Circulatory Failure Research Articles

Renal Doppler ultrasound on admission to predict acute kidney injury in patients with acute circulatory failure

Renal Doppler ultrasound on admission to predict acute kidney injury in patients with acute circulatory failure

Risk factors of peri-intubation cardiovascular collapse in critically ill patients

Risk factors of peri-intubation cardiovascular collapse in critically ill patients

Amniotic fluid embolism rescued using venoarterial extracorporeal membrane oxygenation without initial anticoagulation: A case report and literature review.

Amniotic fluid embolism (AFE) is a fatal obstetric condition that often rapidly leads to severe respiratory and circulatory failure. It is complicated by obstetric disseminated intravascular coagulation (DIC) with bleeding tendency; therefore, the introduction of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is challenging. We report the case of a patient with AFE requiring massive blood transfusion, rescued using VA-ECMO without initial anticoagulation. A 39-year-old pregnant patient was admitted with a complaint of abdominal pain. An emergency cesarean section was performed because a sudden decrease in fetal heart rate was detected in addition to DIC with hyperfibrinolysis. Intra- and post-operatively, the patient had a bleeding tendency and required massive blood transfusions. After surgery, the patient developed lethal respiratory and circulatory failure, and VA-ECMO was introduced. Based on the course of the illness and imaging findings, the patient was diagnosed with AFE. By controlling the bleeding tendency with a massive transfusion and tranexamic acid administration, using an antithrombotic ECMO circuit, and delaying the initiation of anticoagulation and anti-DIC medication until the bleeding tendency settled, the patient was managed safely on ECMO without complications. By day 5, both respiration and circulation were stable, and the patient was weaned off VA-ECMO. Mechanical ventilation was discontinued on day 6. Finally, she was discharged home without sequelae. VA-ECMO may be effective to save the lives of patients who have AFE with lethal circulatory and respiratory failure. For safe management without bleeding complications, it is important to start VA-ECMO without initial anticoagulants and to administer anticoagulants and anti-DIC drugs after the bleeding tendency has resolved.

Circulatory Failure in the Central Retinal Artery during Medial Orbital Wall Blow-out Fracture Repair

Purpose: We report a case of visual impairment due to circulatory failure in the central retinal artery during blow-out fracture repair.Case summary: A 16-year-old male with no underlying disease was diagnosed with a trapdoor type medial orbital wall blow-out fracture after a motorcycle accident and underwent blow-out fracture repair. During the surgery, his left eye was nearly completely dilated. Postoperatively, the visual acuity in the left eye was hand motion and there was ptosis of the left upper eyelid. Concerned with the possibility of orbital implant compression, computed tomography was performed immediately and a second operation was performed. However, there was no direct compression originating from the intraocular implant or any signs of active bleeding. The following day, optical coherence tomography and fluorescein angiography revealed a cherry-red spot on the central fovea with edema of the inner retinal layer and delayed arterial circulation. Under a diagnosis of incomplete central retinal artery occlusion, the patient was treated with intraocular pressure-lowering eye drops and intravenous mannitol. Despite prompt intervention, the visual acuity of the left eye did not improve beyond 0.04 at the 2-year follow-up.Conclusions: When there is visual impairment and pupillary dilation after blow-out fracture repair, we should consider not only compressive factors but also the possibility of central retinal artery occlusion or circulatory failure. In such cases, retinal examinations should be done to assess the retinal blood flow and enable early detection of any complications allowing prompt appropriate intervention.

