate of −4.49 (95% CI: −7.55, −1.44; p = 0.004; I2 = 13%), and a mean difference in mean arterial pressure of 2.31 (95% CI: −0.85, 5.47; p = 0.15; I2 = 66%). BRS demonstrated a significant reduction in complications, including adult respiratory distress syndrome (ARDS), Multiple Organ Dysfunction (MODS), and Total Adverse Effects, when compared to other solutions in the treatment of THS. Additionally, THS patients resuscitated with BRS experienced a notable decrease in heart rate. The findings suggest BRS may contribute to organ stability and potential survival improvement due to its similarity to human Extracellular Fluid and minimal impact on the liver. [ABSTRACT FROM AUTHOR]

The Composite Pulmonary Embolism Shock (CPES) score has been developed to identify normotensive patients with acute pulmonary embolism (PE) and a low cardiac index (referred to as normotensive shock). We aimed to externally assess the validity of this model for predicting a complicated course among hemodynamically stable patients with acute PE. Using prospectively collected data from the PROgnosTic valuE of Computed Tomography scan (PROTECT) study, we calculated the CPES score for each patient and the proportion of patients with a score > 3. We calculated the test performance characteristics to predict a complicated course (i.e., death from any cause, hemodynamic collapse, or recurrent PE) and the discriminatory power using the area under the receiver operating characteristic curve. Sixty-three of the 848 (7.4 %) patients had a complicated course during the 30-day follow-up period. Of the 848 enrolled patients, the CPES score was positive (i.e., score > 3) in 78 (9.2 %). The specificity was 92.1 % (723/785), the positive predictive value was 20.5 % (16/78), and the positive likelihood ratio was 3.22 for a complicated course. The areas under the receiver operating characteristic curve for a complicated course were 0.71 (95 % confidence interval [CI], 0.65–0.78). With the higher score risk classification threshold (cutoff score > 4), the proportion of patients designated as positive was 2.1 %, and the specificity was 98.1 %. When echocardiographic right ventricle (RV) dysfunction was replaced by computed tomographic RV enlargement, the specificity was 85.4 %, the positive predictive value was 14.2 %, and the positive likelihood ratio was 2.06 for a complicated course. When analyses were restricted to the subgroup of patients with intermediate-risk PE, the specificity and the positive predictive value for a complicated course were identical to the overall cohort. The CPES score has acceptable C-statistic, excellent specificity, and low positive predictive value for identification of hemodynamic deterioration in normotensive patients with PE. ClinicalTrials.gov number: NCT02238639. • Adequate risk stratification of PE may influence decisions for more intensive vigilance and escalation of treatment. • The CPES score has been developed to identify normotensive patients with acute PE and a low cardiac index. • The CPES score reliably identifies stable patients with PE who might be at risk for hemodynamic deterioration or death. [ABSTRACT FROM AUTHOR]

Vasodilatory hypotension is common in critically ill and perioperative patients, and is associated with adverse outcomes. As a nitric oxide production inhibitor, methylene blue (MB) exerts its vasoconstrictor property and is an adjuvant for catecholamine-refractory vasodilatory shock. However, the effects of MB on clinically relevant outcomes remain unclear. Therefore, the authors performed a meta-analysis of randomized trials on MB in critically ill and perioperative patients. The authors searched through databases for randomized trials on MB in critically ill and perioperative patients, which yielded 11 studies consisting of 556 patients. The primary outcome was mortality at the longest follow-up. Secondary outcomes included hemodynamic parameters and organ dysfunction (PROSPERO: CRD42023409243). Nine out of the 11 included randomized trials reported mortality, which was significantly lower in the MB group (risk ratio, 0.60 [95% CI 0.43-0.84] p = 0.003), with findings confirmed in septic shock and cardiac surgery subgroups. The authors found reduced lengths of stay in the intensive care unit (mean difference [MD], −0.9 days [95% CI −1.06 to −0.77] p < 0.001) and in the hospital (MD, −2.2 days [95% CI, −2.68 to −1.70] p < 0.001) in the MB group. MB was associated with increased mean arterial pressure (MD, 8.4 mmHg [95% CI 5.01-11.75] p < 0.001) and systemic vascular resistance (MD, 94.5 dyn/s/cm5 [95% CI 17.73-171.15] p = 0.02), with no difference in cardiac output (standardized MD, 0.16 [95% CI, -0.25 to 0.57] p = 0.45). This meta-analysis showed that MB reverses vasodilation in critically ill and perioperative patients and might improve survival. Further adequately powered randomized trials are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase. We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg−1.min−1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly. The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was −0.47 (CI 95%, [−0.55; −0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were − 0.45 (CI 95%, [−0.53; −0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively. In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong. [ABSTRACT FROM AUTHOR]

