• WATCH LIVESTREAM 13th IFAD 2023 (Nov 23-25)

    WATCH LIVESTREAM SESSIONS OF LAST DAY IFAD NOW CLICK LINK BELOW

     https://zoom.us/j/89601181911

     

    November 23-25th 2023
    Hilton Old Town Congress Centre, Antwerp, Belgium

    We are very pleased to announce the 13th International Fluid Academy Days, which will take place on November 23-25th 2023 at the Hilton Old Town Hotel in Antwerp, Belgium. The aim of this 13th edition is again to review recent advances in fluid management and hemodynamic and organ function monitoring in the critical care setting in a comprehensive manner for intensivists, anesthesiologists, and emergency care physicians, as well as interested internists and surgeons. However, the meeting will deal with any broad topic related to critical care. As always, it is also a great way to promote professional interaction between faculty members, participants, and delegates of the industry. This website is regularly updated. Last modification by Adminstrator on July 26th 2023 at 10:00 AM

     

    Get our official event app,

    Get the most out of the app and have a more productive experience!

    1

    NAVIGATE the event agenda and logistics, even without Wi-Fi or data. Access useful information like ridesharing and local attractions through the Community Board

    2

    NETWORK effectively. Plan whom to meet by exploring attendee profiles and sending out messages

    3

    PARTICIPATE in event activities through session likes, comments, ratings, live polling, tweeting, and more

    For Blackberry or Windows Phone, Click here
    For feature details, visit Whova

     

     

    Loading...

     

Incidence of pulmonary embolism in emergency department

Incidence of pulmonary embolism in emergency department

The results of the PESIT trial

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope1

Clinical Question

  • In adult patients who are hospitalised for a first episode of syncope, what is the prevalence of pulmonary embolism (PE)?
  • The authors were concerned that PE is an underappreciated cause of syncope

Design PESIT (Pulmonary Embolism in Syncope Italian Trial)

  • Multi centre cross-sectional study
  • Estimated sample size of 550 patients to obtain a two sided 95% confidence interval of 2.5% (on the basis of the prevalence in a pilot study)

Setting

  • From March 2012 until October 2014
  • Eleven general hospitals in Italy

Population

  • Inclusion:
    • Adult patients > 18 years old
    • Presenting to the emergency department with a first episode of syncope AND admitted to a medical ward
    • “Syncope” defined as a full loss of consciousness for less than 1 minute followed by spontaneous complete resolution 
  • Exclusion:
    • On anticoagulation treatment
    • Recurrent syncope
    • Obvious causes for syncope such as epileptic seizures, stroke and head trauma
  • 2584 patients were assessed for eligibility; 560 patients were included

Intervention/Work up

  • Standardised diagnostic work-up of syncope based on international guidelines2
    • Evaluation to define a subgroup with a potential alternative explanation for syncope
  • Diagnostic work-up for possible PE based on the algorithm of the 2014 guidelines of the European Society of Cardiology 3, using:
    • Pre-test clinical probability - simplified Well’s score (PE unlikely vs likely)
    • D dimer assay if PE unlikely according to Well’s criteria
  • If “unlikely” pre-test probability AND negative D-dimer assay: no further work up
  • If “likely” pre-test probability AND/OR positive D-dimer assay: further work up
    • Computed tomography pulmonary angiography (CTPA)
    • OR ventilation perfusion lung scan (V/Q scan) (if renal impairment or contrast allergy)
  • Evaluation of thrombotic burden in patients with PE through
    • Identification of the most proximal location of embolus on CTPA
    • Measurement of the severity of the perfusion defect on V/Q scan

Statistics

  • Prevalence of pulmonary embolism and associated 95% CI in (sub)group
  • Comparison of baseline characteristics in PE and non-PE group
    • Chi square test for categorical variables
    • Student’s t test for continuous variables
  • Linear regression for Odds ratios with 95% CI

Outcome/Observations

  • Prevalence of PE in patients hospitalised for first episode of syncope
    • Entire cohort: 560 patients were included in the study, 230 underwent imaging or autopsy, and 97 received a diagnosis of PE or thus 17.3% (95%CI 14.2 – 20.5)
    • Cohort with high pre-test probability AND/OR positive D-dimer: 42.2% (95%CI 35.8 – 48.6)
    • Cohort with “syncope of undetermined origin”: 25.4% (95% CI 19.4 – 31.3)
    • Cohort with “potential alternative explanation for syncope”: 12.7% (95% CI 9.2-16.1)
  • PE ruled out in 58.9% of included patients based on low pre-test probability and negative D dimer assay
  • Among patients with PE diagnosed with CTPA, the most proximal location of embolus was:
    • Main pulmonary artery: 41,7%
    • Lobar artery: 25%
    • Segmental artery: 26.4%
    • Subsegmental artery: 6.9%
  • Among patients with PE diagnosed with V/Q scan, the perfusion defect (as compared to the total lung area) involved
    • More than 50%: 16.7%
    • Between 26 and 50%: 33.3%
    • Between 1 and 25%: 50%

