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Objective: The aim of this study was to examine the relative frequency of and risk factors for prolonged opioid prescription (Rx_3-6: ≥1 opioid prescription of any length between 3 and 6 months postevent) and long-term opioid prescription (Rx_>6: ≥1 opioid prescription of any length >6 months postevent) after surgery/trauma. Summary Background Data: Eighty percent of patients undergoing surgery are prescribed opioids; for many this initial time-limited therapy continues for months after surgery. Methods: Included studies were published between January 1998 and April 2018, examined opioid use ≥3 months after surgery/trauma requiring hospitalization, and considered pre-event opioid prescription status. Empirical studies were identified via a systematic literature search. Two independent reviewers assessed studies for inclusion and conducted data extraction and quality appraisal. Results: Thirty-five of the 10,003 screened articles were included; most were retrospective studies of medicoadministrative databases; all studies were observational. The median relative frequency of Rx_3-6 and Rx_>6 was 4.1% and 2.6%, respectively, among patients with no/short-term opioid prescription pre-event and 50.9% and 58.5%, respectively, among patients with prolonged opioid prescription pre-event. Income levels, tobacco dependence, use of antidepressants, and pre-event opioid prescriptions are associated with increased risk of Rx_3-6/Rx_>6. The use of benzodiazepines (current use) or muscle relaxants and the presence of alcohol/drug dependence were found to be potential risk factors for Rx_3-6/Rx_>6 among patients with no/short-term opioid prescription pre-event. Conclusions: Identified risk factors for Rx_3-6/Rx_>6 were predominantly psychosocial factors. This points to the importance of assessing mental and social health before surgery and acutely during hospitalization to ensure safe and optimal recovery. [ABSTRACT FROM AUTHOR]

Objective: To investigate safety and efficacy of temporary portal hemodynamics modulation with a novel percutaneously adjustable vascular ring (MID-AVR) onto a porcine model of 75% hepatectomy. Background: Postoperative liver failure is a leading cause of mortality after major hepatectomy. Portal flow modulation is an increasingly accepted concept to prevent postoperative liver failure. Nonetheless, the current strategies have shortcomings. Methods: Resection was performed under hemodynamic monitoring in 17 large, white pigs allocated into 2 groups. Eight pigs had ring around the portal vein for 3 days with the aim of reducing changes in hemodynamics due to hepatectomy. Analysis of hemodynamics, laboratory, and histopathological parameters was performed. Results: Percutaneous inflation, deflation, and removal of the MID-AVR were safe. Two (25%) pigs in the MID-AVR group and 4 (45%) controls died before day 3 (P = NS). A moderate increase of portal flow rate per liver mass after resection was associated with better survival (P = 0.017). The portocaval pressure gradient was lower after hepatectomy in the MID-AVR group (P = 0.001). Postoperative serum bilirubin levels were lower in the MID-AVR group (P = 0.007 at day 5). In the MID-AVR group, the Ki67 index was significantly higher on day 3 (P = 0.043) and the architectural derangement was lower (P < 0.05). Morphometric quantification of the bile canaliculi revealed a significantly lower number of intersection branches (P < 0.05) and intersection nodes (P < 0.001) on day 7 compared with the preoperative specimen, in the control group. These differences were not found in the ring group. Conclusions: MID-AVR is safe for portal hemodynamics modulation. It might improve liver regeneration by protecting liver microarchitecture. [ABSTRACT FROM AUTHOR]

Objective: To assess the ability of ultrasonography to identify the presence and assess the volume of pleural effusion in the intensive care unit setting.Design: Prospective descriptive clinical study.Setting: Medical-surgical intensive care unit of a teaching hospital.Patients: Initial study group (group I) consisted of 97 patients (mean [+/-SD] Simplified Acute Physiology Score II, 40 +/- 14) with clinically suspected pleural effusion. Fifty-one patients were mechanically ventilated and 55 patients underwent a unilateral or bilateral thoracentesis (58 procedures). All patients underwent supine chest radiography and pleural ultrasonography at bedside. The testing group (group II) consisted of 19 additional patients (17 under ventilation) who underwent thoracentesis.Interventions: None.Measurements and Main Results: Maximal interpleural distance was measured at the base and apex of the pleural space, at both end-expiration and end-inspiration. In group I, interpleural distances were compared to actual volume of fluid in the subset of patients who underwent a complete thoracentesis (n = 49). Prediction of the volume of pleural effusion was subsequently tested prospectively in group II (25 complete thoracenteses). Portable chest radiography and pleural ultrasonography yielded discordant results for 47 patients (48%) in the diagnosis of pleural effusion. The expiratory interpleural distance measured at the thoracic base with ultrasonography was significantly correlated with the volume of fluid (p < .0001; coefficient of determination: right, 0.78; left, 0.51). A pleural effusion > or =800 mL was predicted when this distance was >45 mm (right) or >50 mm (left), with a sensitivity of 94% and 100% and a specificity of 76% and 67%, respectively. In group II, the mean bias between the predicted and observed volumes of pleural effusion determined by thoracentesis was 24 +/- 355 mL, and this decreased to 28 +/- 146 mL for the prediction of pleural effusion <1400 mL.Conclusions: Bedside ultrasonography is well suited for the quantitative assessment of unloculated pleural effusions in intensive care unit patients. [ABSTRACT FROM AUTHOR]