Over the last several decades, the cardiac intensive care unit (CICU) has seen a substantial evolution in the patient population, comorbidities, and diagnoses. However, the generation of high-quality evidence to manage these complex and critically ill patients has been slow. Given the scarcity of clinical trials focused on critical care cardiology (CCC), CICU clinicians are often left to extrapolate from studies that either exclude or poorly represent the patient population admitted to CICUs. The lack of high-quality evidence and limited guidance from society guidelines has led to significant variation in practice patterns for many of the most common CICU diagnoses. Several barriers, both common to critical care research and unique to CCC, have impeded progress. In this multinational perspective, we describe key areas of priority for CCC research, current challenges for investigation in the CICU, and essential elements of a path forward for the field. [Display omitted] • Evidence generation in the modern CICU has not matched the evolution of the patient population. • Beyond difficulties of studying critically ill patients, there are unique barriers to research in CCC. • Overcoming these barriers will require novel research designs and collaboration among multiple stakeholders. [ABSTRACT FROM AUTHOR]

Hydroxocobalamin inhibits nitric oxide pathways contributing to vasoplegic shock in patients undergoing cardiopulmonary bypass (CPB). The objective of this study was to evaluate the effect of intraoperative versus postoperative application of hydroxocobalamin for vasoplegic shock in patients undergoing CPB. This was a historic cohort study. The study was conducted at a quaternary academic cardiovascular surgery program. Adults undergoing cardiac surgery using CPB were participants in the study. Hydroxocobalamin (5 g) intravenously over 15 minutes. The treatment groups were assigned based on the receipt location of hydroxocobalamin (ie, intensive care unit [ICU] versus operating room [OR]). The primary outcome was vasopressor-free days in the first 14 days after CPB. Of the 112 patients included, 37 patients received hydroxocobalamin in the OR and 75 in the ICU. Patients in the OR group were younger than those in the ICU group (57.5 v 63.9 years, p = 0.007), with statistically similar American Society of Anesthesiologists scores. The mean CPB duration was 3.4 hours in the OR group and 2.9 hours in the ICU group (p = 0.09). In both groups, the norepinephrine-equivalent dose of vasopressors at hydroxocobalamin was 0.27 µg/kg/min. Days alive and free of vasopressors were not different between the OR and ICU groups (estimated difference 0.48 [95% CI -1.76-2.72], p = 0.67). The odds of postoperative renal failure, mesenteric ischemia, ICU, hospital length of stay, and in-hospital mortality were also similar between groups. A difference in vasopressor-free days after CPB was not found between patients who received hydroxocobalamin intraoperatively versus postoperatively for vasoplegic shock. [ABSTRACT FROM AUTHOR]

Postoperative hypotension is common after major surgery and is associated with patient harm. Vasopressors are commonly used to treat hypotension without clear evidence of benefit. We conducted a systematic review to better understand the use, impact, and rationale for vasopressor administration after noncardiac, non-obstetric surgery in adults. We conducted a prospectively registered systematic review. Cochrane CENTRAL, EMBASE, MEDBASE, and MEDLINE were searched for RCTs and cohort studies of adult patients receiving vasopressors after noncardiac, non-obstetric surgery. Study quality was critically appraised by two investigators. Findings from the review were synthesised, but formal meta-analysis was not performed because of significant variability in study populations and outcomes. A total of 3201 articles were screened, of which seven RCTs, two prospective cohort studies, and 15 retrospective cohort studies were included in the analysis (24 in total). One study was graded as high quality, two as moderate quality, and the remaining 21 as low quality. Sixteen studies relied on clinical assessment alone to decide on therapeutic interventions. Vasodilation was the most common suggested physiological disturbance. The median proportion of patients receiving vasopressors was 42% (interquartile range: 11.5–74.7%). Norepinephrine was the most common vasopressor used. The evidence supporting the use of vasopressors to treat postoperative hypotension is limited. Future research should focus on whether vasodilatation or other physiological disturbance is driving postoperative hypotension to allow rational decision-making. [ABSTRACT FROM AUTHOR]

[Display omitted] [ABSTRACT FROM AUTHOR]

Despite advances in therapy, the incidence of cardiogenic shock continues to increase, with significant mortality that has improved minimally over time. Treatment options for cardiogenic shock are complex and time-, resource-, and case volume–dependent, and involve multiple medical specialties. To provide early, more equitable, and standardised access to cardiogenic shock expertise with advanced therapies, cardiogenic shock teams with a protocolised treatment approach have been proposed. These processes have been applied across hospitals into integrated cardiogenic shock networks. This narrative review evaluates the role of cardiogenic shock teams, protocolised and regionalised shock networks, and the main individual components of protocolised shock management approaches. [ABSTRACT FROM AUTHOR]