Authors’ Conclusions

  • PE was confirmed in 1/6 (17%) of adult patients hospitalised for a first episode of syncope, not on anticoagulant treatment
  • Although an even higher PE prevalence of 25% was noted in the subgroup with syncope of undetermined origin, also almost 13% of patients considered having another clinical explanation for the syncope had PE.
  • Syncope due to PE is thought to occur because of a sudden obstruction of the most proximal pulmonary arteries that lead to a transient depression in cardiac output. However, in approximately 40 % of the confirmed PE cases the vascular obstruction was “small” (<25% perfusion defect on VQ scan or most proximal location of embolus in (sub)segmental artery). This suggest there might be other associated mechanisms responsible for the syncope.

Strengths

  • Work up for PE regardless of whether another explanation was suggested clinically
  • Multiple centres with consistent results
  • Subgroup analyses were planned a priori

Weaknesses

  • First, Study period quite long (2.5 years) and as such clinical practice may have changed impacting the results, and hence having introduced a bias.
  • Second, No inclusion of ambulatory/discharged patients
  • Third, Syncope diagnosis based on history of patient/bystanders
  • Fourth, Study results not applicable in patients on anticoagulation treatment or with multiple syncope
  • Fifth, The PE incidence number of 17% is eye-catching because it’s entirely discordant with the 2 to 3 percent prevalence of PE in syncope from previously published literature4,5 The authors claim that their number is more accurate but have no solid base for these assumptions because:
    • The fact that 1867 out of the 2584 patients with diagnosis of syncope were discharged to home introduces a large bias as we don’t know how many of those would fit a PE diagnosis
    • Therefore, at most we can conclude that the PE incidence is 97 out of 2584 or thus 3.8% which is closer to the previously reported ranges.
  • Sixth, there are some very interesting differences in the baseline demographics of the PE confirmed and no PE group.
    • 73 patients out of 97 had clinical signs and symptoms present (signs of deep venous thrombosis, previous DVT or PE, tachycardia, tachypnea,…) suggesting that PE diagnosis was simply missed by the emergency physicians
  • Seventh, the results need to be interpreted with caution as previous data has shown that the use of CTPA may overestimate PE in distal branches with about 25%6.
  • Eight, this study appears to be an example of over diagnosis but is being interpreted as a call to change practice and as such should be interpreted with CAUTION, as the (bleeding) risks of (unnecessary) administration of oral anticoagulation in a fragile elderly population may outweigh possible benefits
  • Ninth, the @NEJM twitter handle spread the news that 1 in every 6 patients with syncope or thus 17% has PE (Figure) and thus stimulating possible overuse of anticoagulants in a fragile elderly population without critical analysis and tapering of the conclusions (see caution above)

PESIT NEJM


Take Home Messages

  • In patients with a first episode of syncope, even in the subgroup with a potential other explanation, PE should always be in your differential diagnosis and excluded if considered a possible cause and there is a high pre-test probability and/or a positive D-dimer assay in combination with vital signs abnormalities and clinical signs suspicious of DVT. This is nothing new as nicely stated by Rory Spiegel7 “Furthermore, it is important to note, this is not a cohort of 97 pulmonary embolisms in 560 patients as it will inevitably be portrayed. Rather this was 97 (3.8%) radiographic pulmonary embolisms in 2584 patients presenting to the Emergency Medicine for a syncopal event.”
  • The results of this study however cannot be generalised to other emergency departments where a good clinical and physiological assessment of the patient should normally identify PE much earlier in the diagnostic process.
  • The study does not support the statement that “smaller” PE with limited obstruction can be a potential cause of syncope8,9
  • There is no indication that this study has identified a patient population with occult PE.