Abstract: Study hypothesis : Implementation of a new pathway dedicated to septic patients within the emergency department (ED) would improve early management, organ dysfunction, and outcome. Methods: During phase 1, all consecutive adult patients with infection and qualifying quick Sequential Organ Failure Assessment (qSOFA) score upon ED admission were managed according to standards of care. A multifaceted intervention was then performed (implementation phase): educational program, creation of a sepsis alert upon ED admission incorporated in the professional software, together with severity scores and Surviving Sepsis Campaign (SSC) bundle reminders, and dedication of two rooms to the management of septic patients (sepsis unit). During phase 2, patients were managed according to this new organization. Results: Of the 89,040 patients admitted to the ED over the two phases, 2,643 patients (3.2%) had sepsis including 277 with a qualifying qSOFA score on admission (phase 1, 141 patients; phase 2, 136 patients). Recommendations of SSC 3-h bundle significantly improved between the two periods regarding lactate measurement (87% vs. 96%, P = 0.006), initiation of fluid resuscitation (36% vs. 65%, P < 0.001), blood cultures sampling (83% vs. 93%, P = 0.014), and administration of antibiotics (18% vs. 46%, P < 0.001). The Sequential Organ Failure Assessment score between H0 and H12 varied significantly more during phase 2 (1.9 ± 1.9 vs. 0.8 ± 2.6, P < 0.001). Mortality significantly decreased during the second phase, on day 3 (28% vs. 15%, P = 0.008) and on day 28 (40% vs. 28%, P = 0.013). Conclusion: Systematic detection, education, and per protocol organization with a sepsis unit dedicated to the early management of septic patients appear to improve compliance with SSC bundles, organ dysfunction, and short-term mortality. These results warrant to be confirmed by prospective studies., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by the Shock Society.)

Objectives: Evaluation of left atrial pressure is frequently required for mechanically ventilated critically ill patients. The objective of the present study was to evaluate the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for assessment of the pulmonary artery occlusion pressure (a frequent surrogate of left atrial pressure) in this population., Design: A pooled analysis of three prospective cohorts of patients simultaneously assessed with a pulmonary artery catheter and echocardiography., Settings: Medical-surgical intensive care department of two university hospitals in France., Patients: Mechanically ventilated critically ill patients., Interventions: None., Measurements and Main Results: Of 98 included patients (males: 67%; mean ± SD age: 59 ± 16; and mean Simplified Acute Physiology Score 2: 54 ± 20), 53 (54%) experienced septic shock. Using the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, the predicted pulmonary artery occlusion pressure was indeterminate in 48 of the 98 patients (49%). Of the 24 patients with an elevated predicted left atrial pressure (grade II/III diastolic dysfunction), only 17 (71%) had a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg. Similarly, 20 of the 26 patients (77%) with a normal predicted left atrial pressure (grade I diastolic dysfunction) had a measured pulmonary artery occlusion pressure less than 18 mm Hg. The sensitivity and specificity of American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for predicting elevated pulmonary artery occlusion pressure were both 74%. The agreement between echocardiography and the pulmonary artery catheter was moderate (Cohen's Kappa, 0.48; 95% CI, 0.39-0.70). In a proposed alternative algorithm, the best echocardiographic predictors of a normal pulmonary artery occlusion pressure were a lateral e'-wave greater than 8 (for a left ventricular ejection fraction ≥ 45%) or an E/A ratio less than or equal to 1.5 (for a left ventricular ejection fraction < 45%)., Conclusions: The American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines do not accurately assess pulmonary artery occlusion pressure in ventilated critically ill patients. Simple Doppler measurements gave a similar level of diagnostic performance with less uncertainly.

