470 Correspondence

Vinod K. Chaubey, MD

Department of Medicine, St. Vincent Hospital, University of Massachusetts

Medical School, Worcester, MA Corresponding author. 123 Summer Street, Worcester, MA 01604 Tel.: +1 508 363 5000; fax: +1 508 363 9798

E-mail address: [email protected]

Lovely Chhabra, MD Department of cardiovascular medicine, Hartford Hospital University of Connecticut School of Medicine, Hartford, CT

Nirmal J. Kaur, MD

Department of Medicine, St. Vincent Hospital, University of Massachusetts

Medical School, Worcester, MA

http://dx.doi.org/10.1016/j.ajem.2014.12.064

References

1. Casavecchia Graziapia, Gravina Matteo, Totaro Antonio, Leva Riccardo, Vinci Roberta, Macarini Luca, et al. Role of cardiac magnetic resonance in the differential diagnosis of Tako-Tsubo car- diomyopathy. Am J Emerg Med 2014. http://dx.doi.org/10.1016/j.ajem.2014.11.040.
2. Chhabra L, Khalid N, Kluger J, Spodick DH. Lupus myopericarditis as a preceding stressor for takotsubo cardiomyopathy. Proc (Bayl Univ Med Cent) 2014;27:327-30.
3. Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy. JAMA 2011;306:277-86.
4. Simon MA. Assessment and treatment of right ventricular failure. Nat Rev Cardiol 2013;10:204-18.
5. Haghi D, Athanasiadis A, Papavassiliu T, Suselbeck T, Fluechter S, Mahrholdt H, et al. Right ventricular involvement in Takotsubo cardiomyopathy. Eur Heart J 2006;27(20):2433-9.

   Implication of bedside Cardiopulmonary ultrasound on health care cost: an additional advantage?

   

   To the Editor,

   We read with great interest the work by Gallard et al [1]. Authors’ work is commendable in triaging and diagnosing patients with acute dys- pnea with the use of bedside cardiopulmonary ultrasound. Indeed, the point-of-care (POC) cardiopulmonary ultrasound is not only an important Diagnostic modality but also serves as an immensely useful guide during emergent cardiac procedures (such as pericardiocentesis) and resuscita- tion of critically ill patients [2]. This is especially true with the newest high-quality and easy-to-use handheld cardiac Ultrasound devices.

   The current study especially sparks our interest from a financial per- spective. A recently published New York Times article sheds light on the wide variations of medical billing and reimbursements for echocardio- grams based on the various institutions, practice settings, and medical insurance carriers involved [3]. In our personal opinion, a POC ultra- sound (if appropriately used) may offer a significant impact on reducing the health care costs and improving patient satisfaction. For instance, a point of contact ultrasound may prevent an inpatient admission for a pa- tient presenting to the emergency department (ED) with acute dyspnea demonstrating symptomatic resolution with the initial ED therapy who would otherwise be just admitted for a comprehensive inpatient workup with the limiting time factor being an echocardiogram for many practical purposes [4]. Furthermore, office-based or ED-based POC echocardio- grams billing cost is much lower as opposed to echocardiograms per- formed in hospital-based outpatient or inpatient setting as per the data

   from the Medicare reimbursements. Still, the reimbursements for POC echocardiograms may be considered reasonable for physicians because they involve much lesser time and upfront infrastructure cost. This may be extremely useful in the upcoming model of care of Accountable Care Organization [5].

   However, the big question still remains: “Can handheld ultrasound devices be considered the standard of care across the country’s EDs?” Certainly, the answer is affirmative when the goal is cost-effective health care. This would indeed require a dedicated training of the ED staff and commitment of the ED physicians across the country for its adoption as a new standard of care not only for quick screening but which also meets the more comprehensive diagnostic standards.