Severe Aortic stenosis (AS) complicated by cardiogenic shock (CS) represents a grave clinical condition with limited treatment options. Evidence from small observation studies favors that Transcatheter Aortic Valve Replacement (TAVR) might be a feasible option in these patients in contrast to emergent Balloon Aortic Valvuloplasty (BAV) which is associated with very high short and long-term mortality. 11,405 hospitalizations with severe AS complicated by CS between 2016 and 2020 were identified using the National Inpatient Sample (NIS) Database, and patients were then stratified according to whether they received TAVR or BAV. Propensity-score matching was used to account for differences in the baseline characteristics. Primary and secondary outcomes were then compared between 3485 hospitalizations in direct TAVR group and with 3485 matched hospitalizations in the BAV group. The primary outcome was a composite of all-cause in-hospital death, acute cerebrovascular accident (CVA), and myocardial infarction (MI). Secondary outcomes and safety outcomes were also compared between the two groups. TAVR was associated with fewer primary outcomes events as compared to BAV {36.8 % vs 56.8 %, aOR (95%CI) = 0.38(0.30–0.47)}, due to fewer all-cause in-hospital deaths {17.8 % vs 38.9 %, aOR (95%CI) =0.34 (0.26–0.43)} and MI {12.3 % vs 32.4 %, aOR (95%CI) = 0.29 (0.22–0.39)}. TAVR was associated with higher rates of acute CVA {6.17 % vs 3.44 %, aOR (95%CI) = 1.84 (1.08–3.21)} and pacemaker implantation post procedure {11.9 % vs 6.03 %, aOR (95%CI) = 2.10 (1.41–3.18)}. Direct TAVR in shock and severe Aortic stenosis is a better strategy than rescue Balloon aortic valvotomy. • Severe Aortic stenosis (AS) with cardiogenic shock (CS) is a critical condition with few treatment options. • Medical treatment alone is an unreliable option, and surgery is often deemed prohibitive. • It is unclear whether direct TAVR or BAV followed by elective TAVR after medical stabilization should be performed. • 11, 405 patients were identified who were hospitalized for shock and had TAVR or BAV using the NIS database. • Primary efficacy outcome was a composite of All-cause In-hospital death, Acute CVA, and MI. • TAVR group had fewer primary outcomes events compared to BAV (36.8% vs 56.8% aOR 0.38 95 CI 0.30-0.47, p -value <0.01). [ABSTRACT FROM AUTHOR]

Hydroxocobalamin inhibits nitric oxide-mediated vasodilation, and has been used in settings of refractory shock. However, its effectiveness and role in treating hypotension remain unclear. The authors systematically searched Ovid Medline, Embase, EBM Reviews, Scopus, and Web of Science Core Collection for clinical studies reporting on adult persons who received hydroxocobalamin for vasodilatory shock. A meta-analysis was performed with random-effects models comparing the hemodynamic effects of hydroxocobalamin to methylene blue. The Risk of Bias in Nonrandomized Studies of Interventions tool was used to assess the risk of bias. A total of 24 studies were identified and comprised mainly of case reports (n = 12), case series (n = 9), and 3 cohort studies. Hydroxocobalamin was applied mainly for cardiac surgery vasoplegia, but also was reported in the settings of liver transplantation, septic shock, drug-induced hypotension, and noncardiac postoperative vasoplegia. In the pooled analysis, hydroxocobalamin was associated with a higher mean arterial pressure (MAP) at 1 hour than methylene blue (mean difference 7.80, 95% CI 2.63-12.98). There were no significant differences in change in MAP (mean difference −4.57, 95% CI −16.05 to 6.91) or vasopressor dosage (mean difference −0.03, 95% CI −0.12 to 0.06) at 1 hour compared to baseline between hydroxocobalamin and methylene blue. Mortality was also similar (odds ratio 0.92, 95% CI 0.42-2.03). The evidence supporting the use of hydroxocobalamin for shock is limited to anecdotal reports and a few cohort studies. Hydroxocobalamin appears to positively affect hemodynamics in shock, albeit similar to methylene blue. [ABSTRACT FROM AUTHOR]

Percutaneous cannulation improved femoro-femoral veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) results, reducing infectious complications, but remains limited by vascular complications related to the arterial decannulation. Several techniques were described to perform a percutaneous decannulation but were limited by poor results or lacking reproducibility and fit to the VA-ECMO in cardiogenic shock. We report herein a novel simplified technic for femoro-femoral VA-ECMO decannulation: the combined use of Manta and FemoSeal for percutaneous VA-ECMO decannulation is an easy to learn, reproducible and effective technique, and appears to improve the outcomes of VA-ECMO. [ABSTRACT FROM AUTHOR]

Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress. To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18–50 years; 50–80 years; > 80 years). A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI]). A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18–50 years: −0.03 beats/min/10 mm Hg, 95% CI −0.13–0.07, 51–80 years: −0.43 beats/min/10 mm Hg, 95% CI −0.38 to −0.50, > 80 years: −0.61 beats/min/10 mm Hg, 95% CI −0.53 to −0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection. No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension. [ABSTRACT FROM AUTHOR]