References and useful links

  1. Paolo Prandoni, M.D., Ph.D., Anthonie W.A. Lensing, M.D., Ph.D., Martin H. Prins, M.D., Ph.D., Maurizio Ciammaichella, M.D., Marica Perlati, M.D., Nicola Mumoli, M.D., Eugenio Bucherini, M.D., Adriana Visonà, M.D., Carlo Bova, M.D., Davide Imberti, M.D., Stefano Campostrini, Ph.D., and Sofia Barbar, M.D., for the PESIT Investigators* Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med 2016; 375:1524-1531 View on PubMed - Download PDF
    Trial registration number: NCT01797289
    PMID: 27797317 DOI: 10.1056/NEJMoa1602172
  2. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30: 2631-71. http://eurheartj.oxfordjournals.org/content/ehj/30/21/2631.full.pdf
  3. ESC Guidelines on the diagnosis and management of acute pulmonary embolism, 2014 http://eurheartj.oxfordjournals.org/content/early/2014/08/28/eurheartj.ehu283
  4. Cook OG, Mukarram MA, Rahman OM, et al. Reasons for hospitalization among emergency department patients with syncope. Acad Emerg Med. July 18, 2016; [ePub ahead of print]
  5. Blog article: Pulmonary embolism prevalence examined in patients with syncope http://www.acepnow.com/article/pulmonary-embolism-prevalence-examined-patients-syncope/ posted by Ryan Patrick Radecki, MD, MS on December 14, 2016.
  6. Hutchinson BD, Navin P, Marom EM, et al. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. AJR Am J Roentgenol. 2015;205:271-277.
  7. Blog article: EM Nerd-The Case of the Incidental Bystander. http://emcrit.org/emnerd/the-case-of-the-incidental-bystander/ posted by Rory Spiegel on October 20, 2016.
  8. Blog article: PESIT Investigators: the incidence of PE in those hospitalized following first syncope. pulmccm.org. http://pulmccm.org/main/2016/n-engl-j-med-review/pesit-investigators-pulmonary-embolus-incidence-hospitalized-following-first-syncope/. Published October 2016.
  9. Blog article: JC: Prevalence of PE in patients with syncope. St.Emlyn’s. http://stemlynsblog.org/prevalence-of-pe-in-patients-with-syncope-st-emlyns/ posted by Simon Carley on October 20, 2016.

Leave a comment

You are commenting as guest.

Become a free member!

    Fluid_Academy

    Facebook

    Welcome to our new Blog!

    Prioritization of fluid and nutrition management

    Prioritization of fluid and nutrition management

    Intravenous (IV) fluid therapy plays a fundamental role in the management of hospitalized patients and correct use of IV fluids can be lifesaving. Parenteral nutrition (PN) solutions and additives also give clinicians many opportunities to meet diverse patient needs.

    Read more

    Fluid Stewardship Perspectives and Practice Satellite Symposium

    Fluid Stewardship Perspectives and Practice Satellite Symposium

    IV fluid administration is one of the most common interventions in acute care, but it can be frequently mismanaged, thus we support ongoing education related to fluid stewardship, join us for a session on fluid stewardship

    Read more

    Evidence based personalized fluid decisions

    Evidence based personalized fluid decisions

    More than 80% of hospitalized patients receive IV fluids. However, 1 in 5 patients may suffer complications or morbidity due to inappropriate administration of IV fluids.

    Read more

    2nd Workshop on sepsis and fluid stewardship

    2nd Workshop on sepsis and fluid stewardship

    Despite the request from the WHO many countries do not have a national sepsis plan. Fluid prescribing has been shown to be associated with significant morbidity and mortality and many patients who receive intravenous fluids suffer iatrogenic harm. Now is time to do better!

    Read more

    6th CACU (Critical and Acute Care Ultrasound) Course during IFAD

    6th CACU (Critical and Acute Care Ultrasound) Course during IFAD

    Overview and objectives: The course will start by refreshing core topics in point of care ultrasound of the heart, lung and abdomen. Then we will quickly move towards hands-on sessions to put this in practice. The CACU programme is innovative to meet the needs of beginners and advanced practitioners. The CACU course offers a fantastic opportunity to meet and greet expert sonographers in a small interactive group. You will have a true VIP experience on the front seat where you will be able to improve your skills during the hands-on sessions and to test your knowledge during the interactive cases with voting.

    Read more

    2nd Acid-Base Masterclass during IFAD

    2nd Acid-Base Masterclass during IFAD

    Learning objective:

    • Become a better bedside doctor
    • Never be surprised by your patient’s blood gas ever again
    • Meet world-renown experts in the field
    • Truly master acid-base at the bedside
    • Supported by many interactive clinical cases
    • Bicarbonate Rules, Base Excess, Stewart, Mixed approaches

    Read more

    4th BEACH Course (BElgian Annual eCmo Hands-on)

    4th BEACH Course (BElgian Annual eCmo Hands-on)

    Learning objective: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.

