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

Abstract

Aim: Numerous bedside ultrasound protocols have been developed for the evaluation of critically ill patients with bedside ultrasound. The most widely known of these protocols is the "Rapid Ultrasound for Shock and Hypotension (RUSH)’’ protocol. Diastolic dysfunction is the cause of nearly half of left ventricular dysfunctions, but no ultrasound protocol includes diastolic dysfunction. The aim of this study is to evaluate the contribution of the addition of diastolic assessment to the RUSH protocol to the diagnosis and treatment of critically ill patients. Material and Methods: This prospective, observational study was conducted in a tertiary training and research hospital emergency medicine clinic critical care area for 1 year. Non-traumatic non-pregnant adult patients with systolic blood pressure below 90 mmHg or shock index >1 with signs of circulatory disorder were included in the study. Complaints, clinical findings, and vital signs of all patients included in the study were recorded. With the primary evaluation of the patients, the RUSH protocol was applied, and the findings were recorded. All clinical, laboratory, imaging, and consultation procedures of the patients, as well as the type of shock and its treatment were planned. After the diagnosis of the patients, a second cardiac ultrasound was performed maximum 2 hours later, and diastolic parameters were evaluated and recorded. Whether there was a difference between the diagnoses and treatments of the patients before and after the diastolic parameters were measured, was compared with McNemar and paired T test. Results: A total of 69 patients with a mean age of 67 ± 13 years were included in the study, 54% of whom were females. Before the diastolic parameters of the patients were evaluated, distributive shock was detected in 20.3%, hypovolemic shock in 18.8%, obstructive-type shock in 8.7% and mixed type shock in 40.6% of the patients and their treatment was arranged accordingly. After evaluating the diastolic dysfunction parameters, distributive shock was found in 15.9% of the patients, hypovolemic shock in 18.8%, obstructive-type shock in 5.7% and mixed type shock in 47.8%. However, this change in diagnoses was not statistically significant (p=0.135). On the other hand, the treatment plans were changed in a total of 13 patients by re-adjusting the volume status due to the determination of the diastolic parameter in those patients, and the change was statistically significant (p<0.001). Conclusion: Evaluation of the diastolic parameters may not be necessary in determining the shock type in patients with shock. However, the evaluation of the diastolic parameters is effective in adjusting the treatment and volume status of critically ill patients and may need to be evaluated as soon as possible.