   Lovely Chhabra, MD Department of Cardiovascular Medicine, Hartford Hospital University of Connecticut School of Medicine, Hartford, CT

   Vinod K. Chaubey, MD

   Department of Medicine, Saint Vincent Hospital University of Massachusetts Medical School, Worcester, MA Corresponding author. 123 Summer St., Worcester, MA 01604 Tel.: +1 508 363 5000; fax: +1 508 363 9798

   E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.01.041

   References

   Gallard Emeric, Redonnet Jean-Philippe, Bourcier JeanEudes, Deshaies Dominique, Largeteau Nicolas, Amalric Jeanne-Marie, et al. Diagnostic perfor- mance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea. Am J Emerg Med 2014. http://dx.doi.org/ 10.1016/j.ajem.2014.12.003 [pii: S0735-6757(14)00896-1, Epub ahead of print].

6. Herbst MK, Camargo Jr CA, Perez A, Moore CL. Use of Point-of-Care Ultrasound in Con- necticut Emergency Departments. J Emerg Med 2015;48(2) 191-196.e2.
7. http://www.nytimes.com/2014/12/16/health/the-odd-math-of-medical-tests-one- echocardiogram-two-prices-both-high.html?_r=1.
8. Cardim N, Fernandez Golfin C, Ferreira D, Aubele A, et al. Usefulness of a new minia- turized echocardiographic system in outpatient cardiology consultations as an exten- sion of physical examination. J Am Soc Echocardiogr 2011;24:117-24.
9. Berwick DM. Making good on ACOs’ promise-the final rule for the Medicare shared savings program. N Engl J Med 2011;365:1753-6.

   Implication of bedside cardiopulmonary ultrasound

   

   on health care cost - An additional advantage: Author reply?

   To the Editor,

   We thank you for your interest in our study and agree with you on the importance of thinking about the costs resulting from patient care in the emergency department (ED). Although our study did not focus on this issue, we have demonstrated that, in comparison with the usual procedure, cardiopulmonary ultrasound in the hands of the ED physician succeeds in giving an exact diagnosis for more patients. This allows us nowadays to avoid realizing costly examinations such as N-terminal pro-brain natriuretic peptide or chest x-ray. Neverthe- less, this does not represent the main cost reduction. Ultrasound in the ED allows us to direct elderly patients into units better suited to their pathology. Being better treated and oriented, these patients have a shorter stay, thus reducing the costs, although this still has to

   ? Funding: None. ? Conflict of interest: The authors have no conflict of interest to disclose.

   Correspondence

   be proven by further studies. Beyond the financial aspect, we think that the main interest of cardiopulmonary ultrasound in the ED is to give a faster and more accurate diagnosis, thus allowing to initiate a more appropriate treatment.

   Sincerely yours,

   471

   Mustafa Tanriseven, MD

   Department of General Surgery, Diyarbakir Military hospital

   Diyarbakir, Turkey

   Eyup Duran, MD

   Emeric Gallard, MD? Jean-Eudes Bourcier, MD Jean-Philippe Redonnet, MD

   Didier Garnier, MD

   Emergency, Anesthesiology, and Critical Care Department

   Lourdes Hospital, Lourdes, France

   Corresponding author at: Service d’Accueil des Urgences, CHG Lourdes

   65100 Lourdes, France

   E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2015.01.042

   Department of General Surgery, Elazig Military Hospital, Elazig, Turkey

   http://dx.doi.org/10.1016/j.ajem.2015.02.004

   References

   Sirvent JM, Ferri C, Baro A, Murcia C, Lorencio C. fluid balance in sepsis and septic shock as a determining factor of mortality. Am J Emerg Med 2014. http://dx.doi.org/ 10.1016/j.ajem.2014.11.016.

10. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed ther- apy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77.
11. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with in- creased mortality. Crit Care Med 2011;39:259-65.
12. Coen D, Cortellano F, Pasini S, Tombini V, Vaccaro A, Montalbetti L, et al. Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med 2014;32:563-8.
13. Marik PE, Varon J. Early goal-directed therapy: on Terminal life support? Am J Emerg Med 2010;28:243-5.