Study Objective: We evaluated the early hemodynamic profile of patients presenting with acute circulatory failure to the Emergency Department (ED) using focused echocardiography performed by emergency physicians after a dedicated training program., Methods: Patients presenting to the ED with an acute circulatory failure of any origin were successively examined by a recently trained emergency physician and by an expert in critical care echocardiography. Operators independently performed and interpreted online echocardiographic examinations to determine the leading mechanism of acute circulatory failure., Results: Focused echocardiography could be performed in 100 of 114 screened patients (55 with sepsis/septic shock and 45 with shock of other origin) after a median fluid loading of 500 mL (interquartile range: 187-1,500 mL). A hypovolemic profile was predominantly observed whether the acute circulatory failure was of septic origin or not (33/55 [60%] vs. 23/45 [51%]: P = 0.37). Although a vasoplegic profile associated with a hyperkinetic left ventricle was most frequently identified in septic patients when compared with their counterparts (17/55 [31%] vs. 5/45 [11%]: P = 0.02), early left or right ventricular failure was observed in 31% of them. Hemodynamic profiles were adequately appraised by recently trained emergency physicians, as reflected by a good-to-excellent agreement with the expert's assessment (Κ: 0.61-0.85)., Conclusions: Hypovolemia was predominantly identified in patients presenting to the ED with acute circulatory failure. Although vasoplegia was more frequently associated with sepsis, early ventricular dysfunction was also depicted in septic patients. Focused echocardiography seemed reliable when performed by recently trained emergency physicians without previous experience in ultrasound.

Objective: Although stress cardiomyopathy has been described in association with epilepsy, its frequency in patients with convulsive status epilepticus remains unknown. Accordingly, we sought to determine the prevalence and risk factors of stress cardiomyopathy in patients admitted to the ICU for convulsive status epilepticus., Design: Prospective, descriptive, single-center study., Setting: Medical-surgical ICU of a teaching hospital., Patients: Thirty-two consecutive ventilated patients (21 men; age, 50 ± 18 yr; Simplified Acute Physiology Score II, 53 ± 15; Sequential Organ Failure Assessment, 6 ± 2) hospitalized in the ICU for convulsive status epilepticus., Interventions: None., Measurements and Main Results: Hemodynamic parameters, transthoracic echocardiography, biological data, and electrocardiogram were obtained serially on ICU admission (H0), and after 6, 12, 24, and 48 hours of hospitalization (H6, H12, H24, and H48). Stress cardiomyopathy was defined as a 20% decrease in left ventricular ejection fraction between H0 or H6 and H48. Stress cardiomyopathy was diagnosed in 18 patients (56%; 95% CI, 38-74%). Mean left ventricular ejection fraction, left ventricular stroke index and cardiac index were initially (at H0 or H6 according to lowest individual values) significantly reduced in stress cardiomyopathy patients (45 ± 14% vs 61 ± 6%, p < 0.001; 24 ± 8 vs 28 ± 8 mL/m(2), p < 0.05; 2.3 ± 0.7 vs 3.0 ± 0.8 L/min/m(2), p < 0.05, respectively) and increased secondarily to reach similar mean values than those observed in patients without transient left ventricular dysfunction at H24. Dobutamine was more frequently used in patients with stress cardiomyopathy. Mean lactate level was increased and significantly higher in stress cardiomyopathy patients at H0 and H6, whereas mean central venous oxygen saturation was preserved but significantly lower in this group. Only three patients with stress cardiomyopathy had left ventricular regional wall motion abnormalities but normal coronary angiography. Risk factors of stress cardiomyopathy were age and Simplified Acute Physiology Score II., Conclusions: These results suggest that stress cardiomyopathy is common in patients admitted to the ICU for convulsive status epilepticus. Accordingly, these patients should be screened for stress cardiomyopathy and monitored if they present with hemodynamic compromise.

