Established evidence suggests that in ARDS, platelets may exhibit a dysregulated state that exace... more Established evidence suggests that in ARDS, platelets may exhibit a dysregulated state that exacerbates lung injury. We review evidence that suggests this platelet-mediated lung injury, while present in ARDS in general, is amplified in COVID-19 ARDS in particular. Driven by a quantifiably higher degree of platelet activation and ensuing platelet serotonin liberation into plasma compared to ARDS of other etiologies, the plasma serotonin excess in COVID-19 may be responsible for many of the devastating pulmonary and extra-pulmonary clinical manifestations of the severe disease. There is ample evidence and biologic plausibility to suggest that effective serotonin receptor (5HT-2) antagonism may reverse serotonin-mediated pulmonary vasoconstriction, lessen pulmonary platelet trapping, inhibit platelet activation and aggregation, normalize increased respiratory drive, mitigate risk of pulmonary fibrosis, and counteract adverse renal, neurologic, and cardiovascular phenomena in severe COVID-19. Given we have a well-tolerated, safe, and inexpensive oral 5HT-2 antagonist, cyproheptadine, we hope to build consensus for the need to urgently investigate 5HT-2 receptor antagonism as a treatment option for severe COVID-19.
European heart journal. Acute cardiovascular care, Mar 16, 2023
There is increasing evidence on the role of ultrasound in the evaluation of multiorgan hypoperfus... more There is increasing evidence on the role of ultrasound in the evaluation of multiorgan hypoperfusion and congestion in patients with cardiocirculatory shock both to identify the underlying pathophysiological mechanism and to drive and monitor the treatment. The cardiac and lung ultrasound is included as an integrated multiparametric approach to the very early phase of patients with haemodynamic instability/cardiogenic shock. Splanchnic ultrasound has been mainly applied in heart failure and predominant circulatory failure. Although poorly validated in the critically ill, many ultrasound parameters have a strong physiological background to support their use in the acute setting those that apply either for heart/lung and for splanchnic organ evaluation. This review summarizes the ultrasonographic parameters that have shown evidence in literature in the diagnostic/therapeutic pathway to define the congestion/perfusion profile of the organs that are involved in the pathophysiological cascade of cardiocirculatory shock.
IntroductionVenous congestion is a pathophysiological state where high venous pressures cause org... more IntroductionVenous congestion is a pathophysiological state where high venous pressures cause organ oedema and dysfunction. Venous congestion is associated with worse outcomes, particularly acute kidney injury (AKI), for critically ill patients. Venous congestion can be measured by Doppler ultrasound at the bedside through interrogation of the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV) and intrarenal veins (IRV). The objective of this study is to quantify the association between Doppler identified venous congestion and the need for renal replacement therapy (RRT) or death for patients with septic shock.Methods and analysisThis study is a prespecified substudy of the ANDROMEDA-SHOCK 2 (AS-2) randomised control trial (RCT) assessing haemodynamic resuscitation in septic shock and will enrol at least 350 patients across multiple sites. We will include adult patients within 4 hours of fulfilling septic shock definition according to Sepsis-3 consensus conference. Using ...
BACKGROUND: Pericardial tamponade can often be diagnosed through clinical findings and echocardio... more BACKGROUND: Pericardial tamponade can often be diagnosed through clinical findings and echocardiography; however, the diagnosis can be aided by demonstrating the hemodynamic consequences of the effusion. We describe the use of a wearable carotid Doppler device to help diagnose and monitor pericardial tamponade. CASE SUMMARY: A 54-year-old man developed hypotension after an endobronchial biopsy for a lung mass. Echocardiography showed a pericardial effusion with sonographic evidence of tamponade. A wearable carotid Doppler device demonstrated low corrected carotid flow time (CFT) (a surrogate for stroke volume) with significant respiratory variation, supporting the diagnosis of tamponade. The patient underwent pericardiocentesis which revealed purulent pericardial fluid from a mediastinal abscess. After drainage there was increased CFT and reduced respiratory variability in Doppler, surrogates of improved stroke volume. CONCLUSION: A wearable carotid Doppler device is a noninvasive t...