Diabetic ketoacidosis in type 1 diabetes mellitus in children and adolescents

Background: Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM). Although T1DM can occur in children and adults, DKA caused by T1DM is more severe in children and adolescents and metabolic changes occur more rapidly. This review discusses clinical factors associated with DKA assessed during diagnosis in children and adolescents with T1DM.Current Concepts: DKA is a severe complication that can occur in children with T1DM because of insulin deficiency, leading to high levels of catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, muscle proteolysis, hyperglycemia, and osmotic diuresis. High levels of counterregulatory hormones that enhance ketogenesis have also been noted. High blood sugar levels, dehydration, and the release of ketone bodies into the circulation cause high occurrence of acidosis. DKA can lead to life-threatening complications, such as cerebral edema, which is more common in children than in adults. Other potential complications include kidney failure, respiratory distress, and cardiovascular collapse. Children with T1DM are at a higher risk of developing DKA, particularly during times of illness or stress, or when insulin doses are missed or insufficient. In addition, undiagnosed T1DM in children can lead to DKA when the body enters a state of severe insulin deficiency.Discussion and Conclusion: The risks should be detected earlier and the pathogenesis of T1DM should be understood and assessed by physicians in children and adolescents during check-ups. Furthermore, efforts to increase public awareness are required to reduce the cognitive delays associated with DKA.

Neonatal somatic oxygenation and perfusion assessment using near-infrared spectroscopy : Part of the series on near-infrared spectroscopy by the European Society of Paediatric Research Special Interest Group "Near-Infrared Spectroscopy".

In this narrative review, we summarize the current knowledge and applications of somatic near-infrared spectroscopy (NIRS), with a focus on intestinal, renal, limb, and multi-site applications in neonates. Assessing somatic oxygenation at various body locations in neonates may aid in the understanding of underlying pathophysiology of organ injury. Considering cerebral autoregulation may be active to protect the brain during systemic circulatory failure, peripheral somatic oxygenation may potentially provide an early indication of neonatal cardiovascular failure and ultimate hypoxemic injury to vital organs including the brain. Certain intestinal oxygenation patterns appear to be associated with the onset and course of necrotizing enterocolitis, whereas impaired renal oxygenation may indicate the onset of acute kidney injury after various types of hypoxic events. Peripheral muscle oxygenation measured at a limb may be particularly effective in the early prediction of shock in neonates. Using multi-site NIRS may complement current approaches and clinical investigations to alert for neonatal tissue hypoxemia, and potentially even guide management. However, somatic NIRS has its inherent limitations in regard to accuracy. Interpretation of organ-specific values can also be challenging. Last, currently there are limited prospective intervention studies, and clinical benefits need to be examined further, after the clarification of critical threshold-values. IMPACT: The assessment of somatic oxygenation using NIRS may contribute to the prediction of specific diseases in hemodynamically challenged neonates. Furthermore, it may give early warning signs for impending cardiovascular failure, and impaired cerebral circulation and oxygenation. We present a comprehensive overview of the literature on applications of NIRS to various somatic areas, with a focus on its potential clinical applicability, including future research directions. This paper will enable prospective standardized studies, and multicenter collaboration to obtain statistical power, likely to advance the field.

V-A ECMO window of opportunity: identification of potential responders after an acute myocardial infarction complicated by cardiogenic shock