    Fluid necessity should be followed by central venous pressure?

    

    To the Editor,

    We intentionally read the article “Fluid balance in sepsis and septic shock as a determining factor of mortality” written by Sirvent et al [1] with interest. They concluded that a positive fluid balance in the first 4 days was associated with higher mortality in severe sepsis and patients with septic shock [1].

    There is a global tissue hypoxia in severe sepsis and septic shock, which may proceed to multiorgan failure and death [2]. Too little fluid may result in tissue hypoperfusion and worsen organ dysfunction [3]. Intravenous fluids, source control, vasopressors, inotropic agents, and mechanical ventilation are a key component in the early manage- ment of septic shock [3] and used to a balance in normalized values for mixed venous oxygen saturation, arterial lactate concentration, Base deficit, and pH [2].

    It is necessary that early central venous catheter is placed and a central venous pressure measured as an indicator of volume respon- siveness [4]. The major elements of early goal-directed therapy include fluid resuscitation to achive a central venous pressure of 8 to 12 cm of water and to maintain the Central venous oxygen saturation higher than 70% [5].

    We think that fluid necessity should be followed by central ve- nous pressure. Positive fluid balance is a result of low urine output because of tissue hypoperfusion and renal failure. There is a positive correlation between mortality and renal failure induced by tissue hypoperfusion. For this reason, creatinine and lactate levels should be monitored closely initially and after.

    Hakan Sarlak, MD

    Department of Internal Medicine, Diyarbakir Military Hospital

    Diyarbakir, Turkey Corresponding author. Department of Internal Medicine, Diyarbakir Military Hospital, Seref Inaloz St, 21100 Yenisehir,Diyarbakir, Turkey Tel.: +90 412 2288 225; fax: +90 412 2236 732

    E-mail address: [email protected]

    ? There is no conflict of interests.

    Fluid balance in sepsis: a single parameter does not provide the solution

    To the Editor,

    

    We have read with attention the letter by Hakan Sarlak with the title “Fluid necessity should be followed by central venous pressure” (CVP) about our recent study published in The American Journal of Emergency Medicine [1]. We agree that the CVP provides valuable information about the interaction of pump function of the heart and venous return when we consider simultaneously your changes and cardiac output. However, the analysis is complex in critically ill patients because, in addition to a technically adequate measurement, the interpretation requires consideration of multiple factors affecting the cardiac pressures

    [2] (hence, the importance to avoid inadequate venous return in the Initial resuscitation of critically ill). What choice do we have, in practice, to ensure that we have sufficient venous return, with a fast and simple measure (CVP), applicable to any intensive care unit and emergency department? In addition to Ultrasound techniques, we think that the initial evaluation of septic patients should evaluate the clinical exami- nation and measure the CVP. The recommendation for a CVP, while rec- ognizing its limitations, in the initial resuscitation of septic patient, we think it is a guarantor measure at an initial time of resuscitation in which the priority is to ensure sufficient venous return [2]. Obviously, in our observational study, all patients had a central venous catheter inserted, and CVP and central venous saturation were measured at baseline and at 6 hours.

    However, several studies have emphasized the reduced clinical value of static hemodynamic parameters, such as CVP [3] and pulmonary artery occluding pressure, as compared with dynamic parameters in predicting fluid responsiveness. Such dynamic indicators include pas- sive leg raising, which induced changes in cardiac output [4] and ultra- sound to evaluate the variations of both superior and inferior vena cava diameter and distensibility [5].

    The mechanisms by which positive fluid balance can adversely influence outcomes remain unknown. Nevertheless, hypervolemia might exacerbate capillary leak in septic shock patient, thus contribut- ing to pulmonary edema. Positive fluid balance could also result in intraabdominal hypertension, thus contributing to organ hypoperfusion and subsequent organ failure [6].