Fluid resuscitation is typically needed in patients with cirrhosis, sepsis and hypotension. However, the complex circulatory changes associated with cirrhosis and the hyperdynamic state, characterised by increased splanchnic blood volume and relative central hypovolemia, complicate fluid administration and monitoring of fluid status. Patients with advanced cirrhosis require larger volumes of fluids to expand central blood volume and improve sepsis-induced organ hypoperfusion than patients without cirrhosis, which comes at the cost of a further increase in non-central blood volume. Monitoring tools and volume targets still need to be defined but echocardiography is promising for bedside assessment of fluid status and responsiveness. Large volumes of saline should be avoided in patients with cirrhosis. Experimental data suggest that independent of volume expansion, albumin is superior to crystalloids at controlling systemic inflammation and preventing acute kidney injury. However, while it is generally accepted that albumin plus antibiotics is superior to antibiotics alone in spontaneous bacterial peritonitis, evidence is lacking in patients with infections other than spontaneous bacterial peritonitis. Patients with advanced cirrhosis, sepsis and hypotension are less likely to be fluid responsive than those without cirrhosis and early initiation of vasopressors is recommended. While norepinephrine is the first-line option, the role of terlipressin needs to be clarified in this context. [ABSTRACT FROM AUTHOR]

Shock is defined as failure of the circulatory system resulting in a level of perfusion to tissues, which is inadequate to meet the oxygen demands of cellular metabolism. Haemorrhagic shock is most commonly associated with trauma. Haemorrhage is a leading cause of preventable death in trauma and over the past two decades there has been an increasing understanding of the pathophysiological processes that occur in major haemorrhage associated with trauma. This has been fundamental to the development of the current approach to management of traumatic shock, known as damage control resuscitation (DCR). DCR encompasses three key resuscitative strategies: permissive hypotension, haemostatic resuscitation (the use of blood products as primary resuscitative fluids) and damage control surgery. The implementation of DCR alongside the creation of trauma networks has been revolutionary in the management of the shocked trauma patient. [ABSTRACT FROM AUTHOR]

Electrical storm (ES) reflects life-threatening cardiac electrical instability with 3 or more ventricular arrhythmia episodes within 24 hours. Identification of underlying arrhythmogenic cardiac substrate and reversible triggers is essential, as is interrogation and programming of an implantable cardioverter-defibrillator, if present. Medical management includes antiarrhythmic drugs, beta-adrenergic blockade, sedation, and hemodynamic support. The initial intensity of these interventions should be matched to the severity of ES using a stepped-care algorithm involving escalating treatments for higher-risk presentations or recurrent ventricular arrhythmias. Many patients with ES are considered for catheter ablation, which may require the use of temporary mechanical circulatory support. Outcomes after ES are poor, including frequent ES recurrences and deaths caused by progressive heart failure and other cardiac causes. A multidisciplinary collaborative approach to the management of ES is crucial, and evaluation for heart transplantation or palliative care is often appropriate, even for patients who survive the initial episode. [Display omitted] • ES is a life-threatening condition characterized by recurrent VAs. • Management of patients with ES integrates antiarrhythmic drugs, beta-blockade, sedation, and catheter ablation. • Comprehensive evidence-based treatment algorithms are needed to define best practices for managing patients with ES. [ABSTRACT FROM AUTHOR]

Resuscitative endovascular balloon occlusion of the aorta has been used by trauma surgeons at the bedside for more than a decade in civilian and military settings. Translational and clinical research suggests it is superior to resuscitative thoracotomy for select patients. Clinical research suggests outcomes are superior in patients who received resuscitative balloon occlusion of the aorta compared with those who did not. Technology has advanced considerably in the past several years, leading to the improved safety profile and wider adoption of resuscitative balloon occlusion of the aorta. In addition to trauma patients, resuscitative balloon occlusion of the aorta has been rapidly implemented for patient with nontraumatic hemorrhage. [ABSTRACT FROM AUTHOR]

The article focuses on the management of cardiogenic shock after acute coronary syndromes. Topics include the definition and pathophysiology of cardiogenic shock, the role of early mechanical circulatory support, and the importance of a multidisciplinary approach in managing the condition. The article also explores the challenges and controversies surrounding the use of mechanical circulatory support in this patient population.