Abstract Funding Acknowledgements None. Background V-A ECMO is designed to supply oxygen demands in patients with circulatory failure. Neutral results obtained in recent cardiogenic shock (CS) trials are probably related to the inclusion of a high proportion of patients with SCAI C stage, in many of whom, the device might not provide hemodynamic benefit despite the addition of inherent complications. Mechanical circulatory support could potentially have a role only for patients in SCAI D-E stages. Purpose Our aim was to explore the excess in mortality explained by a SCAI D-E stage at 12h, compared to a SCAI A-C stages at 12h, in patients admitted due to an acute myocardial infarction (AMI) complicated by CS (stages C-E at admission). Additionally, we aimed to identify those factors at admission—clinical, electrocardiographic, gasometrical, echocardiographic, and angiographic—which predict whether a patient will progress to SCAI D-E stages within the subsequent 12h from CS onset. Main Outcome: SCAI D and E stage at 12h. Methods We retrospectively analysed those patients admitted due to an AMI in SCAI C-E stages at admission, that had been prospectively screened for EUROSHOCK trial. We classified the patients in two groups: "SCAI A-C" and "SCAI D-E" at 12 hours and conducted a survival analysis. Additionally, we conducted a univariate and multivariate analysis including arrival potential predictors for SCAI D-E at 12 hours. Results A total of 72 patients were included. At admission 25 patien were in SCAI D-E. At 12 hours, 42 patients were in SCAI D-E, and this group showed a higher 30-day mortality rate particularly explained by an excess of mortality within the first 7 days (Figure 1). There were no significant differences between groups in most baseline characteristics (Table 1) such as age or gender. We observed a fewer proportion of previous chronic treatment with negative inotropes (betablockers and calcium channel antagonists) in the SCAI D-E group. Overall, anterior ST elevation on EKG was more prevalent among SCAI D-E group, median pH lower and median glycaemia and lactate higher. In the multivariate analysis after adjustment by confounders, the independently predictors at arrival for the development of a SCAI D-E stage at 12h were culprit LAD, cardiac arrest in the cath Lab, low initial median pH and final TIMI <3 result. Conclusions In a cohort of AMI patients complicated by CS, those patients who remained in a SCAI D-E stage at 12 hours from CS onset, compared to those in A-C, showed a 26% excess mortality at 30-day follow-up, especially during the first week. Patients who presented with LAD as the culprit artery, low initial pH, cardiac arrest in the cath lab, and got a TIMI <3 result after PCI were independently associated with the development of SCAI D-E within 12 hours from admission. Patients meeting these criteria could benefit from early selective mechanical support and be taken into consideration in the design of future randomized controlled trials.

Dynamic changes of hepatic vein Doppler velocities predict preload responsiveness in mechanically ventilated critically ill patients

BackgroundAssessment of dynamic parameters to guide fluid administration is one of the mainstays of current resuscitation strategies. Each test has its own limitations, but passive leg raising (PLR) has emerged as one of the most versatile preload responsiveness tests. However, it requires real-time cardiac output (CO) measurement either through advanced monitoring devices, which are not routinely available, or echocardiography, which is not always feasible. Analysis of the hepatic vein Doppler waveform change, a simpler ultrasound-based assessment, during a dynamic test such as PLR could be useful in predicting preload responsiveness. The objective of this study was to assess the diagnostic accuracy of hepatic vein Doppler S and D-wave velocities during PLR as a predictor of preload responsiveness.MethodsProspective observational study conducted in two medical–surgical ICUs in Chile. Patients in circulatory failure and connected to controlled mechanical ventilation were included from August to December 2023. A baseline ultrasound assessment of cardiac function was performed. Then, simultaneously, ultrasound measurements of hepatic vein Doppler S and D waves and cardiac output by continuous pulse contour analysis device were performed during a PLR maneuver.ResultsThirty-seven patients were analyzed. 63% of the patients were preload responsive defined by a 10% increase in CO after passive leg raising. A 20% increase in the maximum S wave velocity after PLR showed the best diagnostic accuracy with a sensitivity of 69.6% (49.1–84.4) and specificity of 92.8 (68.5–99.6) to detect preload responsiveness, with an area under curve of receiving operator characteristic (AUC–ROC) of 0.82 ± 0.07 (p = 0.001 vs. AUC–ROC of 0.5). D-wave velocities showed worse diagnostic accuracy.ConclusionsHepatic vein Doppler assessment emerges as a novel complementary technique with adequate predictive capacity to identify preload responsiveness in patients in mechanical ventilation and circulatory failure. This technique could become valuable in scenarios of basic hemodynamic monitoring and when echocardiography is not feasible. Future studies should confirm these results.

