Accuracy of rush protocol in diagnosis of septic shock

ABSTRACT

Background: Rapid ultrasound in shock (RUSH) is the most recent emergency ultrasound protocol, designed to help clinicians better recognize distinctive shock etiologies in a shorter time frame.

Objectives:  In this study, we evaluated the accuracy of the RUSH protocol in predicting septic shock among shocked patients.

Patients and Methods: RUSH protocol was performed over all patients suspected having septic shock. All patients were closely followed to determine their final clinical diagnosis.  Sensitivity, specificity, positive predictive value (PPV) , negative predictive value (NPV) and accuracy of RUSH for diagnosis of septic shock were calculated.

Results: We performed RUSH protocol on 168 patients. Its accuracy for septic shock diagnosis is 77.27%,its sensitivity was 74.55%,its specificity was 84.09%,its positive predictive value was 92.13% and its negative predictive value was 56.92%.

Conclusion:  This study highlights the role of the RUSH exam performed by an emergency physician, to make a rapid and reliable diagnosis of shock etiology, especially in order to rule out obstructive, cardiogenic and hypovolemic shock types in initial exam of shock patients.

Keywords: Emergency; Ultrasound; Shock,septic shock.

REFERENCES

1. Dombrovskiy VY, Martin AA, Sunderram J, Paz HL. Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003. Critical care medicine. 2007;35(5):1244-50. Epub 2007/04/07.
2. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Critical care medicine. 2001;29(7):1303-10. Epub 2001/07/11.
3. Rose JS, Bair AE, Mandavia D, Kinser DJ. The UHP ultrasound protocol: Anovel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient. Am J Emerg Med 2001;19:299-302.  
4. Atkinson PR, McAuley DJ, Kendall RJ, Abeyakoon O, Reid CG, Connolly J, et al. Abdominal and cardiac evaluation with sonography in shock (ACES): An approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009;26:87-91.  
5. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid ultrasound in shock in the evaluation of critically ill patient. Emerg Med Clin North Am 2010;28:29-56.  
6. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam 2012: Rapid ultrasound in shock in the evaluation of critically ill patient. Ultrasound Clin 2012;7:255-78.  
7. Joseph M, Disney P. Transthoracic echocardiog-raphy to identify or exclude cardiac cause of shock. Chest 2004;126:1592–7.
8. Bealieu Y. Specific skill set and goals of focused echocardiography for critical care physicians. CritCare Med 2007;35:S144–9.
9. Grifoni S, Olivotto I, Cecchini P, et al. Utility of an integrated clinical, echocardio- graphic and venous ultrasound approach for triage of patients with suspected pulmonary embolism. Am J Cardiol 1998;82:1230–5.
10. Jardin F, Veillard-Baron A. Ultrasonographic examination of the vena cavae. Intensive Care Med2006;32:203–6.
11. Marik PA. Techniques for assessment of intravas-cular volume in critically ill patients. J Int CareMed 2009;24(5):329–37.
12. Blehar DJ, Dickman E, Gaspari R. Identification of congestive hear t failure via respiratory variation of inferior vena cava. Am J Em Med 2009;27:71–5.
13. Nagdev AD, Merchant RC, Tirado-Gonzalez A,et al. Emergency department bedside ultrasono-graphic measurement of the caval index for nonin-vasive determination of low central venous pressure. Ann Emerg Med 2010;55:290–5.
14. Schefold JC, Stor m C, Bercker S, et al. Inferior vena cava diameter correlates with invasive hemo-dynamic measures in mechanically ventilated intensive care patients with sepsis. J Emerg Med2010;38(5):632–7.
15. Jang T, Aubin C, Naunheim R, et al. Ultrasonog-raphy of the internal jugular vein in patients with dyspnea without jugular venous distention on phys-ical examination. Ann Emerg Med 2004;44:160–8.
16. Simon MA, Kliner DE, Girod JP, et al. Detection of elevated right atrial pressure using a simple bedside ultrasound measure. Am Heart Journ2010;159:421–7.
17. Connolly JP. Hemodynamic measurements during a tension pneumothorax. Crit Care Med 1993;21:294–6.
18. Carvalho P, Hilderbrandt J, Charan NB. Changes in bronchial and pulmonar y ar terial blood flow with Perera et al274progressive tension pneumothorax. J Appl Physiol 1996;81:1664–9.
19. Volpicelli G, Caramello V, Cardinale L, et al.Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J EmMed 2008;26:585–91.
20. Lichtenstein D. Ultrasound examination of the lungs in the ICU. Pediatr Crit Care 2009;10(6):693–8.
21. Lensing AW, Prandoni P, Brandjes D, et al. Detec-tion of deep vein thrombosis by real time B-mode ultrasonography. N Engl J Med 1989;320:342–5.
22. B irdwe l l B G, R as ko b GE, Whi t se tt TL, e t al . The c li nic al va l idi ty of n or ma l co mpres sio n ul tr as o-n ogr a phy in o utp at ie nts su sp ec ted of h av in gde ep ve no us th rombo si s. An n Int er n Me d 199 8 ;1 28: 1 –7 .
23. Farahmand S, Farnia M, Shahriaran S, et al. The accuracy of limited B-mode compression tech-nique in diagnosing deep venous thrombosis in lower extremities. Am J Emerg Med 2011;29(6):687–90.
24. Ghane MR, Gharib M, Ebrahimi A, Saeedi M, Akbari-Kamrani M, Rezaee M, Rasouli H. Accuracy of early rapid ultrasound in shock (RUSH) examination performed by emergency physician for diagnosis of shock etiology in critically ill patients. J Emerg Trauma Shock 2015;8:5-10.
25. Shahram Bagheri -Hariri & Meysam Yekesadat & Shervin Farahmand &Mona Arbab & Mojtaba Sedaghat & Neda Shahlafar & Alireza Takzare &Seyedhossein Seyedhossieni-Davarani & Amir Nejati, The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department. Emergency Radiology2015;22(3).DOI:10.1007/s10140-014-1279-0).
26. Volpicelli G, Lamorte A, Tullio M, Cardinale L, Giraudo M, Stefanone V, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med 2013;39:1290-8.  
27. Opal SM, Cross AS. Clinical trials for severe sepsis: Past failures and future hopes. Infect Dis Clin North Am 1999;13:285-97.  
28. King EG, Bauza GJ, Mella JR, Remick DG. Pathophysiologic mechanisms in septic shock. Lab Invest 2014;94:4-12