The fluid resuscitation of patients with acute circulatory failure aims to increase systolic volume and consequently improve cardiac output for better tissue oxygenation. However, this effect does not always occur because approximately half of patients do not respond to fluids. The evaluation of fluid responsiveness before their administration may help to identify patients who would benefit from fluid resuscitation and avoid the risk of fluid overload in the others. The dynamic parameters of fluid responsiveness evaluation are promising predictive factors. Of these, the echocardiographic measurement of the respiratory variation in the inferior vena cava diameter is easy to apply and has been used in the hemodynamic evaluation of intensive care unit patients. However, the applicability of this technique has many limitations, and the present studies are heterogeneous and inconsistent across specific groups of patients. We review the use of the inferior vena cava diameter respiratory variation, measured via transthoracic echocardiography, to decide whether to administer fluids to patients with acute circulatory failure in the intensive care unit. We explore the benefits and limitations of this technique, its current use, and the existing evidence.

Being the first case of a right-sided Bochdalek hernia in the adult with a herniated ileo-cecal appendix, we name it Almeida-Reis hernia.

Collagen implant with gentamicin sulphate (Collatamp(®)) reduces SSI in the groin incision in ischaemic patients submitted to femoropopliteal PTFE prosthetic bypass. Days of hospitalization are also reduced. Decreasing SSI rate and in-hospital days, this implant may also reduce health care costs. Because this is a small pilot study, a multicentre RCT is necessary for validation.

IntroductionSymmetrical peripheral gangrene (SPG) is a rare syndrome defined by the peripheral ischemic lesion of two or more extremities in the absence of major vascular obstructive disease.Presentation of caseA 45yo woman, admitted in intensive care unit due to urinary septic shock, in need of high doses of amines, developed cold extremities with acrocyanosis that rapidly progressed to gangrene. Laboratory analysis revealed increased inflammatory parameters, liver shock, thrombocytopenia, prolonged coagulation times, increased D-Dimers and isolation of Acinetobacter baumanni in urine culture. An intravenous vasodilator was initiated with clinical benefits. After improvement and delimitation of the lesions, the patient underwent the amputation of the distal phalanges of the 2nd, 3rd and 4th fingers of the right hand and the toes of both feet.Discussion/conclusionEven though there is no consensus regarding SPG treatment, consequences should be mitigated, particularly when vasodilators are used, in order to avoid major amputation.

HighlightsColorectal metastases to thyroid are rare.The majority of the cases of colorectal thyroid metastases are diagnosed lately in the evolution of a known malignancy.A low threshold of suspicion is crucial to make a timely diagnosis in order to avoid its high morbidity.Colorectal thyroid metastization could be clinically silent and a raise in tumoral markers could be the only sign.Treatment is controversial and the prognosis is usually poor. Without surgery, the need may arise for tracheostomy.