A case of multisystem inflammatory syndrome in children/pediatric inflammatory multisystem syndrome presenting with central nervous system lesions and circulatory failure

A case of multisystem inflammatory syndrome in children/pediatric inflammatory multisystem syndrome presenting with central nervous system lesions and circulatory failure

Antepartum and Intrapartum Characteristics Associated With Neonatal Encephalopathy [ID 2683510

INTRODUCTION: We aim to identify antepartum and intrapartum characteristics associated with neonatal encephalopathy (NE). METHODS: This is a retrospective cohort study from 2013 to 2023. Neonates greater than 34–35 weeks of gestation with NE were identified based on ICD-9/ICD-10 codes. Each case was matched to three controls. Neonates (>34–35 weeks of gestation, cord pH >7, no NE) next to index case were identified as controls. Congenital anomalies, chromosomal abnormalities, and less than 34 weeks were excluded. The outcome measures are incidence and trends of NE in last 10 years and antepartum and intrapartum risk factors associated with NE. This study was IRB approved. RESULTS: Twenty cases were included and matched with 60 controls. The number of cases increased since 2013. 1 in 6,000 neonates delivered was identified as NE in 2014, versus 4 of the 5,700 births in 2016, versus 3 of the 2,114 neonates delivered in 2023. Mean maternal age, race/ethnicity/insurance are similar between groups. Cases are more likely to have obesity class 3 (P=.05) and nulliparous (P=.01), class A2 gestational diabetes mellitus (GDMA2) (P=.05), preterm prelabor rupture of membranes (PPROM) (P=.0.01), and tobacco use (P=.00). There is statistically significant difference in Category 3 fetal heart tracing (P=.00), meconium (P=.03), placental abruption (P=.00), and general anesthesia (P=.00) between groups. Mode of delivery, breech, shoulder dystocia cord prolapse, chorioamnionitis, uterine rupture, amniotic fluid embolism, and maternal cardiovascular collapse were similar between groups. Gestational age at delivery, birth weight, and gender were similar between groups. CONCLUSION: The risk factors associated with NE in our study are obesity class 3, nulliparity, tobacco use, GDMA2, PPROM, Category 3 tracing, meconium, and placental abruption.

A case report on digoxin toxicity

Digoxin is an inotropic drug that is commonly prescribed in patient with heart related diseases. The effective dose of digoxin is 0.8-2.0 ng/ml beyond which digoxin causes toxic effects like visual dysfunction, irregular heartbeat, and cardiovascular collapse. Digoxin toxicity is caused due to increased automaticity and inotropy due to intracellular calcium and decreased dromotropy due to poisoning of sodium potassium transporter and AV nodal blockade. Digoxin toxicity should be assessed by continuous hemodynamic and cardiac monitoring including 12-lead electrocardiogram. There should be timely and immediate evaluation of electrolyte levels like potassium, calcium, serum creatinine and digoxin levels and prompt intensive care unit admission, if necessary. In this case study we studied a 43 old female patient prescribed with digoxin 0.25 mg, who had a medical history of congestive cardiac failure presented with symptoms of digoxin toxicity. The patient was assessed with electrocardiography (ECG) and managed by keeping digoxin on hold and effective patient counselling.

Detection of Arrhythmias Using Smartwatches-A Systematic Literature Review.

Smartwatches represent one of the most widely adopted technological innovations among wearable devices. Their evolution has equipped them with an increasing array of features, including the capability to record an electrocardiogram. This functionality allows users to detect potential arrhythmias, enabling prompt intervention or monitoring of existing arrhythmias, such as atrial fibrillation. In our research, we aimed to compile case reports, case series, and cohort studies from the Web of Science, PubMed, Scopus, and Embase databases published until 1 August 2023. The search employed keywords such as "Smart Watch", "Apple Watch", "Samsung Gear", "Samsung Galaxy Watch", "Google Pixel Watch", "Fitbit", "Huawei Watch", "Withings", "Garmin", "Atrial Fibrillation", "Supraventricular Tachycardia", "Cardiac Arrhythmia", "Ventricular Tachycardia", "Atrioventricular Nodal Reentrant Tachycardia", "Atrioventricular Reentrant Tachycardia", "Heart Block", "Atrial Flutter", "Ectopic Atrial Tachycardia", and "Bradyarrhythmia." We obtained a total of 758 results, from which we selected 57 articles, including 33 case reports and case series, as well as 24 cohort studies. Most of the scientific works focused on atrial fibrillation, which is often detected using Apple Watches. Nevertheless, we also included articles investigating arrhythmias with the potential for circulatory collapse without immediate intervention. This systematic literature review provides a comprehensive overview of the current state of research on arrhythmia detection using smartwatches. Through further research, it may be possible to develop a care protocol that integrates arrhythmias recorded by smartwatches, allowing for timely access to appropriate medical care for patients. Additionally, continuous monitoring of existing arrhythmias using smartwatches could facilitate the assessment of the effectiveness of prescribed therapies.