Objectives: Primary objective was to identify leukocyte subsets that could predict the early evolution of sepsis at 48 hours (i.e., deterioration or stability/improvement). Secondary objectives were to evaluate the prognostic value of leukocyte subsets on mortality and immunosuppressive properties of immature granulocytes., Design: Twenty-three peripheral blood leukocyte subsets were analyzed using a new-generation 10-color flow cytometry. T-cell killing activity of immature granulocytes was explored using a sorting method specifically developed., Setting: ICUs and emergency departments., Patients: All patients admitted to emergency department and ICU for sepsis ongoing for less than 24 hours were eligible. Exclusion criteria were pregnancy, age less than 18 years, solid tumors, HIV infection, hematological or inflammatory conditions, and immunosuppressive drugs. Finally, 177 patients were included., Interventions: None., Measurements and Main Results: The two most salient features of sepsis were decreased CD10 (CD10) and CD16 (CD16) expressions on granulocytes. With a threshold of 90% of CD10 and 15% of CD16 granulocytes, these immunophenotypic features, which are those of immature granulocytes, predicted sepsis deterioration at 48 hours with a sensitivity of 57% and 70% and a specificity of 78% and 82%, respectively. Survival rate at day 30 was 99% for patients without CD10 and CD16, 85% for patients with increased CD16 only, and 63% for patients with increased CD16 and CD10 granulocytes (p < 0.001). Among CD16 immature granulocytes, we identified a CD14/CD24 myeloid-derived suppressor cell subset with the capability of killing activated T cells. Consistently, an excess of CD16 immature granulocytes was associated with both CD3 and CD4 T-cell lymphopenia in deteriorating patients., Conclusions: Circulating immature granulocytes predicted early sepsis deterioration and were enriched in myeloid-derived suppressor cells which could be responsible for immunosuppression through the induction of T-cell lymphopenia.

Purpose of Review: Left-ventricular diastolic dysfunction is associated with various conditions frequently encountered in ICU patients. Due to prolonged relaxation and increased left-ventricular stiffness, patients with diastolic dysfunction are at high risk of developing abrupt pulmonary venous congestion. The present review describes the clinical spectrum of left-ventricular diastolic abnormalities in ICU patients., Recent Findings: Left-ventricular diastolic dysfunction is associated with a preserved ejection fraction in half of the patients presenting with acute pulmonary edema. These patients may have dramatic presentation, such as flash pulmonary edema during a hypertensive crisis. Left-ventricular diastolic dysfunction is frequently involved in patients who fail extubation and may trigger weaning pulmonary edema. Sepsis and myocardial ischemia may also be associated with left-ventricular diastolic dysfunction. The diagnosis of left-ventricular diastolic dysfunction practically relies on two-dimensional and Doppler echocardiography. Further large-scale clinical studies are needed to better characterize the prevalence, the clinical relevance and time-course of left-ventricular diastolic dysfunction in ICU patients., Summary: Left-ventricular diastolic dysfunction accounts for a growing proportion of cardiogenic pulmonary edema and weaning failure in ICU patients. It may be reversible when induced by sepsis or myocardial ischemia. Its prognostic value in the ICU settings remains to be further investigated.

Objective: To describe the clinical spectrum of infective endocarditis in critically ill patients and assess the impact of neurologic complications on outcomes., Design: Prospective multicenter observational study conducted from April 2007 to October 2008., Setting: Thirty-three intensive care units in 23 university-affiliated and 10 general French hospitals., Patients: Two hundred twenty-five patients with definite IE were studied. Factors associated with neurologic complications and predictors of 3-month mortality were identified by logistic regression analysis. Functional outcomes of patients with neurologic complications were evaluated with the modified Rankin Scale., Interventions: None., Measurements and Main Results: Among 198 patients with definite left-sided infective endocarditis, 108 (55%) experienced at least one neurologic complication. These complications were ischemic stroke (n = 79), cerebral hemorrhage (n = 53), meningitis or meningeal reaction (n = 41), brain abscess (n = 14), and mycotic aneurysm (n = 10). Factors independently associated with neurologic complications were (subhazard ratio [95% confidence interval]): Staphylococcus aureus infective endocarditis (1.45 [1.02-2.05]), mitral valve infective endocarditis (1.54 [1.07-2.21]), and nonneurologic embolic events (1.51 [1.09-2.09]). In contrast, health care-associated infective endocarditis had a protective effect (0.46 [0.27-0.77]). Multivariate analysis identified three variables associated with 3-month mortality (odds ratio [95% confidence interval]): neurologic failure, as defined as a Glasgow Coma Scale <10 (7.41 [2.89-18.96]), S. aureus infective endocarditis (3.26 [1.53-6.94]), and severe comorbidities before admission as defined as a Charlson score >2 (3.16 [1.47-6.77]). Among the 106 patients with neurologic complications assessed at follow-up (3.9 [3-8.5] months), 31 (29%) had a modified Rankin Scale score ≤3 (ability to walk without assistance), nine (9%) a modified Rankin Scale score of 4 or 5 (severe disability), and 66 (62%) a modified Rankin Scale score of 6 (death)., Conclusions: Neurologic events are the most frequent complications in infective endocarditis patients requiring intensive care unit admission. They contribute to a severe prognosis, leaving less than one-third of patients alive with functional independence. Neurologic failure at intensive care unit admission represents a major determinant of mortality regardless of the underlying neurologic complication.