    Read more

    IFADmini Istanbul

    IFADmini Istanbul

    The International Fluid Academy will review recent advances in fluid management and hemodynamic and organ function monitoring in critical care at the IFADmini during WICC 2023. Gain an in-depth understanding of fluid therapy and its consequences in the care of critically ill patients. Besides, learn the use of technologies and tools to assess fluid responsiveness. Register now for the IFADmini Course.

    Read more

    IFA Position statement on equity, diversity and inclusion

    IFA Position statement on equity, diversity and inclusion

    Position statement from the IFA Board members on equity, diversity and inclusion (EDI). This position statement outlines the board’s current policies and practices aiming to achieve equity, diversity and inclusion.

    Read more

    Avoid inappropriate fluid therapy

    Avoid inappropriate fluid therapy

    1 in 5 patients may suffer complications or morbidity due to inappropriate administration of IV fluids

    Read more

    Watch Baxter's educational videos and recorded masterclass sessions.

    Watch Baxter's educational videos and recorded masterclass sessions.

    Watch Baxter's educational videos and recorded masterclass sessions on fluid management, hemodynamic monitoring and how to implement fluid stewardship.

    Read more

    An Introduction to Fluid Stewardship - A Belgian perspective

    An Introduction to Fluid Stewardship - A Belgian perspective

    Fluid stewardship is defined as a series of coordinated interventions, introduced to select the optimal fluid, dose and duration of therapy that results in the best clinical outcome, the prevention of side effects and complications and cost reduction

    Read more

    Join us for #iFADmini pop-up meeting in Cracow 2022 (June 10th) (Copy)

    Join us for #iFADmini pop-up meeting in Cracow 2022 (June 10th) (Copy)

    Due the global Corona and COVID19 pandemic the different IFADmini pop-up meetings in 2020 around the globe have been cancelled. Join us now for the IFADmini pop-up meeting in Cracow on June 10th.

    Read more

    Join us for #iFADmini pop-up meeting in Dubai 2022 (May13th)

    Join us for #iFADmini pop-up meeting in Dubai 2022 (May13th)

    Due the global Corona and COVID19 pandemic the different IFADmini pop-up meetings in 2020 around the globe have been cancelled. Join us now for the IFADmini pop-up meeting in Dubai on May 13th.

    Read more

    The three pillars of hemodynamic management

    The three pillars of hemodynamic management

    Each product in the portfolio is designed with the patient at the centre of our design process. For example, we select the most appropriate materials in our Leadercath arterial catheter range to ensure accurate signal quality during the life of the catheter.

    Read more

    Optimising Fluid Therapy in the Critically Ill

    Optimising Fluid Therapy in the Critically Ill

    Fluid Replacement in the Critically Ill Patient: Impact of Current Recommendations in the Real World. This PeerVoice independent medical education activity has been endorsed by the International Fluid Academy.

    Read more

    Assessing immunological abnormalities in COVID-19 disease may inform patient care

    Assessing immunological abnormalities in COVID-19 disease may inform patient care

    A growing list of publications indicate that the assessment of lymphocyte subset counts may provide prognostic information for COVID-19 disease severity and convalescence when considered in conjunction with other clinical information.

    Read more

    Fluids in #COVID19

    Fluids in #COVID19

    Fluid administration and management are one of the fundamental practices of intensive care. The principles of good fluid practice are built upon the foundations of a firm understanding of the underlying pathophysiological process. COVID-19 is a novel illness and presents unique challenges not just to clinical practice but the entire healthcare system.

    Read more

    Unlocking the potential for improved outcomes in IV fluid management

    Unlocking the potential for improved outcomes in IV fluid management

    Fluid administration and management are one of the fundamental practices of intensive care. The principles of good fluid practice are built upon the foundations of a firm understanding of the underlying pathophysiological process. Read this blog by our Diamond sponsor.

    Read more

    What is Cardiac Cycle Efficiency and what is its clinical value?

    What is Cardiac Cycle Efficiency and what is its clinical value?

    Cardiac Cycle Efficiency (CCE) is a unique hemodynamic variable exclusive to MostCare Up. CCE provides a global assessment of total cardiovascular performance, measured in terms of energy expenditure.