Validation of Difficult Airway Physiological Score (DAPS) in Critically Ill Adults Undergoing Endotracheal Intubation in the Emergency Department

Background. Critically ill patients have increased risk of cardiovascular collapse following endotracheal intubation due to physiological instability. This study aims to validate the Difficult Airway Physiological Score (DAPS) in adults to predict the risk of serious outcomes in the emergency department of a tertiary care private hospital. Methods. This is a cohort study conducted in the emergency department (ED) from 2021 to 2022. Difficult Airway Physiological Score (DAPS) was derived from a sample of 1021 patients through a retrospective study. The variables in the score were age, gender, time of intubation, vitals and vomiting at presentation, pH <7.3, fever, physician’s anticipation for patient decline, and agitation. The model performance was assessed prospectively on a separate dataset (n = 326) using train-test split method. Postintubation desaturation, hypotension, cardiac arrest, and mortality postintubation were the serious outcomes. ROC analysis, sensitivity, specificity, PPV, and NPV were used to assess score validity. Results. Our study includes 326 patients, of which 123 (37.7%) were males and 203 (62.2%) were females. The sample was divided into high-risk (DAPS ≥10) group, n = 194 with mean age of 52 (SD = ±18) years, and low-risk (DAPS <10) group, n = 132 with mean age of 47.7 (SD = ±17.4) years. The shock index ≥0.9 was in 128 (66%), while it was <0.9 in low-risk n = 111 (84%), p value <0.001. Similarly, pH <7.3 was seen in 70 (36.1%) in high-risk group compared to 4 (3%) in low-risk group, p value <0.001. Cardiac arrest was observed in 56 (17.2%) patients, of which 45 (23.2%) were in high-risk and 11 (8.3%) in low-risk groups (p<0.001). Hypotension was the primary outcome in the high-risk group 100 (51.5%) versus 32 (24.2%) in low-risk group (p<0.001). The DAPS of 10 had an area under the curve of 0.865 (0.71–0.84). The sensitivity of DAPS was 78.5%, specificity 77.9%, and accuracy 78.2%. Conclusion. The score can accurately predict serious outcomes in critically ill adult patients with physiologically difficult airway demonstrating good sensitivity and specificity.

Ineffectiveness of hemoadsorption in large animals with abdominal sepsis: a randomized controlled porcine study.