Objective: To assess the efficacy of a limited, tailored training program for noncardiologist residents without experience in ultrasound to reach competence in basic critical care echocardiography., Design: Prospective descriptive clinical study., Setting: Medical-surgical intensive care unit of a teaching hospital., Patients: 201 patients (125 men; age: 61 ± 16 yrs; Simplified Acute Physiologic Score II: 37 ± 17; 145 ventilated patients) who required a transthoracic echocardiography were studied., Intervention and Measurements: The curriculum consisted of a 12-hr learning program blending didactics, interactive clinical cases, and tutored hands-on sessions. After completion of this tailored training program, all eligible patients subsequently underwent a transthoracic echocardiography performed in random order by a recently trained resident and an experienced intensivist with expertise in critical care echocardiography who was used as a reference. The agreement between responses to clinical questions provided by the two investigators who independently interpreted the transthoracic echocardiography study at bedside was used as an indicator of effectiveness of the tested curriculum., Main Results: Residents performed a mean of 33 transthoracic echocardiograms during the study period (range: 29-38). Experienced intensivists had significantly fewer unaddressed clinical questions than did residents (57 [5.7%] vs. 111 [11.0%] of 1,005 clinical questions: p < .0001). When compared to residents, the experienced intensivists performed shorter transthoracic echocardiography examinations (3.0 ± 1.0 min vs. 7.0 ± 2.5 min: p < .0001) with more acoustic windows (888 vs. 828 of 1,005 potential windows: p < .0001). Residents adequately assess global left ventricle systolic function (κ: 0.84; 95% confidence interval: 0.76-0.92). They accurately identified dilated left ventricle (κ: 0.90; 95% confidence interval: 0.80-1.0), dilated right ventricle (κ: 0.76; 95% confidence interval: 0.64-0.89), dilated inferior vena cava (κ: 0.79; 95% confidence interval: 0.63-0.94), and pericardial effusion (κ: 0.79; 95% confidence interval: 0.58-0.99) and diagnosed two cases of tamponade., Conclusions: A 12-hr training program blending didactics, interactive clinical cases, and tutored hands-on sessions dedicated to noncardiologist residents without experience in ultrasound appears well suited for reaching competence in basic critical care echocardiography.

Purpose of Review: The evaluation of hemodynamic status in critically ill patients is a leading recommended indication of transesophageal echocardiography in the intensive care unit. Advantages and diagnostic yield of transesophageal echocardiography in this setting are particularly relevant when considering limitations and questioned prognostic impact of pulmonary artery catheterization., Recent Findings: Recent clinical studies have been performed to validate and assess the value of transesophageal echocardiography in determining cardiac output, cardiac preload dependence, right ventricular function, and left ventricular filling pressure. In addition, diagnostic capacity and therapeutic impact of transesophageal echocardiography have been widely reported in various intensive care unit settings., Summary: Transesophageal echocardiography appears well suited for the determination of cardiac index and to track its variations after therapeutic interventions. Although repeated measurements of left ventricular end-diastolic dimension allows to accurately track preload variations, a single determination is not reliable to predict fluid responsiveness in intensive care unit patients. Identification of preload dependence in hemodynamically unstable patients currently tends to rely mainly on dynamic parameters that use cardiopulmonary interactions under mechanical ventilation. Transesophageal echocardiography also allows to adequately assess right ventricular function and left ventricular filling pressure using combined Doppler modalities. Adequate education and training of intensivists and anesthesiologists is crucial to further develop the use of transesophageal echocardiography in the intensive care unit setting. Despite the absence of randomized controlled studies documenting transesophageal echocardiography benefits on patient outcome, present evidence and experience strongly recommend a larger use of echocardiography Doppler for a comprehensive functional hemodynamic assessment of critically ill patients with circulatory failure.