Established evidence suggests that in ARDS, platelets may exhibit a dysregulated state that exace... more Established evidence suggests that in ARDS, platelets may exhibit a dysregulated state that exacerbates lung injury. We review evidence that suggests this platelet-mediated lung injury, while present in ARDS in general, is amplified in COVID-19 ARDS in particular. Driven by a quantifiably higher degree of platelet activation and ensuing platelet serotonin liberation into plasma compared to ARDS of other etiologies, the plasma serotonin excess in COVID-19 may be responsible for many of the devastating pulmonary and extra-pulmonary clinical manifestations of the severe disease. There is ample evidence and biologic plausibility to suggest that effective serotonin receptor (5HT-2) antagonism may reverse serotonin-mediated pulmonary vasoconstriction, lessen pulmonary platelet trapping, inhibit platelet activation and aggregation, normalize increased respiratory drive, mitigate risk of pulmonary fibrosis, and counteract adverse renal, neurologic, and cardiovascular phenomena in severe COVID-19. Given we have a well-tolerated, safe, and inexpensive oral 5HT-2 antagonist, cyproheptadine, we hope to build consensus for the need to urgently investigate 5HT-2 receptor antagonism as a treatment option for severe COVID-19.
European heart journal. Acute cardiovascular care, Mar 16, 2023
There is increasing evidence on the role of ultrasound in the evaluation of multiorgan hypoperfus... more There is increasing evidence on the role of ultrasound in the evaluation of multiorgan hypoperfusion and congestion in patients with cardiocirculatory shock both to identify the underlying pathophysiological mechanism and to drive and monitor the treatment. The cardiac and lung ultrasound is included as an integrated multiparametric approach to the very early phase of patients with haemodynamic instability/cardiogenic shock. Splanchnic ultrasound has been mainly applied in heart failure and predominant circulatory failure. Although poorly validated in the critically ill, many ultrasound parameters have a strong physiological background to support their use in the acute setting those that apply either for heart/lung and for splanchnic organ evaluation. This review summarizes the ultrasonographic parameters that have shown evidence in literature in the diagnostic/therapeutic pathway to define the congestion/perfusion profile of the organs that are involved in the pathophysiological cascade of cardiocirculatory shock.
IntroductionVenous congestion is a pathophysiological state where high venous pressures cause org... more IntroductionVenous congestion is a pathophysiological state where high venous pressures cause organ oedema and dysfunction. Venous congestion is associated with worse outcomes, particularly acute kidney injury (AKI), for critically ill patients. Venous congestion can be measured by Doppler ultrasound at the bedside through interrogation of the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV) and intrarenal veins (IRV). The objective of this study is to quantify the association between Doppler identified venous congestion and the need for renal replacement therapy (RRT) or death for patients with septic shock.Methods and analysisThis study is a prespecified substudy of the ANDROMEDA-SHOCK 2 (AS-2) randomised control trial (RCT) assessing haemodynamic resuscitation in septic shock and will enrol at least 350 patients across multiple sites. We will include adult patients within 4 hours of fulfilling septic shock definition according to Sepsis-3 consensus conference. Using ...
BACKGROUND: Pericardial tamponade can often be diagnosed through clinical findings and echocardio... more BACKGROUND: Pericardial tamponade can often be diagnosed through clinical findings and echocardiography; however, the diagnosis can be aided by demonstrating the hemodynamic consequences of the effusion. We describe the use of a wearable carotid Doppler device to help diagnose and monitor pericardial tamponade. CASE SUMMARY: A 54-year-old man developed hypotension after an endobronchial biopsy for a lung mass. Echocardiography showed a pericardial effusion with sonographic evidence of tamponade. A wearable carotid Doppler device demonstrated low corrected carotid flow time (CFT) (a surrogate for stroke volume) with significant respiratory variation, supporting the diagnosis of tamponade. The patient underwent pericardiocentesis which revealed purulent pericardial fluid from a mediastinal abscess. After drainage there was increased CFT and reduced respiratory variability in Doppler, surrogates of improved stroke volume. CONCLUSION: A wearable carotid Doppler device is a noninvasive t...
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