An adaptive even order weighted essentially non-oscillatory polynomial reconstruction procedure (WPR) with Z-type weights (WENO-Za) is proposed to reduce the numerical dissipation and improve the resolution of the fine-scale structures in a long-time simulation of the hyperbolic conservation laws. The new spatial solver combines the even and odd order (even order plus one) WENO finite difference schemes together. The novel WENO-Za scheme adapts the ideal weights, instead of the nonlinear weights, between the even and odd order based on a nonlinear transition function, which is a function of the odd order global smoothness indicator and a user-adjustable parameter. The dissipation and dispersion behaviors of the WENO-Za scheme is illustrated by the approximate dispersion relation technique. For the Euler equations, the WPR procedure is performed on each positive and negative split flux variable in the characteristic space. The performance of the WENO-Za scheme, in terms of resolution, essentially non-oscillatory shock-capturing, and efficiency, are evaluated by solving several benchmark shock-tube problems, such as the extended shock-entropy interaction problem, the extended shock-density interaction problem, the two blast-waves interaction problem, the Riemann problem, and the forward-facing step problem. The results show that the WENO-Za scheme can 1) retain the fine-scale structures in the smooth regions better due to the reduction of numerical dissipation of the even order scheme in exchange for a slightly larger dispersive error in a long-time simulation and 2) capture localized strong gradients and shocks in an essentially non-oscillatory manner due to the strong sub-stencil biasing in the odd order scheme. The space-time evolutions of the transition functions demonstrate the robust adaptive nature of the WENO-Z4a5 scheme in the regions of shock, contact discontinuity, and rarefaction waves. • The new spatial solver combines the even- and odd- orders WENO schemes together (WENO-Za) with the adaptive ideal weights. • The adaptivity is based on a transition function of the odd-order global smoothness indicator. • The WENO-Za scheme's substantial reduction of numerical dissipation is verified by the ADR analysis. • It maintains the fine-scale structures in long time simulation and captures strong shocks in an ENO manner. [ABSTRACT FROM AUTHOR]

That the bladder can be compressed by extraperitoneal hematoma induced by obstetrics and gynecologic diseases, is well known. However, there have been no reports on the clinical significance of compressed bladder induced by pelvic fracture (PF). We therefore retrospectively investigated the clinical features of compressed bladder induced by the PF. From January 2018 to December 2021, we performed a retrospective review of the hospital medical charts of all emergency outpatients who were treated by emergency physicians at the department of acute critical care medicine in our hospital, and who were diagnosed with PF based on computed tomography (CT) on arrival. The subjects were divided into two groups: the Deformity group, in which the bladder was compressed by extraperitoneal hematoma, and the Normal group. Variables were compared between the two groups. During the investigation period, 147 patients with PF were enrolled as subjects. There were 44 patients in the Deformity group and 103 in the Normal group. There were no significant differences between the two groups with regard to sex, age, GCS, heart rate or final outcome. However, the average systolic blood pressure in the Deformity group was significantly lower, and the average respiratory rate, injury severity score, rate of unstable circulation, rate of transfusion and duration of hospitalization in the Deformity group were significantly greater in comparison to the Normal group. The present study showed that bladder deformity induced by PF tended to be a poor physiological sign that was associated with severe anatomical abnormality, unstable circulation requiring transfusion, and long hospitalization. Accordingly, physicians should evaluate shape of bladder when treating PF. [ABSTRACT FROM AUTHOR]

Patients with acute pulmonary embolism (PE) and hypotension (high-risk PE) have high mortality. Cardiogenic shock can also occur in nonhypotensive or normotensive patients (intermediate-risk PE) but is less well characterized. The authors sought to evaluate the prevalence and predictors of normotensive shock in intermediate-risk PE. Intermediate-risk PE patients in the FLASH (FlowTriever All-Comer Registry for Patient Safety and Hemodynamics) registry undergoing mechanical thrombectomy with the FlowTriever System (Inari Medical) were included. The prevalence of normotensive shock (systolic blood pressure ≥90 mm Hg but cardiac index ≤2.2 L/min/m2) was assessed. A composite shock score consisting of markers of right ventricular function and ischemia (elevated troponin, elevated B-type natriuretic peptide, moderately/severely reduced right ventricular function), central thrombus burden (saddle PE), potential additional embolization (concomitant deep vein thrombosis), and cardiovascular compensation (tachycardia) was prespecified and assessed for its ability to identify normotensive shock patients. Over one-third of intermediate-risk PE patients in FLASH (131/384, 34.1%) were in normotensive shock. The normotensive shock prevalence was 0% in patients with a composite shock score of 0 and 58.3% in those with a score of 6 (highest score). A score of 6 was a significant predictor of normotensive shock (odds ratio: 5.84; 95% CI: 2.00-17.04). Patients showed significant on-table improvements in hemodynamics post-thrombectomy, including normalization of the cardiac index in 30.5% of normotensive shock patients. Right ventricular size, function, dyspnea, and quality of life significantly improved at the 30-day follow-up. Although hemodynamically stable, over one-third of intermediate-risk FLASH patients were in normotensive shock with a depressed cardiac index. A composite shock score effectively further risk stratified these patients. Mechanical thrombectomy improved hemodynamics and functional outcomes at the 30-day follow-up. [Display omitted] [ABSTRACT FROM AUTHOR]