    Read more

    Advantages of individualised hemodynamic management

    Advantages of individualised hemodynamic management

    Advantage Hemodynamic parameters like cardiac output and its determinants can be useful for optimising individual goal-directed therapy. Read this blog by our Golden Sponsor

    Read more

    Fill in #COVID19 survey on Hemodynamic Monitoring

    Fill in #COVID19 survey on Hemodynamic Monitoring

    We designed an international electronic survey to better understand current practice and alignment with international guidelines in critically ill COVID-19 patients. Little is known about the cardiovascular consequences of COVID-19 and the hemodynamic management of patients requiring ICU admission.

    Read more

    Fill in #COVID19 survey on Fluid Management

    Fill in #COVID19 survey on Fluid Management

    We designed an international electronic survey to better understand current practice and alignment with international guidelines in critically ill COVID-19 patients. Fluid administration and management are one of the fundamental practices of intensive care, however few colleagues consider fluids as drugs.

    Read more

    Fill in #COVID19 survey on General Management

    Fill in #COVID19 survey on General Management

    We designed an international electronic survey to better understand current practice and alignment with international guidelines in critically ill COVID-19 patients. The impact of the present COVID-19 crisis on all levels of society is devastating. Therefore we would like to know the following: Tell us how you managed ICU patients. Tell us what you feel. Tell us what you think. Tell us what you have done

    Read more

    Join us for different #iFADmini pop-up meetings in 2021

    Join us for different #iFADmini pop-up meetings in 2021

    Due the global Corona and COVID19 pandemic the different IFADmini pop-up meetings in 2020 around the globe have been cancelled. The following meetings were planned in 2020 in Jakarta (Indonesia, April 6), Milano during SMART (Italy, May 28), Barcelona during ESA specialist society session (Spain, June 2), Krakau (Poland, June 5), Mexico city durine RECAT (Mexico, August 1-2), and Kuala Lumpur (Maleysia, Sep 6). We hope to organise them once global evolution and travelling allows us... Check our website for updates and stay safe!

    Read more

    3RD BEACH Course - Session 3

    3RD BEACH Course - Session 3

    Sedation and analgesia during ECMO (M Raes)

    Weaning from ECMO (D dos Reis Miranda)

    Read more

    3rd BEACH Course - Session 2

    3rd BEACH Course - Session 2

    How to deal with antibiotics and fluids (H Peperstraete)

    Radiology of ECMO (K Nieboer)

    How to deal with nutrition? (E de Waele)

    Neuro-monitoring during ECMO (F Taccone)

     

    Read more

    3rd BEACH Course - Session 1

    3rd BEACH Course - Session 1

    Indications and contraindications (S Bouchez)

    ECMO principles and different modes (F Taccone)

    Anticoagulation (H Peperstraete)

    Read more

    3rd BEACH (Belgian Annual ECMO Handson) Course

    3rd BEACH (Belgian Annual ECMO Handson) Course

    Setting the scene for the day

    Read more

    Livestream 40 year ICU Symposium

    Livestream 40 year ICU Symposium

    Watch the Livestream of the 40th Anniversary ICU Symposium in Brussels (Oct 12)

    Read more

    Livestream #BEACH2019

    Livestream #BEACH2019

    Follow the livestream of the 3rd BEACH course in Brussels (Oct 11)

    BElgian Annual eCmo Hands-on Course

    Read more

    Donate for FOAM

    Donate for FOAM

    We need your help to collect money to support research on IV Fluids. Save lives, donate now.

    Read more

    #IFAD2018 Social Media Report

    #IFAD2018 Social Media Report

    The #IFAD2018 Social Media Report is out. Find out more and download the 297 page report!

    Read more

    #BEACH2018 Social Media Report

    #BEACH2018 Social Media Report

    The #BEACH2018 Social Media Report is out. Find out more and download the 9 page report!

    Read more

    Ventilation in patients with intra-abdominal hypertension

    Ventilation in patients with intra-abdominal hypertension

    Monitoring of the respiratory function and adapting the ventilatory settings during anaesthesia and critical care are of great importance. This article will focus on how to deal with the respiratory derangements in critically ill patients with abdominal hypertension.

    Read more

    Minimizing secondary brain injury at the bedside #ISICEM19

    Minimizing secondary brain injury at the bedside #ISICEM19

    Talk given by Victoria McCredie, University of Toronto. Secondary brain injury is a frequent event in TBI patients. These events greatly influence prognosis and are potentially preventable. Our understanding of secondary brain injury mechanisms and physiologic responses to treatment is evolving.

    Read more

    Social Media

      like us on Facebook

      follow us on Twitter

      join Discussion group

      join us on Linkedin

      newsletter sign up

      post on the blog