The use of hemoadsorption (HA) has become popular in the treatment of vasoplegic states associated with massive cytokine release, including septic shock. However, this approach does not seem to be based on robust evidence, and it does not follow international guidelines. To understand the pathophysiological rationale and timing of HA, we conducted a large animal septic shock experiment. Prospective randomized large-animal peritoneal septic shock experiment. Laboratory investigation. Twenty-six anesthetized, mechanically ventilated, and instrumented pigs randomly assigned into (1) sham-operated group with HA (SHAM, n = 5); (2) sepsis animals without HA (SEPSIS, n = 5); (3) sepsis group with HA at norepinephrine initiation (EARLY, n = 8); and (4) sepsis group with HA initiated at norepinephrine rate reaching 0.5 μg/kg/min (LATE, n = 8). Peritoneal sepsis was induced by cultivated autologous feces inoculation. A CytoSorb cartridge (200 g) with a blood flow rate of 200 mL/min and heparin anticoagulation was used to perform HA. The animals received sedation and intensive organ support up to 48 h or until they experienced cardiovascular collapse. Systemic hemodynamics, multiple-organ functions, and immune-inflammatory response were measured at predefined periods. The HA treatment was not associated with any measurable benefit in terms of systemic hemodynamics and organ support. The systemic inflammatory markers were unaffected by any of the treatment timings. In contrast, the HA resulted in higher vasopressor load and decreased 36-h survival (5 animals in SHAM (100%), 4 (80%) in SEPSIS, 4 (57%) in EARLY, and 2 (25%) in LATE; p = 0.041). The HA exposure in healthy animals was associated with hemodynamic deterioration, systemic inflammatory response, and cytopenia. In this large-animal-controlled fulminant sepsis study, the HA was unable to counteract the disease progression in the early or advanced septic shock phase. However, findings from the HA-exposed sham animals suggest potential safety concerns.

704 Hydroxocobalamin Is Not Associated with Methemoglobinemia in Patients with Inhalation Injury and Suspected Cyanide Toxicity

Abstract Introduction Cyanide poisoning is a serious threat to burn patients, especially those exposed to smoke from fires, often leading to cyanide toxicity and cardiovascular collapse. Cyanokit, a widely used hydroxocobalamin product able to convert cyanide molecules into safe compounds, is known for its potential to avoid methemoglobinemia, a side effect of other treatments. Concerns about cyanokit's safety, especially in burn patients, have arisen due to recent cases with elevated methemoglobin levels. This study investigates methemoglobin levels in burn patients treated with Cyanokit, aiming to enhance our understanding of cyanide antidote therapy complexities, ultimately leading to safer treatment strategies. Methods A retrospective study was conducted of burn patients admitted to a single institution from 2013-2023 with inhalation injury treated with cyanokit for suspected cyanide toxicity. We also analyzed a control cohort of similar patients with inhalation injury not treated with cyanokit. We analyzed changes and peaks in methemoglobin, lactate levels, kidney function tests, ventilator days, % total body surface area (TBSA), medications and dressings, and mortality. Results In the study, 36 patients with suspected inhalation injury were treated with cyanokit, compared to 32 patients with inhalation injury who weren't treated with cyanokit. Baseline characteristics showed no statistically significant differences between the groups, including age, gender, BMI, and %TBSA. No significant differences were found in initial, final, peak, or change in methemoglobin levels, initial lactate levels, mortality, Baux score, kidney function tests, ventilator days, surgeries, or use of medications/treatments (e.g., Silvadene dressings, Vitamin C) between the two groups (Table 1). When controlling for covariates, multiple linear regression analysis (age, gender, and %TBSA) indicated that cyanokit administration was not significantly associated with changes in methemoglobin or mortality. Conclusions Contrary to our initial hypothesis, our study did not find significant harm or benefit of cyanokit in burn patients during the acute phase. Methemoglobin, lactate levels, mortality, and kidney function remained largely unchanged. This study's limitations, particularly the rarity of inhalation injury cases with concern for cyanide toxicity, warrant consideration. Further research is required to comprehensively elucidate the impact of cyanokit administration on burn patients' outcomes. Applicability of Research to Practice Given the high stakes involved in treating cyanide poisoning promptly, our study holds significance for refining treatment strategies and enhancing patient safety. This insight is vital for medical practitioners making critical decisions in managing cyanide poisoning in burn patients, while also underlining the need for further research to fully understand the broader impact of cyanokit administration in this context.