To describe the trend in plasma renin activity over time in patients undergoing cardiac surgery on cardiopulmonary bypass, and to investigate if increased plasma renin activity is associated with postcardiopulmonary bypass vasoplegia. A prospective cohort study. Patients were enrolled from June 2020 to May 2021 at a tertiary cardiac surgical institution. A cohort of 100 adult patients undergoing cardiac surgery on cardiopulmonary bypass. None. Plasma renin activity was measured at 5 time points: baseline, postoperatively, and at midnight on postoperative days 1, 2, and 3. Plasma renin activity and delta plasma renin activity were correlated with the incidence of vasoplegia and clinical outcomes. The median plasma renin activity increased approximately 3 times from baseline immediately after cardiac surgery, remained elevated on postoperative days 0, 1, and 2, and began to downtrend on postoperative day 3. Plasma renin activity was approximately 3 times higher at all measured time points in patients who developed vasoplegia versus those who did not. In patients undergoing cardiac surgery on cardiopulmonary bypass, plasma renin activity increased postoperatively and remained elevated through postoperative day 2. Additionally, patients with vasoplegic syndrome after cardiac surgery on cardiopulmonary bypass had more robust elevations in plasma renin activity than nonvasoplegic patients. These findings support the need for randomized controlled trials to determine if patients undergoing cardiac surgery with high plasma renin activity may benefit from targeted treatment with therapies such as synthetic angiotensin II. [ABSTRACT FROM AUTHOR]

This study was designed to compare the effects of levosimendan and dobutamine on hemodynamics and clinical efficacy in patients with severe septic cardiomyopathy (left ventricular ejection fraction [LVEF] ≤35%). A prospective, single-blind, randomized controlled study. In Baoding, China. Thirty patients with severe septic cardiomyopathy treated in the authors' hospital's Department of Critical Medicine from September 2018 to September 2021 were enrolled in this study. These patients were divided randomly into the levosimendan group and dobutamine group. The LVEF, cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index, heart rate, norepinephrine dose, and lactate at the time of enrollment and the 24th hour were compared, along with myocardial injury markers on the third day, C-reactive protein, mechanical ventilation time, length of intensive care unit (ICU) stay, cost, and 28-day mortality. The primary outcome was 28-day mortality. At the 24th hour after treatment, CI, LVEF, SVI, and fluid volume were found to be higher in the levosimendan group than in the dobutamine group, whereas the dose of norepinephrine was lower in the former rather than the latter group. On the third day of treatment, cardiac troponin I in the levosimendan group was lower than that in the dobutamine group. Although the differences in 28-day mortality, ICU stay, and ICU treatment cost between the groups were not statistically significant, the ventilator application time of the levosimendan group was significantly shorter than that of the dobutamine group. Compared with dobutamine, levosimendan was more effective at improving cardiac function, reducing myocardial injury, and reducing mechanical ventilation time in patients with severe septic cardiomyopathy. [ABSTRACT FROM AUTHOR]

Dual-combustion ramjets have the advantages of both ramjets and scramjets, and further research is required to understand the combustion flow state in supersonic combustors and improve the overall performance of engines. Based on the computational fluid dynamics method, the objective of this study was to explore whether the two distinct combustion flow modes, scramjet and ramjet modes, can emerge in a dual-combustion ramjet under the same operating conditions when it was burned with a constant area. If so, the combustion flow characteristics and comprehensive engine performance under the two modes would be compared. Kerosene C 12 H 23 was used as fuel and the equivalence ratio was 0.71. A 6-species 4-step chemical reaction mechanism was adopted, and the RNG k − ε turbulent flow model was selected. The altitude was 35 km and the Mach number was 7. The results show that, under the same operating conditions, the scramjet and ramjet modes can be achieved when the dual-combustion ramjet burns with a constant area. The generation of the two modes is related to the ignition efficiency, and the ramjet mode requires higher ignition efficiency. In the supersonic combustor, type X-shock waves with a first Mach stem length of 20 mm were generated under the scramjet mode, and a C-shock wave with a Mach stem length of 52 mm was generated under the ramjet mode. The core principle of mode transition is to control the rate of heat released in the supersonic combustor. The engine performance was better under the ramjet mode in this case. Specifically, the thrust, specific impulse, and specific thrust of the ramjet mode were all 1.4 times those of the scramjet mode. This is because, compared to the scramjet mode, the total pressure loss of the ramjet mode was slightly higher by 1.4%, but the combustion efficiency increased by 31.5%, significantly improving the engine performance. The ramjet mode can improve the combustion process and combustion efficiency. The reason is that, on one hand, the recirculation zone formed by the C-shock wave not only has a larger number of vortices, but also has a longer length, which is conducive to the efficient mixing of high temperature gas and secondary flow. On the other hand, the airflow velocity in the ramjet mode is lower, which is equivalent to an increase in the residence time of the airflow. [Display omitted] • The scramjet and ramjet modes can be achieved under the same operating conditions. • The generation of the two modes is related to the ignition efficiency. • Type C-shock and X-shock waves were formed. • The core principle of mode transition is to control the rate of heat released. • The performance of ramjet mode was better due to its high combustion efficiency. [ABSTRACT FROM AUTHOR]