Background: No objective criteria have been described to help selecting patients with major blunt aortic injury (BAI) for postponed surgical repair. The efficacy of conservative management of minor BAI needs further evaluation., Methods: We studied 31 patients (Injury Severity Score, 48 +/- 15) who sustained a BAI diagnosed using transesophageal echocardiography (TEE). In patients with major BAI, the timing of surgery was made on the basis of clinical findings (grade 2) or TEE results (grade 3). We retrospectively separated patients into group I (rapid surgery, < or = 12 hours; n = 13) and group II (late or no surgery; n = 11). All major BAIs were confirmed by alternative imaging modalities or surgery. Patients with minor BAI (grade 1; n = 7) prospectively underwent conservative management with serial TEE follow-up., Results: All patients with grade 3 BAI (n = 4) were promptly operated on. No group II patient died as a result of aortic rupture, and all of them exhibited a small false aneurysm formation (ratio between the maximal diameter of the injured aortic isthmus and the diameter of the normal descending aorta < 1.4) and hemomediastinum (< 7.2 mm). TEE follow-up of group II patients (mean, 5 months) showed stable BAI, whereas follow-up of patients with minor BAI (mean, 15 months) disclosed total healing (n = 3) or stable lesions (n = 4)., Conclusion: Conservative management of minor BAI with serial follow-up appears to be appropriate. In patients with a grade 2 BAI and small false aneurysm formation and hemomediastinum, postponed surgical repair appears to be safe. However, these TEE criteria remain to be tested prospectively.

Background: Diastolic wall motion asynchrony is a major determinant of impaired left ventricular (LV) filling in patients with concentric hypertrophy and coronary artery disease. We evaluated the ability of Color Kinesis, a new echocardiographic technique that color-encodes endocardial motion, to quantitatively assess global and regional LV filling properties., Methods and Results: Color Kinesis images and mitral and pulmonary vein flow Doppler data were acquired in 29 patients with LV hypertrophy and 29 age-matched control subjects. In addition, Color Kinesis data were correlated to coronary angiographic findings in 15 patients with suspected coronary artery disease. Segmental analysis of Color Kinesis images was used to obtain time histograms of regional diastolic fractional area change, wherein early and late peaks (peaks 1 and 2) reflected rapid LV filling and atrial contraction, respectively. Regional mean LV filling time and filling curves were used to objectively identify diastolic endocardial motion asynchrony in patients with LV hypertrophy and coronary artery disease. None of the mitral and pulmonary vein Doppler indices differentiated patients with normalized mitral Doppler profile (n=13) from control subjects, whereas reduced peak1/peak2 ratio and prolonged mean filling time indicated augmented contribution of atrial contraction toward LV filling (P<.05). In 22 of 25 patients with LV hypertrophy and preserved systolic function and in all patients with coronary artery disease, delayed diastolic endocardial motion was observed in at least one segment., Conclusions: Analysis of Color Kinesis images provides objective assessment of global and regional LV filling properties and allows identification of both diastolic dysfunction in patients with normalized Doppler indices and wall motion asynchrony.

Background: We describe a method for objective assessment of left ventricular (LV) endocardial wall motion based on Color Kinesis, a new echocardiographic technique that color-encodes pixel transitions between blood and myocardial tissue., Methods and Results: We developed a software that analyzes Color Kinesis images and provides quantitative indices of magnitude and timing of regional endocardial motion. Images obtained in 12 normal subjects were used to evaluate the variability in each index. Esmolol, dobutamine, and atropine were used to track variations in LV function in 14 subjects. Objective evaluation of wall motion was tested in 20 patients undergoing dobutamine stress testing. Regional fractional area change, displacement, and radial shortening were displayed as histograms and time curves. Global function was assessed by calculating magnitude and timing of peak ejection or filling rates and mean time of ejection or filling. Patterns of endocardial motion were consistent between normal subjects. Fractional area change and peak ejection rate decreased with esmolol and increased with dobutamine. Time to peak ejection and mean time of contraction were prolonged with esmolol and shortened with dobutamine. Using atropine, we proved that our findings with dobutamine were not secondary to its chronotropic effects. Dobutamine induced regional wall motion abnormalities in 10 patients in 38 segments diagnosed conventionally. Segmental analysis detected abnormalities in 36 of these 38 segments and in an additional 5 of 322 segments., Conclusions: Analysis of Color Kinesis images allows fast, objective, and automated evaluation of regional wall motion sensitively enough to evaluate clinical dobutamine stress data. This method has significant potential in the diagnosis of myocardial ischemia.