The Physiologically Difficult Airway and Management Considerations

Abstract Purpose of Review This paper evaluates the recent literature regarding the physiologically difficult airway. Recent Findings Adverse events mainly desaturation, cardiovascular collapse, and cardiac arrest remain common complications. This risk is greatly increased in patients with altered physiology prior to intubation. Studies published over the last 5 years have explored many aspects surrounding the epidemiology, risks, and approach to managing the physiologically difficult airway. Summary Important work has been done to identify directly modifiable risks of complications related to the physiologically difficult airway, but a large percentage of patients remain at high risk despite optimizing induction agents, preoxygenation, and first attempt success.

Severe pulmonary hypertension and circulatory failure associated with Congenital syphilis. Case report.

Congenital syphilis is a vertical infection caused by Treponema pallidum. Despite the implementation of preventive strategies during pregnancy, its incidence is increasing, and it constitutes an important public health problem. Most patients with congenital syphilis are asymptomatic; however, a small group may develop severe disease at birth with the need of advanced resuscitation in the delivery room, acute hypoxemic respiratory failure, and hemodynamic instability. Therefore, awareness is needed. This series describes the clinical course of two late preterm infants with congenital syphilis who developed acute hypoxemic respiratory failure, pulmonary hypertension, and circulatory collapse early after birth. Integrated hemodynamic evaluation with neonatologist-performed echocardiography (NPE) and therapeutic management is provided. A comprehensive hemodynamic evaluation including early and serial functional echocardiography in these patients is needed to address the underlying complex pathophysiology and to help to establish accurate treatment.

A Guide to the Use of Vasopressors and Inotropes for Patients in Shock.

Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.

Challenges in the diagnosis and management of brown widow spider (Latrodectus geometricus) envenomation in dogs

This study reports two cases of araneism in dogs caused by the bite of the brown widow spider (Latrodectus geometricus), one of which resulted in death. The first case presented mild signs, successfully treated with medication and ice packs. The second case, more severe, involved exacerbated local signs such as extensive edema and ecchymosis, and diffuse cutaneous hemorrhage in the affected limb, as well as systemic signs, including vomiting, tetraparesis, ataxia, and epileptic seizure, culminating in renal and hepatic failure, circulatory collapse, and death. The treatments employed were based on the symptoms and included the use of analgesics and anti-inflammatories. The study highlights the importance of early diagnosis and appropriate treatment, including the use of specific antivenoms in more severe cases. It emphasizes the importance of preventive measures, such as the use of insecticides, to prevent future accidents. Awareness of the clinical signs of poisoning and the available treatment options is crucial for healthcare professionals and veterinarians to ensure proper management of these incidents and minimize their consequences.

Effect of volume infusion on left atrial strain in acute circulatory failure

BackgroundLeft atrial strain (LAS) is a measure of atrial wall deformation during cardiac cycle and reflects atrial contribution to cardiovascular performance. Pathophysiological significance of LAS in critically ill patients with hemodynamic instability has never been explored. This study aimed at describing LAS and its variation during volume expansion and to assess the relationship between LAS components and fluid responsiveness.MethodsThis prospective observational study was performed in a French ICU and included patients with acute circulatory failure, for whom the treating physician decided to proceed to volume expansion (rapid infusion of 500 mL of crystalloid solution). Trans-thoracic echocardiography was performed before and after the fluid infusion. LAS analysis was performed offline. Fluid responsiveness was defined as an increase in velocity-time integral (VTI) of left ventricular outflow tract ≥ 10%.ResultsThirty-eight patients were included in the final analysis. Seventeen (45%) patients were fluid responders. LAS analysis had a good feasibility and reproducibility. Overall, LAS was markedly reduced in all its components, with values of 19 [15 – 32], -9 [-19 – -7] and − 9 [-13 – -5] % for LAS reservoir (LASr), conduit (LAScd) and contraction (LASct), respectively. LASr, LAScd and LASct significantly increased during volume expansion in the entire population. Baseline value of LAS did not predict fluid responsiveness and the changes in LAS and VTI during volume expansion were not significantly correlated.ConclusionsLAS is severely altered during acute circulatory failure. LAS components significantly increase during fluid administration, but cannot be used to predict or assess fluid responsiveness.