Shock is a life-threatening clinical state in which cellular hypoxia develops due to an imbalance between oxygen supply and demand resulting in end organ dysfunction. It is the end result of a number of pathophysiological processes, and multiple processes may coexist. Shock may be reversible in early stages; however, if appropriate treatment is delayed the effects become irreversible, resulting in multiorgan failure and death. Given the morbidity and mortality associated with shock, its significance has been emphasized in medical education and public health campaigns globally in recent years. Early recognition and timely interventions to treat shock and address the underlying cause(s) are essential to improve outcomes. This article provides an overview of shock syndromes, presents an approach to assessment and investigations, and reviews the management of shock in a general context. It is beyond the scope of one article to discuss the vast subject of shock in as much depth as it deserves. [ABSTRACT FROM AUTHOR]

Severe burns are a significant cause of life-threatening conditions in both peacetime and wartime. Shock is a critical complication during the early stages of burn injury, contributing substantially to mortality and long-term disability. Effective fluid resuscitation is crucial for preventing and treating shock, with prompt administration being vital. However, timely intravenous fluid resuscitation is often challenging, and errors in resuscitation significantly contribute to mortality. Therefore, exploring a more rapid and effective non-invasive method of fluid resuscitation is necessary. Oral rehydration therapy (ORT) has shown considerable potential in this regard. This paper reviews ORT's historical development and current research progress, discussing its application in early anti-shock treatment for burns. While ORT is generally safe, potential complications like diarrhoea, vomiting, and abdominal discomfort must be noted, particularly if the rehydration rate is too rapid or if gastrointestinal issues exist. Careful patient assessment and monitoring are essential during ORT administration. Based on a comprehensive review of relevant research, we present provisional guidelines for ORT in burn patients. These guidelines aim to inform clinical practice but should be applied cautiously due to limited clinical evidence. Implementation must be tailored to the patient's condition under healthcare supervision, with adjustments according to evolving circumstances: ① Initiation timing: Start as soon as possible, and the ideal start time is usually within 6 h after injury. ② Rate of application: Employing a fractional administration approach, wherein small quantities of approximately 150–250 millilitres are provided for each instance and the initial fluid rate of oral rehydration can be simplified to 100 mL/kg/24 h. ③ Composition combination: In addition to essential salts and glucose, the oral rehydration solution can incorporate various anti-inflammatory and cellular protection constituents. • This paper summarizes the evolution and research on oral rehydration therapy for burn shock. • WHO-ORS provides initial moisture and electrolytes but has limited correction ability for ischemic and hypoxic conditions. • We offer solutions for oral rehydration in burn injuries considering several factors. • Several oral fluid replacement components for burns with good application prospects are now summarised in this paper. [ABSTRACT FROM AUTHOR]

Diamond is, by virtue of the covalent bonding between atoms and the very strong carbon to carbon bonds, the hardest natural material. It has been a fascinating material since its discovery, first as a decorative gem and more recently, for its numerous industrial uses because of its extreme hardness, elastic modulus, and optical transparency. In recent years, it has become a preferred ablator for laser shock experiments, and this has led to its choice as the capsule material for fusion experiments at the National Ignition Facility. This review covers both experimental and computational (including machine learning) advancements in research on diamond subjected extreme conditions of temperature and pressure. The synergy between shock and ramp loading experiments and atomic level simulations is proving to be powerful in advancing our understanding of diamond under extremes. [ABSTRACT FROM AUTHOR]

Patients with intermediate-risk pulmonary embolism (PE) commonly present with a significantly reduced cardiac index (CI). However, the identification of this more severe profile requires invasive hemodynamic monitoring. Whether inferior vena cava (IVC) contrast reflux, as a marker of worse right ventricular function, can predict invasive hemodynamics has not been explored. This was a single-center retrospective study over a 3-year period of consecutive patients with PE undergoing mechanical thrombectomy and simultaneous pulmonary artery catheterization. CT pulmonary angiograms were reviewed, and contrast reflux was graded as no/minimal reflux (limited to the IVC) or substantial (opacification including hepatic veins) based on an established scale. Substantial contrast reflux was present in 29 of 85 patients (34 %) and associated with a lower CI (1.8 ± 0.4 L/min/m2 v. 2.6 ± 1.0 L/min/m2, p < 0.001), higher pulmonary artery systolic pressure (53.2 ± 19.5 mmHg v. 44.0 ± 12.1 mmHg, p = 0.025), and worse right ventricular systolic function. An IVC contrast reflux grade > 3 was a significant predictor for a CI ≤2.2 L/min/m2 (OR: 22.5, 95 % CI: 4.8, 104.4, p < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value for substantial contrast reflux for a CI ≤2.2 L/min/m2 were 62.6 %, 93.1 %, 94.6 %, and 56.2 %, respectively. These findings remained significant in a multivariable model and were similar when isolating for intermediate-risk patients (n = 72, 85 %). The degree of contrast reflux is highly specific for a reduced cardiac index in PE even when isolating for intermediate-risk patients. Real-time prediction of a hemodynamic profile may have added value in the risk-stratification of PE. [Display omitted] • Higher grades of contrast reflux on CT are specific for a low cardiac index in PE. • Contrast reflux predicts worse RV function and higher PA pressures. • Contrast reflux may aid in risk stratification and identification of occult shock. [ABSTRACT FROM AUTHOR]