Background: Color kinesis is a new technology for the echocardiographic assessment of left ventricular wall motion based on acoustic quantification. This technique automatically detects endocardial motion in real time by using integrated backscatter data to identify pixel transitions from blood to tissue during systole on a frame-by-frame basis. In this study, we evaluated the feasibility and accuracy of quantitative segmental analysis of color kinesis images to provide objective evaluation of regional systolic endocardial motion., Methods and Results: Two-dimensional echocardiograms were obtained in the short-axis and apical four-chamber views in 20 normal subjects and 40 patients with regional wall motion abnormalities. End-systolic color overlays superimposed on the gray scale images were obtained with color kinesis to color encode left ventricular endocardial motion throughout systole on a frame-by-frame basis. These color-encoded images were divided into segments by use of custom software. In each segment, pixels of different colors were counted and displayed as stacked histograms reflecting the magnitude and timing of regional endocardial excursion. In normal subjects, histograms were found to be highly consistent and reproducible. The patterns of contraction obtained in normal subjects were used as a reference for the objective automated interpretation of regional wall motion abnormalities, defined as deviations from this pattern. The variability in the echocardiographic interpretation of wall motion between two experienced readers was similar to the diagnostic variability between the consensus of the two readers and the automated interpretation., Conclusions: Color kinesis is a promising new tool that may be used clinically to improve the qualitative and quantitative evaluation of spatial and temporal aspects of global and regional wall motion. In this initial study, segmental analysis of color kinesis images provided accurate, automated, and quantitative diagnosis of regional wall motion abnormalities.

Objective: To assess the value of routine transesophageal echocardiography (TEE) in diagnosing traumatic disruption of the aorta (TDA) in trauma patients presenting without enlarged mediastinum on chest x-ray films., Design: Prospective study., Materials and Methods: TEE was routinely performed to exclude the presence of TDA in patients who sustained severe trauma secondary to abrupt deceleration collisions and presented with an upper mediastinum of fewer than 8 cm on supine chest x-ray films. Patients were divided into two groups according to the presence (group I) or absence (group II) of mediastinal hematoma diagnosed during TEE examination. Radiographic signs regarded as indicators of the presence of TDA were evaluated in both groups., Results: Among the 40 consecutive patients studied, TEE demonstrated two cases of TDA associated with a mediastinal hematoma that were confirmed by both aortography and surgery. One of the patients had a normal mediastinum on presentation chest x-ray films, and the other only exhibited a blurred aortic knob. Radiographic mediastinal abnormalities suggestive of TDA were observed in 13 patients, but chest x-ray films were unremarkable in 12 patients. Twenty patients had multiple rib fractures. The frequency of chest radiographic abnormalities was not significantly higher in group I (n = 6) when compared with group II patients (n = 34). TEE examination demonstrated a normal thoracic aorta in 35 patients and was nondiagnostic in 3 patients (normal aortography)., Conclusion: TEE should be routinely performed in victims of violent deceleration collisions, even in patients presenting apparently normal mediastinum on supine chest radiography.

Background: Traumatic disruption of the aorta (TDA) is a life-threatening injury that requires rapid diagnosis and treatment. Emergency aortography, which is the current standard diagnostic imaging modality, is invasive, time-consuming, and difficult to perform in hemodynamically unstable patients with multiple trauma. We performed transesophageal echocardiography (TEE) in patients with suspected TDA to determine the diagnostic accuracy and impact on patient management of this alternative, portable imaging modality., Methods and Results: Thirty-two consecutive trauma patients (mean age, 40 +/- 16 years) with suspected TDA (violent deceleration accident and mediastinum > 8 cm on admission chest x-ray) prospectively underwent a TEE examination in the emergency room. Findings during TEE were compared with those encountered during aortography, surgery, or necropsy. Two subsets of traumatic aortic injuries with distinct echocardiographic signs were observed: (1) subadventitial TDA (n = 10) and (2) traumatic intimal tears (n = 3). Eighteen patients had normal TEE confirmed by aortography. One 2-mm medial tear was missed by TEE (necropsy). The sensitivity and specificity of TEE for the diagnosis of subadventitial TDA were 91% and 100%, respectively. Patients with subadventitial TDA were taken to surgery immediately, whereas patients with intimal aortic tears were treated conservatively. Eighteen patients (mean age, 57 +/- 15 years) with confirmed acute aortic dissection involving the aortic isthmus were also included to establish the echocardiographic differential diagnostic criteria between this entity and TDA., Conclusions: TEE should be considered the first-line imaging modality for the evaluation of trauma patients with suspected injuries of the thoracic aorta because of its portability, safety, diagnostic accuracy, and potential impact on patient management.

Objective: To determine the occurrence rate of bacteremia associated with transesophageal echocardiography in intensive care unit (ICU) patients., Design: A prospective study of 139 patients undergoing transesophageal echocardiography., Setting: The medical ICU of a tertiary referral teaching hospital., Patients: One hundred thirty-nine ICU patients (mean age 58 yrs) who underwent transesophageal echocardiography., Interventions: Blood samples were systematically drawn for aerobic and anaerobic culture at the following times: before (blood culture 1), at the end of (blood culture 2), and 30 mins after (blood culture 3) transesophageal echocardiography examinations., Measurements and Main Results: The mean duration of transesophageal echocardiography was 35 mins (range 7 to 120). One hundred thirty-four patients received mechanical ventilation; 125 patients had a nasogastric tube. Fifty-one patients had one or more underlying conditions that usually justify antimicrobial prophylaxis of bacterial endocarditis before high-risk procedures. Fifty-six patients did not receive any antibiotic treatment at the time of transesophageal echocardiography. In 114 patients, the three blood cultures were negative. In six patients, transesophageal echocardiography was performed during a preexisting bacteremia. A contamination (only one positive blood culture of the three sampling times) with coagulase-negative staphylococci occurred in four patients at blood culture 1, five patients at blood culture 2, and six patients at blood culture 3. Contamination with Corynebacterium species occurred in two patients at blood culture 2. In one patient receiving cefotaxime and netilmicin, blood culture 1 was sterile and blood cultures 2 and 3 yielded coagulase-negative staphylococci. In one patient receiving no antibiotic treatment, blood culture 1 was sterile and blood cultures 2 and 3 yielded Enterococcus faecalis. None of these two patients received a specific antibiotic treatment or developed any secondary septic focus., Conclusions: The overall frequency of bacteremia induced by transesophageal echocardiography in ICU patients was 1.4% (two of 139 patients) (95% confidence interval 0.2% to 5.1%). The frequency did not differ whether patients received antibiotics before transesophageal echocardiography (one [1.2%] of 83 patients) or not (one [1.8%] of 56 patients) (p = .96). Therefore, routine antimicrobial prophylaxis does not appear justified before transesophageal echocardiography in ICU patients.

Background: Diagnosis of a mechanical mitral valve prosthesis thrombosis is currently made with transthoracic Doppler echocardiography and occasionally with fluoroscopy. However, identifying a thrombus on a valve prosthesis may be difficult, especially if the thrombus is nonobstructive. To prospectively define the role of transesophageal echocardiography for identification of nonobstructive thrombi, we studied a series of patients in whom the prosthetic valve was considered to function normally on clinical examination and transthoracic echocardiography., Methods and Results: One hundred fourteen consecutive patients with mechanical mitral valve prosthesis were investigated by both transthoracic echocardiography and transesophageal echocardiography. These examinations were performed for recent systemic emboli (15 patients), fever of unknown etiology (11 patients), routine postoperative evaluation (56 patients), and other reasons (32 patients). Based on transthoracic echo diagnosis, all prostheses were considered normal. Yet, in 20 patients transesophageal echocardiography revealed the presence of a 2- to 15-mm-long mobile thrombus localized on the atrial surface of the prosthesis. When compared with the remaining 94 patients with no visible thrombi, there was no significant difference between the two groups in terms of incidence of atrial fibrillation (65% versus 52%), left atrial size (48 +/- 9 versus 51 +/- 13 mm), left ventricular end-diastolic diameter (49 +/- 10 versus 51 +/- 13 mm) and fractional shortening (28 +/- 9% versus 31 +/- 10%), presence of spontaneous contrast to the left atrium (40% versus 41%), transprosthetic mean pressure gradient (4.0 +/- 1.4 versus 3.9 +/- 1.5 mm Hg), or the type of prosthesis used. After we discovered a nonobstructive thrombosis, patients were treated with heparin (n = 9) or oral anticoagulation (n = 11). The presence of a localized thrombus was confirmed in 3 patients who were operated on. In the present study, evolution appeared to depend on thrombus size: of 14 patients exhibiting a small (< 5 mm) thrombus, 10 had an uneventful course, whereas 5 of 6 patients with a large (> or = 5 mm) thrombus developed complications or died., Conclusions: Transesophageal echocardiography appears to be a reliable method to diagnose thrombi on a mechanical mitral valve prosthesis, even when transthoracic Doppler echocardiographic parameters appear to be normal. Transesophageal echo assessment of thrombus size may be helpful in deciding whether a patient with mitral prosthesis should be treated by anticoagulation, thrombolysis, or valve rereplacement.

A technique for measuring average velocity in the inferior vena cava (IVC) by using phase-display magnetic resonance (MR) imaging is described. Fifteen healthy subjects were imaged, and the velocities and spectra obtained by MR were compared with pulsed Doppler results. Distortions of the "zebra-striped" images obtained along the axis of the vessel were measured at the same level of the IVC as in pulsed Doppler. Measurements of average velocities in the IVC made by the two methods were very similar, and velocity curves obtained during the cardiac cycle were superimposable. Phase-display MR imaging has the potential to noninvasively assess blood flow in large vessels as accurately as pulsed Doppler.