Cities around the world face both acute and ongoing stressors from climate change and other shocks. The degree to which linguistic, ethnic, and citizenship characteristics drive vulnerability, social connectedness, and mental health outcomes during such shocks remains an open question. Analyzing a new survey of nearly 240 residents of Cloverdale using regression models and social network analysis, we find that non White residents faced poorer outcomes across a variety of fields. Controlling for age, income, job status, and other demographic factors we find that Hispanic identities correlate with worse vulnerability and resilience indicators including worse mental health and feelings of support. These findings come with a variety of policy recommendations for cities, NGOs, and decision makers. • 240 residents were surveyed in Cloverdale, CA about resilience to recent crises. • Hispanic residents faced heightened vulnerability and reduced resilience. • Hispanic residents faced lower levels of social trust compared to White peers. • Cross-cutting ties between ethnic groups boost resilience, according to regressions. • Findings hold post-control for age, income, and other indicators of vulnerability. [ABSTRACT FROM AUTHOR]

Technological advances over the past two decades have paved the way for the prehospital use of ultrasound. This practice was first developed in traumatology and then in a multitude of other indications, including cardiology. The development of pulmonary ultrasound is certainly the most visible illustration of this. Firstly, because it is an extra-cardiac examination that provides the answer to a cardiac question. Secondly because from a theoretical point of view this ultrasound indication was a bad indication for the use of ultrasound due to the air contained in the thorax. Thirdly, because this indication has become a 'standard of care' when caring for a patient with dyspnea – a practice that has become widespread during the COVID epidemic. In patients with heart failure, ultrasound has a high diagnostic power (including for alternative diagnoses) which is all the more precise since the technique is non-invasive, the response is obtained quickly, the examination can be repeated at desire to follow the evolution of the patient. The main other indications for prehospital ultrasound are cardiac arrest to search for a curable cause, identification of residual mechanical cardiac activity, monitoring of cerebral perfusion; chest pain, for both positive and negative diagnoses; shock for the search for an etiology and therapeutic follow-up or even pulmonary embolism or ultrasound for the search for dilation of the right ventricle which is now at the forefront of the recommendation algorithm. [ABSTRACT FROM AUTHOR]

• Diagnostic accuracy of point-of-care ultrasound (POCUS) in patients with dyspnea, non-traumatic hypotension, and shock is higher when compared to not using POCUS in the initial workup. • POCUS narrows the differential diagnoses and speeds up in time to diagnosis, where chest X-ray needs reporting and laboratory results are pending. • POCUS has better diagnostic properties to identify pneumonia than chest X-ray, this effect is most pronounced when symptoms are present for less than 24 h. • The discriminatory capabilities of POCUS and NT-proBNP in patients with acute decompensated heart failure are similar but POCUS can rule out patients with false positive NT-proBNP levels, and has more value in monitoring treatment effect. • Most studies in this review were undertaken by POCUS experts thereby reducing the generalizability of the presented data to the average internal medicine department across Europe. Point-of-care ultrasound (POCUS) has been adopted as a powerful tool in acute medicine. This systematic review aims to critically appraise the existing literature on point-of-care ultrasound in respiratory or circulatory deterioration. Original studies on POCUS and dyspnea, nontraumatic hypotension, and shock from March 2002 until March 2022 were assessed in the PubMed and Embase Databases. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. We included 89 articles in this review. Point-of-care ultrasound in the initial workup increases the diagnostic accuracy in patients with dyspnea, nontraumatic hypotension and shock in the ED, ICU and medical ward setting. No improvement is found in patients with severe sepsis in the ICU setting. POCUS is capable of narrowing the differential diagnoses and is faster, and more feasible in the acute setting than other diagnostics available. Results on outcome measures are heterogenous. The quality of the included studies is considered low most of the times, mainly because of performance and selection bias and absence of a gold standard as the reference test. We conclude that POCUS contributes to a higher diagnostic accuracy in dyspnea, nontraumatic hypotension, and shock. It aides in narrowing the differential diagnoses and shortening the time to correct diagnosis and effective treatment. INPLASY; Registration number: INPLASY202220020; URL: https://inplasy.com/. [ABSTRACT FROM AUTHOR]